WORKERS COMPENSATION Claims Kit

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1 WORKERS COMPENSATION Claims Kit

2 Dear Customer, Thank you for choosing ProSight Specialty Insurance as your Workers Compensation Insurance carrier. We pride ourselves on providing excellent service and will do our very best to meet your Workers Compensation Claims needs. ProSight Specialty Insurance writes our Workers Compensation policies through our New York Marine and General Insurance Company underwriting company, which is the name you will see listed on your policy. ProSight has partnered with a leading Workers Compensation claims service provider, LWP Claims Solutions, for our policyholders who do business exclusively in California. LWP will assist us in the administration of claims and will be the primary point of contact for your claims. Please make sure to include your Policy Number on all correspondence. For your convenience, the following documents can be found inside your claims kit: Instructions on how to report a claim Claim Handling Map List of Claim office locations, mailing addresses, and claim contacts How to locate a Physician/Facility in California Pharmacy cards Links to your state s Workers Compensation forms and Web Pages Blank forms to use when reporting a claim (California only) Please do not hesitate to contact us should you have any questions or concerns. Workers Compensation Claims Department ProSight Specialty Insurance 412 Mt. Kemble Avenue Morristown, NJ Phone: Fax:

3 California State Reporting Forms Reporting Forms for all other states can be obtained by accessing your state s Workers Compensation website (see previous page)

4 State of California Please complete in triplicate (type if possible) Mail two copies to: EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony. OSHA CASE NO. FATALITY California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health. 1. FIRM NAME Ia. Policy Number 2. MAILING ADDRESS: (Number, Street, City, Zip) E 2a. Phone Number M P L 3. LOCATION if different from Mailing Address (Number, Street, City and Zip) 3a. Location Code O Y E 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc. 5. State unemployment insurance acct.no R 6. TYPE OF EMPLOYER: 7. DATE OF INJURY / ONSET OF ILLNESS (mm/dd/yy) 1 1. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY? Yes No Private State 8. TIME INJURY/ILLNESS OCCURRED County City School District 9. TIME EMPLOYEE BEGAN WORK Other Gov't, Specify: 10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy) AM PM AM PM 12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) 14. IF STILL OFF WORK, CHECK THIS BOX: Please do not use this column CASE NUMBER OWNERSHIP INDUSTRY OCCUPATION 15. PAID FULL DAYS WAGES FOR DATE OF 16. SALARY BEING CONTINUED? 17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM SEX NJURY OR LAST Yes No INJURY/ILLNESS (mm/dd/yy) FORM (mm/dd/yy) DAY WORKED? Yes No 19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning AGE I N J U R Y O R 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) 20a. COUNTY 21. ON EMPLOYER'S PREMISES? Yes No 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop. 23. Other Workers injured or ill in this event? Yes No 24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold 25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck. DAILY HOURS DAYS PER WEEK WEEKLY HOURS I L L N E S S 26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY WEEKLY WAGE COUNTY 27. Name and address of physician (number, street, city, zip) 27a. Phone Number NATURE OF INJURY 28. Hospitalized as an inpatient overnight? No Yes If yes then, name and address of hospital (number, street, city, zip) 28a. Phone Number 29. Employee treated in emergency room? Yes No ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. See CCR Title (b)(6)-(10) & (b)(2)(E)2. Note: Shaded boxes indicate confidential employee information as listed in CCR Title (b)(2)(E)2*. 30. EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. DATE OF BIRTH (mm/dd/yy) PART OF BODY SOURCE EVENT E M P L O Y E E 33. HOME ADDRESS (Number, Street, City,Zip) 33a. PHONE NUMBER 34. SEX Male Female 37. EMPLOYEE USUALLY WORKS hours per day, 35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers) days per week, total weekly hours 37a. EMPLOYMENT STATUS regular, full-time temporary part-time seasonal 36. DATE OF HIRE (mm/dd/yy) 37b. UNDER WHAT CLASS CODE OF YOUR POLICY WHERE WAGES ASSIGNED SECONDARY SOURCE EXTENT OF INJURY 38. GROSS WAGES/SALARY Completed By (type or print) 39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)? $ per Yes No Signature & Title Date (mm/dd/yy) Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title ), to others for the purpose of processing a workers' compensation or other insurance claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title ). CCR Title requires provision upon request to certain. state and federal workplace safety agencies. FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

5 State of California Department of Industrial Relations DIVISION OF WORKERS COMPENSATION WORKERS COMPENSATION CLAIM FORM (DWC 1) Employee: Complete the Employee section and give the form to your employer. Keep a copy and mark it Employee s Temporary Receipt until you receive the signed and dated copy from your employer. You may call the Division of Workers Compensation and hear recorded information at (800) An explanation of workers' compensation benefits is included as the cover sheet of this form. You should also have received a pamphlet from your employer describing workers compensation benefits and the procedures to obtain them. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony. Estado de California Departamento de Relaciones Industriales DIVISION DE COMPENSACIÓN AL TRABAJADOR PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL TRABAJADOR (DWC 1) Empleado: Complete la sección Empleado y entregue la forma a su empleador. Quédese con la copia designada Recibo Temporal del Empleado hasta que Ud. reciba la copia firmada y fechada de su empleador. Ud. puede llamar a la Division de Compensación al Trabajador al (800) para oir información gravada. En la hoja cubierta de esta forma esta la explicatión de los beneficios de compensación al trabajador. Ud. también debería haber recibido de su empleador un folleto describiendo los benficios de compensación al trabajador lesionado y los procedimientos para obtenerlos. Toda aquella persona que a propósito haga o cause que se produzca cualquier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores lesionados es culpable de un crimen mayor felonia. Employee complete this section and see note above Empleado complete esta sección y note la notación arriba. 1. Name. Nombre. Today s Date. Fecha de Hoy. 2. Home Address. Dirección Residencial. 3. City. Ciudad. State. Estado. Zip. Código Postal. 4. Date of Injury. Fecha de la lesión (accidente). Time of Injury. Hora en que ocurrió. a.m. p.m. 5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. 6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. 7. Social Security Number. Número de Seguro Social del Empleado. 8. Signature of employee. Firma del empleado. Employer complete this section and see note below. Empleador complete esta sección y note la notación abajo. 9. Name of employer. Nombre del empleador. 10. Address. Dirección. 11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. 12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. 13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. 14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros. 15. Insurance Policy Number. El número de la póliza de Seguro. 16. Signature of employer representative. Firma del representante del empleador. 17. Title. Título. 18. Telephone. Teléfono. Employer: You are required to date this form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the claim within one working day of receipt of the form from the employee. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día hábil desde el momento de haber sido recibida la forma del empleado. EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD Employer copy/copia del Empleador Employee copy/ Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado 6/10 Rev.

6 Need to Report a Claim? By By phone: (800) Press 1 to report a claim (Available anytime- days, nights & weekends) By fax: (800) Press 2 to inquire about a claim (Available 8:00am to 5:00pm EST) By Mail: ProSight Specialty Insurance Claims Department 412 Mt. Kemble Avenue Suite 300C Morristown, NJ Additional Instructions: If you are a Workers Compensation Policyholder you are eligible to participate in online reporting of your Workers Compensation Claims. (Registration is required for online reporting, see instructions below) Online: To register for online reporting, please your request to with your full name, company name, phone number, fax number, policy number and be sure to mention that you are a ProSight customer. If you have any supporting documents (reports, bills, etc.) associated with a newly reported claim, please wait for the examiner s contact information. Do not send these documents to the call center. EXPERIENCED PROFESSIONALS. INSIGHTFUL SOLUTIONS.SM

7 Claims Handling Offices California Mailing LWP Claims Solutions, Inc. P.O. Box Sacramento, CA Toll Free: Phone: Fax: California Contacts LaVonne Cianci Claims Supervisor

8 Navigating LWP s Kaiser Signature Medical Provider Lookup Website For Policyholders enrolled in the Kaiser Network, use this search tool to locate In-Network Medical Providers in California Only, excluding all other states Go to The next page will give you four options to choose from: Select by Distance: This option is a radius search from a centralized address. Select by Name: Allows the user to look up a certain provider in the database by name. Regional Listing: This option allows the user to search in a specific region such as city, county, zip code, etc. Statewide Directory: Enter your address to recive a statewide directoy of providers. Panel Cards: This option allows the user to make a Panel Card once they have initiated a search for providers by using on of the methods listed above. SELECT BY DISTANCE Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties and/or distance. Once you click on find providers your results will be displayed. SELECT BY NAME Use the Name Search tab if you already know a Provider s name or group affiliation. REGIONAL LISTING Use this feature if you are searching for a provider in a specific area. STATEWIDE DIRECTORY Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine, Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific address. PANEL CARDS This page is used to create Panel Cards or batches of Panel Cards. For your convenience, you can choose providers from one of the three search methods and create a Panel Card for the providers closest to each of your locations.

9 Navigating the Coventry Primary Medical Provider Directory Website Use this search tool to locate In-Network Medical Providers in California Only, excluding all other states Go to The next page will give you four options to choose from: Address Search: This option is a radius search from a centralized address. Name Search: Allows the user to look up a certain provider in the database by name or phone. Region Search: This option allows the user to search in a specific region such as city, county, zip code, etc. Quick Search: A search using a limited number of specialties for providers who provide initial treatment to a maximum radius of 35 miles around an address. Creates output to a custom Worksite Poster or Directory. Worksite Posters: This option allows the user to make a Worksite Poster with the closest network providers while following all jurisdictional regulations and guidelines. ADDRESS SEARCH Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties and/or distance. Once you click on find providers your results will be displayed. NAME SEARCH Use the Name Search tab if you already know a Provider s name, group affiliation or phone REGION SEARCH Use this feature if you are searching for a provider in a specific area. QUICK SEARCH Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine, Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific address. WORKSITE POSTER (WSP) This page is used to create Worksite Posters or batches of Posters. For your convenience, you can upload your Locations and create your posters!

10 Temporary Prescription Services ID California Only Attached you will find a prescription form (also called a temporary pharmacy card) that must be given to each and every employee when there is an on the job injury. The employee needs to go to one of the pharmacies listed on the bottom of the form to get their Workers Compensation prescription(s) filled. They should follow the steps on the top of the form under the heading Injured Party. It is a good idea to distribute these forms to your Supervisors, Team Leaders, and your Human Resources department so they are familiar with the form. Chances are they will receive the notices of injury and will likely be responsible for handing the form to the injured employee. They need to follow the steps under the heading Instructions for Company.

11 Prescription Authorization LWP Claims Solutions, Inc/Workers Compensation LWP Claims Solutions, Inc. and Progressive Medical, Inc. have joined together to provide your eligible injured parties with a First Fill prescription medication card program. At the bottom of this form is a First Fill medication card that enables injured parties to obtain the initial prescription(s) needed upon injury, with little to no out of pocket expense. Instructions for Company to use this First Fill card: Injury occurs and a report of injury is made to the appropriate personnel. Fill in the eligible injured party s name, social security number, employer, date of birth, gender and date of injury on the form below. After explaining the instructions for this card, please give the eligible injured party this document. Instruct the eligible injured party to take the First Fill card and their prescription to the pharmacy. Report the claim to the appropriate insurance company/tpa. The pharmacist fills the medication; the bill is processed and sent to Progressive Medical. The First Fill card is available for a one time use. **Please note: If additional, ongoing medication is required, the claims handler should contact Progressive Medical to utilize our Retail Medication Card Program. Injured Party: At the bottom of this form is a First Fill Card that will enable you to obtain the initial prescription(s) needed upon injury with little to no out-of-pocket expense. A sample list of Participating Pharmacy Chains that accept this First Fill card is also included below. This card is for a one time use to receive your medication(s) per your employer/insurance company. Use of this card is restricted to your allowed condition. To receive this benefit, present this card to a participating pharmacy along with your prescription from your Doctor. If you have any questions, call Progressive Medical, toll free, at MEDS. Out Client Service Specialists are available 24-hours a day to take care of your needs. **Please note: If your claim is accepted, you will receive a retail pharmacy card in the mail. Present that card when filling subsequent related prescriptions. Participating Pharmacies: Brooks Pharmacy CVS Pharmacy Eckerd Pharmacy Giant Eagle Pharmacy Harris Teeter Pharmacy Kmart Pharmacy Kroger Pharmacy Longs Drugs Rite Aid Pharmacy Walgreens Pharmacy Wal-Mart Pharmacy Winn Dixie Pharmacy For additional pharmacies in your area, please visit Select the Total Pharmacy Management option, then select the Pharmacy Locator. Enter your City, State, or Zip Code and click the locator button. You will see a listing of all participating pharmacies within your specified area. Instructions for Pharmacist: LWP Claims Solutions, Inc. participates with Progressive Medical in an online pharmacy benefit program. This form is valid for Workers Compensation prescriptions only. Please transmit all claims online to Progressive Medical: Bin #: Process Control #: 7777 Group #: A290 For all other questions call toll-free the Progressive Medical Pharmacy Help Desk at Injured Worker Information: Name of Eligible Injured Party: ID/Auth # (Combination of Social Security Number 9 digits, no dashes, and today s date/date of injury 6 digits, no dashes; ie., Social Security Number of and Date of Injury July 17, 2006 would be the ID# ) Date of Birth: Gender: Employer: First Fill

12 Autorización de medicamentos recetados LWP Claims Solutions, Inc/Compensación del seguro obrero LWP Claims Solutions, Inc. y Progressive Medical, Inc. se han unido para proporcionar a las personas lesionadas que califican un programa de tarjeta de medicamentos recetados First Fill. A pie de página figura una tarjeta de medicamentos First Fill que permite a las personas lesionadas obtener la receta o recetas iniciales necesarias después de sufrir una lesión sin gastos de su propio bolsillo o con muy pocos gastos. Instrucciones para que la Compañía use esta tarjeta First Fill : Se produce una lesión y se notifica dicha lesión al miembro del personal correspondiente. Se llena el nombre de la persona lesionada que califica, su número de seguro social, empleador, fecha de nacimiento, sexo y fecha de la lesión. Después de explicar las instrucciones referentes a esta tarjeta, se da este documento a la persona lesionada que califica. Se indica a la persona lesionada que califica que lleve la tarjeta First Fill y la receta a la farmacia. Se notifica la reclamación a la compañía de seguros o TPA (administrador de terceros) correspondiente. El farmacéutico surte la receta, se procesa la factura y se envía a Progressive Medical. La tarjeta First Fill está disponible para usarse sólo una vez. **Nota: Si se requieren más medicamentos para continuar el tratamiento, el encargado de las reclamaciones debe comunicarse con Progressive Medical para utilizar nuestro Programa de Tarjeta para Medicamentos al Por Menor. Persona lesionada: A pie de página figura una tarjeta First Fill que le permitirá obtener la receta o recetas iniciales necesarias después de sufrir una lesión sin gastos de su propio bolsillo o con muy pocos gastos. Se incluye más adelante una lista de las Cadenas farmacéuticas participantes que aceptan esta tarjeta First Fill. Esta tarjeta es para usarse una vez con el fin de recibir el medicamento o medicamentos según su empleador/compañía de seguros El uso de esta tarjeta se limita a la lesión/problema médico permitido. Para recibir este beneficio, presente esta tarjeta en una farmacia participante junto con la receta de su médico. Si tiene alguna pregunta, llame gratis a Progressive Medical al MEDS. Nuestros especialistas en servicio al cliente se encuentran a su disposición las 24 horas del día para atender sus necesidades. **Nota: Si se acepta su reclamación, recibirá por correo una tarjeta para farmacias minoristas. Presente esa tarjeta al surtir recetas posteriores relacionadas. Farmacias participantes: Brooks Pharmacy CVS Pharmacy Eckerd Pharmacy Giant Eagle Pharmacy Harris Teeter Pharmacy Kmart Pharmacy Kroger Pharmacy Longs Drugs Rite Aid Pharmacy Walgreens Pharmacy Wal-Mart Pharmacy Winn Dixie Pharmacy Si desea conocer otras farmacias en su área, visite Seleccione la opción Total Pharmacy Management (Gestión total de farmacias) y, seguidamente, seleccione Pharmacy Locator (Localizador de farmacias). Introduzca su ciudad, estado o código postal y haga clic en el botón del localizador. Verá una lista de todas las farmacias participantes en un área específica. Instructions for Pharmacist: LWP Claims Solutions, Inc. participates with Progressive Medical in an online pharmacy benefit program. This form is valid for Workers Compensation prescriptions only. Please transmit all claims online to Progressive Medical: Bin #: Process Control #: 7777 Group #: A290 For all other questions call toll-free the Progressive Medical Pharmacy Help Desk at Información sobre el trabajador lesionado: Nombre de la persona lesionada que califica: No. de ID/Autorización [Combinación del número de seguro social (9 dígitos, sin guiones) y la fecha de hoy/fecha de la lesión (6 dígitos, sin guiones); por ejemplo, el número de seguro social y la fecha de lesión del 17 de julio de 2006 daría el número de ID ]. Fecha de nacimiento: Sexo: Empleador:

13 Dear Policyholder: For your convenience, we have included the following website addresses to your state s Workers Compensation web page. From the links below, you can access any forms that you might need when submitting a Workers Compensation claim. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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