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1 RE: Workers Compensation Claims Kit - Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee, we want you to have all the information you might need in the event occurs. Enclosed is our Workers Compensation Injury Reporting Kit that contains the Florida First Report of Injury form, Workers Compensation Information for Florida s Employers Pamphlet and a stepby-step process to follow in case an employee sustains an injury. Please note if one of your employees does sustain an injury, an informational packet will be sent to the employer detailing required additional information regarding the claim and procedures for each claim that is reported. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the How to File an Injury form included in this packet. The Tower Group claim office which will be handling your claim is located in Maitland, Florida. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the Florida s workers compensation process. The following State forms have been included in your claims kit packet: 1. Florida First Report of Injury or Illness- Form DFS-F2-DWC-1- Employees must report injury to their employers within thirty (30) days of occurrence. If it is an occupational disease, then this time period extends to ninety (90) days from the time that the employee first became incapacitated. 2. Florida Wage Statement- Form DFS-F2-DWC1A- This form must be completed by the employer to report required wage information to the insurance company within fourteen (14) days of learning of an injury that will require the employee to miss work for more than seven( 7) days or that results in a permanent impairment. 3. Important Workers Compensation Information for Florida s Workers- Form DFS-F2-DWC-60- This guide provides guidelines and resources for the worker. 4. Important Workers Compensation Information for Florida s Workers- Form DFS-F2-DWC-61- Spanish 5. Important Workers Compensation Information for Florida s Employers- - Form DFS-F2-DWC-65- This guide provides guidelines and resources for the employer 6. Important Workers Compensation Information for Florida s Employers- - Form DFS-F2-DWC-66- Spanish 7. Medical Authorization- Please have the injured employee fill out and sign this form and send to Tower Group Companies at the time of an injury. We thank you for your business and look forward to being of service to you. Very truly yours, Tower Group Companies CL TGC (08/10)

2 HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Workers compensation claims can be reported in several different ways, you can: Complete and submit the Florida First Report of Injury or Illness- Form DFS-F2-DWC-1- and submit the form via one of the following: the completed form to This is the preferred method of reporting an injury. Fax to Tower Group Companies at Call the Tower Group Companies Claims office at By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call The after hours telephone number for reporting claims provides the opportunity to report a claim 24 hours a day 7 days a week. Loss details will be gathered to determine if an emergency exists and if an immediate field contact is indicated. IN02 08/08

3 FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION For assistance call or contact your local EAO Office Report all deaths within 24 hours or (850) PLEASE PRINT OR TYPE EMPLOYEE INFORMATION NAME (First, Middle, Last) Social Security Number Date of Accident (Month-Day-Year) Time of Accident HOME ADDRESS EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury) AM PM Street/Apt #: City: State: Zip: TELEPHONE Area Code Number OCCUPATION INJURY/ILLNESS THAT OCCURRED PART OF BODY AFFECTED DATE OF BIRTH SEX / / M F COMPANY NAME: D. B. A.: Street: City: State: Zip: EMPLOYER INFORMATION FEDERAL I.D. NUMBER (FEIN) NATURE OF BUSINESS DATE FIRST REPORTED (Month/Day/Year) POLICY/MEMBER NUMBER TELEPHONE Area Code Number DATE EMPLOYED / / PAID FOR DATE OF INJURY YES NO EMPLOYER'S LOCATION ADDRESS (If different) Street: City: State: Zip: LOCATION # (If applicable) LAST DATE EMPLOYEE WORKED / / RETURNED TO WORK YES NO IF YES, GIVE DATE / / WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS' COMP? YES LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS' COMP / / PLACE OF ACCIDENT (Street, City, State, Zip) Street: City: State: Zip: COUNTY OF ACCIDENT DATE OF DEATH (If applicable) / / AGREE WITH DESCRIPTION OF ACCIDENT? Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s Section (7), F.S. I have reviewed, understand and acknowledge the above statement. YES NO RATE OF PAY $ PER Number of hours per day Number of hours per week Number of days per week NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL HR DAY WK MO EMPLOYEE SIGNATURE (If available to sign) EMPLOYER SIGNATURE DATE DATE CLAIMS-HANDLING ENTITY INFORMATION AUTHORIZED BY EMPLOYER YES NO 1(a) Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3) 1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employee s 8 TH Day of Disability / / Entity s Knowledge of 8 TH Day of Disability / / 3. Lost Time Case - 1st day of disability / / Full Salary in lieu of comp? YES Full Salary End Date / / Date First Payment Mailed / / AWW Comp Rate T.T. T.T. - 80% T.P. I.B. P.T. DEATH SETTLEMENT ONLY REMARKS: Penalty Amount Paid in 1 st Payment $ Interest Amount Paid in 1 st Payment $ INSURER NAME INSURER CODE # EMPLOYEE'S CLASS CODE EMPLOYER'S NAICS CODE CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Form DFS-F2-DWC-1 (03/2009) Rule 69L-3.025, F.A.C.

4 DWC-1 Purpose and Use Statement The collection of the social security number on this form is specifically authorized by Section (2), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.

5 WAGE STATEMENT RECEIVED BY CLAIMS-HANDLING ENITY FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION NOTICE TO EMPLOYEE: If you have any questions about the information contained on this form, please contact your employer or claim-handling entity. If further assistance is needed, contact the Division's Employee Assistance Office at PLEASE PRINT OR TYPE EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT (Month-Day-Year) EMPLOYER NAME & ADDRESS CONCURRENT EMPLOYER NAME & ADDRESS (If applicable) ARE THE WAGES LISTED BELOW FOR A SIMILAR EMPLOYEE? YES NO SIMILAR EMPLOYEE'S NAME TELEPHONE TELEPHONE OCCUPATION OF SIMILAR EMPLOYEE EMPLOYEE'S CUSTOMARY WORK WEEK EMPLOYEE'S CUSTOMARY DAYS WORKED/WEEK EMPLOYEE'S CUSTOMARY HOURS WORKED/WEEK EMPLOYER'S CUSTOMARY WORK WEEK (ex. Saturday thru Friday - Use 7 calendar day period) (ex. 5 days / week) (ex. 40 hours / week) (ex. Saturday thru Friday - Use 7 calendar day period) NOTICE TO EMPLOYER: Please read all instructions on the back of this form carefully. Complete the form as fully as possible and submit it to your claims-handling entity within 14 days after knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days. If you discontinue providing any fringe benefits, you must file a corrected Wage Statement with your claims-handling entity within 7 days of such termination, reflecting the type and amount of fringe benefits that were paid, and the last date they were provided. Please list wages earned for the 13 calendar weeks (Sunday through Saturday) immediately preceding the accident. GRATUITIES AS REPORTED TO THE Do Not Report Any Wages Earned During The Week of the Accident Use The 13 Calendar Weeks Immediately Preceding FRINGE BENEFITS (employee rec'd) EMPLOYER COST ONLY The Accident WEEK # OF DAYS # HOURS EMPLOYER IN WEEK WORKED WORKED GROSS WRITING AS HEALTH RENT/ NO. FROM TO THAT WEEK THAT WEEK PAY TAXABLE INCOME INSURANCE HOUSING * * RETURN THIS FORM TO: (Claims-handling entity Name, Address & Telephone #) TOTAL WILL EMPLOYER CONTINUE TO PROVIDE ABOVE BENEFITS? YES NO YES NO TOTAL FRINGE BENEFITS $ TOTAL OF GROSS PAY, GRATUITIES AND FRINGES $ (FOR CLAIMS-HANDLING ENTITY USE ONLY) AWW COMP RATE Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s Section (7), F.S. PREPARER'S NAME TELEPHONE # DATE Form DFS-F2-DWC-1a (03/2009) Rule 69L-3.025, F.A.C.

6 WAGE STATEMENT REPORTING INSTRUCTIONS General: Florida law requires disabled employees to be compensated at a certain percentage of their average weekly wage. If the injured employee worked during substantially the whole of 13 calendar weeks immediately preceding the accident, the employee s average weekly wage is one-thirteenth of the total amount of wages earned during the 13 calendar weeks. The term substantially the whole of 13 calendar weeks means not less than 75% of the total customary full-time hours of employment during that period. NOTICE TO EMPLOYER: Please read all instructions on this form carefully. Complete the form as fully as possible and submit it to your claims-handling entity within 14 days after your knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days. If you discontinue providing any fringe benefits, you must file a corrected Form DWC-1a (Wage Statement) with your claims-handling entity within 7 days of such termination, reflecting the type and amount of fringe benefits that were paid, and the last date they were provided. DO NOT combine wages of two or more employees. Calendar Week: means a seven-day period of time, which starts on Sunday and continues through Saturday. Week of Accident DO NOT report any wages earned during the week of the accident. Use the 13 calendar weeks immediately preceding the week of the accident and start with the most recent full calendar week before the week of the accident. For example, if the accident occurred on a Wednesday, then week No. 1 should begin the preceding Sunday and end the preceding Saturday. Reporting Gross Pay: Complete all columns as applicable. Report the actual gross earnings of the injured employee for the consecutive 13 calendar week period immediately preceding the accident. The 13 calendar week period includes Saturdays, Sundays, holidays, and other non-working days. Remember to include all overtime and any bonuses paid during the 13 calendar week period. If the injured employee was not employed for you for approximately 68 days during that period, enter the wages of a similar employee in the same employment who was employed for approximately 68 days of the 13 calendar week period. DO NOT combine wages for two or more employees to yield wages for the 13 calendar weeks. The spaces immediately following week #13 are to be used for reporting the wages earned in a partial week when requested. Reporting Gratuities & Fringe Benefits: Gratuities reported should include only those gratuities reported to the employer in writing as taxable income received in the course of employment from others than the employer. The reportable value of a fringe benefit is the actual cost to the employer for the benefit furnished. The only fringe benefits that can be included for dates of accident occurring on or after 07/01/1990 are employer contributions for health insurance for the employee or the employee s dependents, and the reasonable value of housing furnished to the employee by the employer which is intended as the permanent year-round housing of the employee. If you have questions or need assistance in the completion of this required form, please contact the claims-handling entity listed on the front of this form. Form DFS-F2-DWC-1a (03/2009) Rule 69L-3.025, F.A.C.

7 Employee Assistance Office The Division of Workers Compensation, Employee Assistance Office (EAO), helps prevent and resolve disputes between injured workers, employers and carriers. If the insurance carrier does not provide benefits to which you believe you are entitled, you may call EAO s toll-free hotline at EAO specialists are knowledgeable about the workers compensation system. They will be able to address your concerns and attempt to prevent or resolve disputes. EAO has offices throughout the state that you can call or visit. You can find EAO statewide locations at WC/organization/eao_offices.html. Services provided by EAO include: Educating and providing information to you about your claim. Assisting you in resolving disagreements regarding your claim, at no cost to you. Assisting you with understanding the procedures for filing a Petition for Benefits with a Judge of Compensation Claims. Information regarding your rights and responsibilities under the Workers Compensation Law is available in an on-line Injured Worker Workshop presentation on the Division s Web site at com/wc/employee/index.html, and answers to frequently asked questions can be accessed at You may also submit specific questions relating to your claim to us at and receive answers directly by . Statute of Limitations Once you are injured at work or become aware of a workers compensation injury or illness, you have 30 days in which to report your injury or illness to your employer. Failure to report your injury within 30 days may jeopardize your claim. Generally, you have two years from the date of your injury or illness to file a claim for workers compensation benefits. Failure to report your injury or illness within 30 days may be used as a defense against your claim regardless of the two-year statute of limitations for filing a claim. Your eligibility for benefits may also be eliminated one year from the date you last received a wage replacement check or approved medical treatment. Denial of Benefits If the insurance carrier does not provide benefits to which you believe you are entitled, or has denied your claim, contact the Employee Assistance Office (EAO). Although the EAO does not provide legal advice, our specialists will answer questions about your rights and responsibilities and may be able to resolve problems you re having with your workers compensation claim. This help is free and available by contacting the EAO at Petition for Benefits To begin the judicial procedure for obtaining benefits that you believe are due and owing under the law and have not been provided by the employer or insurance carrier, a Petition for Benefits form must be filed with the Office of Judges of Compensation Claims. The form can be accessed at Re-employment Services If you are unable to perform the duties required for your former job as a result of your work-related injury or illness, you can contact the Department of Education, Division of Vocational Rehabilitation at or call for free re-employment services. Legal Representation You are not required to have an attorney. If you do hire an attorney to represent you with your workers compensation claim, the fees and costs may come out of your benefits, unless your employer or workers compensation carrier is held responsible for paying your attorney fees. Although the Division does not provide legal advice, the Division will answer questions about your rights and responsibilities and may be able to resolve problems you may have with your workers compensation claim. This help is free and available by contacting the Employee Assistance Office at Anti-Fraud Reward Program Workers compensation fraud occurs when any person knowingly and with intent to injure, defraud or deceive any employer or employee, insurance carrier or selfinsured program files false or misleading information. Workers compensation fraud is a third-degree felony that can result in fines, civil liability and jail time. Rewards of up to $25,000 may be paid to individuals who provide information that lead to the arrest and conviction of persons committing insurance fraud. To report suspected workers compensation fraud, call Disclaimer: This publication is being offered as an informational tool only and complies with s (4) F.S., with the understanding that this is not official language of the Florida Statutes. In no event will the Division of Workers Compensation be liable for direct or consequential damages resulting from the use of this printed material. 69L , F.A.C. Injured Worker Informational Brochure Rule 69L-3.025, F.A.C. Forms DFS-F2-DWC-60 Revised March 2010 EMPLOYEE FACTS IMPORTANT WORKERS COMPENSATION INFORMATION FOR FLORIDA S WORKERS DIVISION OF WORKERS COMPENSATION Florida Department of Financial Services

8 Medical Benefits replacement benefits. medical and partial wage coverage may entitle you to workers compensation accident, your employer s result of a work-related If you are injured as a Wage Replacement Benefits Communicate with the Carrier: Injured Worker Responsibilities Communicate with the Employer: Carrier Responsibilities Communicate with the Authorized Treating Physician:

9 Oficina De Ayuda al Trabajador La División de Compensación por Accidentes de Trabajo, Oficina de Ayuda al Trabajador (Employee Assístance Office [EAO]) ayuda prevenir y resolver disputas entre trabajadores lesionados, empleadores y compañías de seguros. Si la compañía de seguros no le provee beneficios a lo cuales usted cree tener derecho, puede llamar a la línea gratis del EAO Ext Los especialistas de la EAO están bien informados sobre el sistema de compensación por accidentes de trabajo. Ellos podrán tratar sus preocupaciones y procurar prevenir o resolver disputas. EAO tiene oficinas por todo el estado donde usted puede visitar o llamar. Usted puede localizar estas oficinas estatales visitando nuestra página de web: Servicios Proveído por el EAO incluyen: Educar y proveer información sobre su reclamo. Asistirle a resolver desacuerdos referentes a su reclamo sin ningún costo para usted. Asistirle a entender los procedimientos para iniciar el proceso judicial y someter una petición de beneficios a la oficina de jueces de reclamaciones de compensación. Además, información sobre sus derechos y responsabilidades conforme a la ley de compensación por accidentes de trabajo esta disponible en el Taller Para Empleados Lesionados en la página Web de la División de Compensación por Accidentes de Trabajo: Se pueden obtener las respuestas a preguntas que se hacen con frecuencia en: Usted también puede someternos sus preguntas específicas relacionadas con su reclamo al y recibir la respuesta directamente por correo electrónico. Estatuto de Limitaciones Una vez que usted se ha dañado en su trabajo o se da cuenta que su lesión es relacionada a su trabajo, usted tiene 30 días para reportar su lesión a su empleador. La falta de divulgar su lesión en el plazo de 30 días puede comprometer su demanda. Generalmente, usted tiene dos años a partir de la fecha de su lesión o enfermedad para reclamar beneficios por accidentes de trabajo. La falta de reportar su lesión u enfermedad en el plazo de 30 dias se puede utilizar como defensa contra su reclamo sin importar el estatuto de dos años de las limitaciones para archivar una reclamación. Su elegibilidad para beneficios de reemplazo de salario se puede terminar un año después de recibir el último cheque de beneficio de reemplazo de salario o del último tratamiento médico que fue autorizado. Negación de Beneficios Si la compañía de seguro no le provee los beneficios que usted cree que tiene derecho a recibir, puede contactar a la Oficina de Ayuda al Trabajador (EAO). Aunque la EAO no provee consejos legales, nuestros especialistas contestarán preguntas sobre sus derechos y responsabilidades y posiblemente resuelvan problemas que usted tenga con su reclamo. Esta ayuda es gratis y disponible si contacta EAO al Ext Petición por Beneficios Para comenzar el procedimiento judicial para obtener beneficios que se le deben según la ley y no han sido proveídos por el empleador o la compañía de seguros, debe presentar el formulario Petición por Beneficios (titulado en inglés Petition for Benefits) a la Oficina de Jueces de Reclamos de Compensación. El formulario se puede obtener en el sitio: state.fl.us/jcc/forms/.asp. Servicios de Reempleo Si como resultado de su lesión u enfermedad de trabajo, usted no puede realizar los deberes que son requeridos en el lugar de empleo anterior, puede contactar al Departamento de Educación, División de Rehabilitación Vocacional en o puede llamar al para recibir servicios de re-empleo gratis. Representación Legal No se requiere que usted tenga un abogado. Si usted contrata un abogado para que le ayude con su reclamo, es posible que se use una porción de sus beneficios para pagar el honorario y los gastos del abogado a no ser que su empleador o la compañía de seguros se haga responsable de pagarlos. Aunque la División de Compensación por Accidentes de Trabajo no provee asesoramiento legal, la División contestará preguntas sobre sus derechos y responsabilidades y posiblemente podrá resolver problemas que usted pueda tener con su reclamo. La ayuda es gratis y está disponible si usted contacta la Oficina de Ayuda al Trabajador (EAO) al Ext Programa de Recompensa por Anti-Fraude El fraude de seguro por accidentes de trabajo ocurre cuando cualquier persona con conocimiento y con el intento de hacer daño, defrauda o engaña a cualquier empleador o trabajador, compañía de seguros, o auto aseguradora, presenta información falsa o engañosa. El fraude de seguros por accidentes de trabajo es un delito mayor de tercer grado que puede resultar en multas, responsabilidad civil, o encarcelamiento. Recompensas de hasta $25, se pueden pagar a personas que proporcionan la información que conduce a la detención y a la convicción de personas que han cometido fraude de seguro. Llame al para reportar sospechas de fraude de seguro por accidentes de trabajo. Limitación de responsabilidad Esta publicación esta siendo ofrecida sólo como una herramienta de información, acata s (4) F.S. con el entendimiento que esto no es lenguaje oficial de los Estatutos de la Florida. Bajo ningunas circunstancias será la División de Compensación por accidentes de trabajo responsable de daños directos o resultantes del uso de ese material. 69L , F.A.C. Injured Worker Informational Brochure Rule 69L-3.025, F.A.C. Forms DFS-F2-DWC-61 Revised March 2010 Información Para Trabajadores INFORMACIÓN IMPORTANTE DE SEGURO DE INDEMNIZACION POR ACCIDENTES DE TRABAJO PARA LOS TRABAJODORES DE LA FLORIDA DIVISION OF WORKERS COMPENSATION Florida Department of Financial Services

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11 Workers Compensation Exemptions Construction Industry Non-Construction Industry An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers compensation coverage. An employer in the non-construction industry, who employs four or more part-time or full-time employees, must obtain workers compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10-percent ownership. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability member are allowed to be exempt. A $50 fee is required for each application submitted to obtain an exemption. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Sole proprietors and partners in the non-construction industry are automatically exempt from the law, but can elect to be covered. Non-construction industry corporate officers may elect to be exempt if: The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. There is no limit to the number of corporate officers who can be exempt and there is no application fee. Non-construction exemptions are valid until a voluntary revocation is filed or the exemption is revoked by the Division. For copies of the exemption form, contact the Division s Bureau of Compliance at (850) or go to and click on Rule 69L-6 and Form number DWC-250, Notice of Election to Be Exempt. What Your Employee Can Expect From the Insurance Carrier Timely provision of medical treatment Timely payment of wage replacement benefits Timely payment of medical bills Timely reporting of the employee s claim information to the Division of Workers Compensation Timely notification of any changes in the status of the employee s claim. This information should be provided to the injured worker by mail on either a Notice of Action/ Change form (DWC-4) or a Notice of Denial form (DWC-12) Questions about workers compensation? Please visit our Web site at where you will find extensive information such as publications, databases, rules and forms that will give you a better understanding of workers compensation. Employee Assistance and Ombudsman Office Hotline Injured worker inquiries Customer Service (850) Employer inquiries Workers Compensation Fraud Hotline Frequently Asked Questions Q) How many days do employees have to report workrelated injuries or illnesses? A) Employers should encourage employees to report accidents as soon as the work related injuries or illnesses occur. By law, however, employees are required to report work related injuries or illnesses within 30 days. Q To whom should I report the work-related injury? A) You should report the accident to your insurance company as soon as you have knowledge of the injury. By law, you have seven days from your first knowledge of the work related injury. Q) Do I have to report a claim if I do not believe it is a workrelated injury or illness? A) Yes. You should report all claims of work-related injuries or illnesses to your workers compensation insurance carrier. This includes claims in which there are no witnesses of the injury or illness. It is your workers compensation insurance carrier s responsibility to investigate all claims and determine if employees are entitled to benefits under Florida s Workers Compensation Law. Q) Does the employee pay any part of my workers compensation insurance premium? A) No. The law is very specific on this point. It is the employer s responsibility to pay the entire premium for workers compensation. Employers who secure workers compensation coverage can also apply to become a drug-free workplace and may receive a premium discount. To learn more about the Drugfree Workplace Program, please call the Division of Workers Compensation Customer Service Office at Q) Who should I call if my employees have questions or concerns regarding their workers compensation claims? A) You should first contact your insurance carrier. If your carrier is unable to answer the question or resolve the problem, you or your employees should call the Employee Assistance and Ombudsman Office at Disclaimer: This publication is being offered as an informational tool only and complies with s (4) F.S., with the understanding that this is not official language of the Florida Statutes. In no event will the Division of Workers Compensation be liable for direct or consequential damages resulting from the use of this printed material. 69L , F.A.C. Employer Informational Brochure Rule 69L-3.025, F.A.C. Forms DFS-F2-DWC-65 Revised March 2010 EMPLOYER FACTS IMPORTANT WORKERS COMPENSATION INFORMATION FOR FLORIDA S EMPLOYERS DIVISION OF WORKERS COMPENSATION Florida Department of Financial Services

12 First Report of Injury Workers Compensation Notice This brochure will give you a better understanding of your role and responsibilities under the workers compensation system. Your workers compensation insurance policy covers medical and partial wage-replacement benefits for any employee who sustains a work related injury or illness. Medical Benefits Workplace Fatalities Wage Replacement Benefits Anti-Fraud Reward Program Petition for Benefits Employee Assistance Office Wage Statement Form

13 Certificado de elección para exenciones Industrias dedicadas a la construcción Industrias que no se dedican a la construcción Empleadores en las industrias de la construcción con un (1) empleado o más a jornada completa o jornada parcial, incluyendo el dueño, debe obtener la cobertura de seguro por accidentes de trabajo. Un empleador que no participa en la industria de construcción y tiene cuatro (4) empleados o más de jornada completa o jornada parcial tiene que obtener la cobertura de seguros por accidentes de trabajo. Oficiales o miembros de una sociedad de responsabilidad limitada (LLC) de una corporación en la industria de la construcción pueden elegir ser exentos si: Poseen un mínimo de diez por ciento (10%) de titularidad de acciones de la corporación o en el caso de un LLC hay una declaración que da testimonio a la propiedad del 10 por ciento mínima. El oficial de la compañía aparece como oficial de la corporación en el registro del Departamento del Estado de la Florida, División de Corporaciones. La corporación aparece activa en el registro del Departamento del Estado de la Florida, División de Corporaciones. Solamente tres oficiales de una corporación o sociedades de responsabilidad limitada pueden elige ser exentos. Se requiere pagar $50 por cada aplicación presentada para obtener una exención. Exenciones en las industrias que participan en la construcción son validas por dos años o hasta que se registre una revocación voluntaria o si la exención es revocada por la división. Propietarios únicos y socios en industrias que no participan en la construcción están automáticamente exentos de la ley, pero pueden elegir ser cubierto. Oficiales de una corporación que no se dedica a la construcción puede elegir ser exentos si: El oficial esta listado como oficial de la corporación en el registro del Departamento del Estado de la Florida, División de Corporaciones. La corporación esta listada activa en el registro del Departamento del Estado de la Florida, División de Corporaciones. No hay límite de oficiales que pueden ser elegibles para ser exentos y no le cobrarán por llenar la aplicación para la exención. Exenciones en las industrias que no se dedican a la construcción son válidas por dos años o hasta que se registre una revocación voluntaria o si la exención es revocada por la división. Para conseguir copias de la notificación de elección para ser exento [en inglés Notice of Election to Be Exempt] llame al (850) o vaya a nuestro sitio Web en y haga clic en la regla 69L-6 y número del formulario DWC-250 Elección de ser exento. Lo que su empleado puede esperar de parte de la compañía de seguros: Provisión oportuna de tratamiento médico Provisión oportuna de beneficios de reemplazo de salario Pago oportuno de cuentas médicas Notificación oportuna de su reclamación a la División de Compensación por Accidentes de Trabajo Notificación oportuna de cualquier cambio del estado de su reclamación. Esta información se le será proveída por correo en un formulario titulado Notice of Action/Change (DWC4) [Notificación de Acción o Cambio (DWC4)] o Notice of Denial (DWC12) [Notificación de Negación (DWC12)] Tiene preguntas sobre el seguro por accidentes de trabajo? Por favor, visite nuestra página Web en donde usted encontrará información extensa tal como publicaciones, un número de bases de datos, reglas, y formas que le dará un mejor entendimiento del seguro para accidentes de trabajo. Oficina de Ayuda al Trabajador (Oficina de asistencia para el trabajador) Empleados lesionados pueden hacer preguntas por correo electrónico Servicio al cliente (850) Empleadores pueden hacer preguntas por correo electrónico Preguntas sobre el programa contra el fraude Preguntas hechas con frecuencia P) Cuántos días tienen los empleados para reportar lesiones u enfermedades relacionadas con el trabajo? R) Los patrones deben aconsejar a sus empleados que reporten accidentes tan pronto como ocurran lesiones o enfermedades relacionadas con el trabajo. Por ley, sin embargo, se requiere que empleados reporten lesiones o las enfermedades relacionadas con el trabajo en el plazo de 30 días. P) A quién le debo reportar la lesión relacionada con el trabajo? R) Usted debe reportar el accidente a su compañía de seguros tan pronto usted tenga conocimiento de la lesión. Por ley, usted tiene siete días desde su primer conocimiento de la lesión relacionada con el trabajo. P) Tengo que reportar un reclamo si no creo que la lesión o enfermedad es relacionada con el trabajo? R) Sí. Usted debe reportar todas las demandas de lesiones o de enfermedad relacionadas con el trabajo a su compañía de seguros. Esto incluye las demandas de las cuales no hay testigos de las lesiones u de las enfermedades. Es responsabilidad de la compañía de seguros por accidentes de trabajo investigar todas las demandas y determinar si el empleado tiene derecho a recibir beneficios de acuerdo a la ley de seguros por accidentes de trabajo. P) El empleado paga parte de la prima de seguro por accidentes de trabajo? R) No. La ley es muy específica en este punto. Es la responsabilidad del empleador pagar la prima entera del seguro por accidentes de trabajo. P) A quién debo llamar si mis empleados tienen preguntas o preocupaciones con respecto a sus reclamaciónes? R) Usted debe primero contactar a su compañía de seguro. Si la aseguradora no puede contestar la pregunta o resolver el problema, usted o sus empleados deben llamar la oficina de la ayuda al Trabajador en Empleadores que adquieran una póliza de seguros por accidentes de trabajo pueden también aplicar para ser un lugar de trabajo libre de drogas y pueden recibir un descuento de prima. Para aprender más sobre el programa, llame por favor a la División de Compensación por Accidentes, la oficina del servicio de atención al cliente al Limitación de responsabilidad Esta publicación esta siendo ofrecida sólo como una herramienta de información, acata s (4) F.S. con el entendimiento que esto no es lenguaje oficial de los Estatutos de la Florida. Bajo ningunas circunstancias será la División de Compensación por accidentes de trabajo responsable de daños directos o resultantes del uso de ese material. 69L , F.A.C. Employer Informational Brochure Rule 69L-3.025, F.A.C. Forms DFS-F2-DWC-66 Revised March 2010 Información Para Empleadores INFORMACIÓN IMPORTANTE DEL SEGURO DE INDEMNIZACION POR ACCIDENTES DE TRABAJO PARA LOS EMPLEADORES DE LA FLORIDA DIVISION OF WORKERS COMPENSATION Florida Department of Financial Services

14 Primer reporte de la lesión o enfermedad Aviso de seguro por accidentes de trabajo Este folleto le dará una mejor comprensión de su papel y responsabilidades bajo el sistema de seguro por accidentes de trabajo. Su póliza de seguro por accidentes de trabajo cubre beneficios médicos y reemplazo parcial del salario para cualquier empleado que sostenga lesión o una enfermedad relacionada con su trabajo. Beneficios médicos Fallecimientos relacionados con el trabajo Formulario de la declaración del salario Beneficios de reemplazo de salario Programa de recompensación contra fraude Petición para beneficios Oficina de ayuda al trabajador

15 WORKERS COMPENSATION INJURY MEDICAL AUTHORIZATION Authorization for Medical Records And Communication Release By this form or copy thereof, I, hereby authorize any licensed physician, chiropractor, medical practitioner, hospital, clinic or other related medical or medically related facility, insurance company or other organization, institution, or person, that has any records or knowledge of my mental, physical health, history, condition or well being, to supply such information to my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys. I specifically authorize any treating physician or medical care provider to communicate orally or in writing with my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys as to my care and treatment and as to any other issues including but not limited to diagnosis, prognosis, causal connection of care and treatment to my work injury or duties and ability to work. In conjunction with this, I authorize any treating physician or medical provider to review any additional medical records provided to them. I understand that by signing this authorization for medical records and communication release that my applicable medical provider will be releasing information subject to the HIPPA restrictions. I specifically waive any rights or protections that I may have under the HIPPA regulation and request that the medical providers release the requested information. A photo copy of this authorization shall be valid as the original. This release shall remain valid for the length of my claim. Name (Please Print) Address (Street, City/Town, Zip Code) Signature Date Signed TWR05 08/08

16 WORKERS COMPENSATION MANAGED CARE PROGRAMS Tower Group Companies strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers needs in managing their workers compensation claims. Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker. A summary of each program is outlined below. Medical Bill Review Services The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs. Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and Aetna networks; as well as other top regional PPO s. The combination of these network providers offers coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work. In some states, such as California and Texas state regulations allow specialty networks which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments. One of the first steps in providing quality medical care to your injured employee is to understand how to access network providers, and generate workplace provider panel cards or provider listings. There are two convenient ways to locate a network provider or develop provider network listings: 1. Telephonically: Simply call Coventry at x Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via Internet Access: For the standard national workers compensation network go to and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network.

17 If you participate in a Specialty Network, such as a MPN or HCN, select the applicable network from the drop-down box. For California, chose the First Health Select CA MPN; Texas participants in the Coventry HCN. For large panel card production or if you require additional information regarding web access please contact Tower Group Medical Management division at Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims. Tower s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee s lost time and medical costs. Your Tower Group designated adjuster will be responsible for managing all aspects of the injured employee s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these programs.

18 Re: Important Information about your Workers Compensation Prescriptions This letter is provided to inform you that your employer s workers compensation, Tower Group Companies, has selected PMSI as its workers compensation pharmacy partner.with PMSI, you can choose to pick-up your medications for your work-related injury at a nearby pharmacy through a program known as Tmesys, or have them delivered to your home through the mail. Within the next few weeks, you will receive a new workers compensation pharmacy card in the mail. You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your next refill or new prescription for your work-related injury. If you do not receive your new pharmacy card within two weeks, please call Tmesys at and we will be happy to assist you or send another card. If you are interested in finding out about how to receive your prescriptions through the mail, please call To help you transition to the new pharmacy program, we have provided answers to some frequently asked questions: Q: How do I know if my pharmacy participates with the new program? A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the Pharmacy Center on our website, Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at to find a network pharmacy near you. Q: How does this affect my workers compensation claim? A: Using PMSI s program for your workers compensation medications will enable you to continue to receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy, as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you can have your prescriptions delivered to your home through our convenient mail order program. Q: Who do I call with questions about the program? A: PMSI has representatives available to help you with any questions that you may have about the pharmacy program. Please call our help desk at to speak to a representative. If you have any questions about your workers compensation claim, we will help you reach your claims adjuster for assistance. We look forward to serving you and meeting your workers compensation medication needs. Sincerely, PMSI Necesitas ayuda en español? Llame al

19 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. Questions? Call Necesitas ayuda en español? Llame al Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk Notice to Cardholder: This card should be presented to your pharmacy to receive medication for your work-related injury. It is only valid within 30 days of your date of injury. For information regarding the program or to find nearby pharmacies call NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information from the card. 3. The Help Desk will provide an ID number for adjudication. (To create a card for your wallet, cut along outer line and fold in half.) Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: Visit your local Walgreens or Rite Aid Pharmacy Call us: Use our pharmacy locator online: PMSI, Inc. All rights reserved. C

20 First Fill Temporary Pharmacy Card En Primer Relleno Tarjeta Temporal de Farmacia Hacerlo fácil de llenar sus recetas de la compensación del trabajador. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Empleado Lesionado: 1. Si usted necesita una receta para un accidente de trabajo o enfermedad ocupacional, ir a una farmacia de la red Tmesys. 2. Dar esta página al farmacéutico. 3. El farmacéutico surtir su receta sin costo alguno. Preguntas? Llame al Need help in English? Call Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # (Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.) Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information listed above. 3. The Help Desk will provide an ID number for adjudication. Encontrar una farmacia de la red Utilice uno de estos métodos fáciles para encontrar una farmacia de la red: Visite a su local de Walgreens y Rite Aid Pharmacy. Nos llame al: Utilice nuestro localizador de farmacias en linea: PMSI, Inc. Todos los derechos reservados. C

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