Dear Policyholder: We thank you for your business, and look forward to being of service to you. Very truly yours, Tower Group Companies

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1 Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never has to experience an injury to an employee, we want you to have all the information you might need in the event one does. Enclosed is our Workers Compensation Injury Reporting Kit that contains the California State mandated forms, and a step-by step process to follow in case of an injury to an employee. When a claim occurs, please contact the Tower First Report Unit in Irvine, California. Contact information for the First Report Unit is listed on the Reporting Work Related Accidents form included in this packet. Once reported, a claims representative will contact you to get additional information about the injured employee and to answer any questions that you might have regarding the California workers compensation process. 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 Reporting Work Related Accidents The timely reporting of work related accidents is critical in helping to reduce the overall costs associated with these claims. Please remember to notify us immediately if one of your employees is injured at work or becomes ill due to conditions on the job. By doing so we can work together to help control claim costs. It is very important to include contact numbers for both the employee and the employer when submitting an Employer s Report of Occupational Injury of Illness Form (Form 5020). We recommend that you list both the landline and cell phone numbers. Reporting a work related accident can be done by fax, , phone, or mail. Simply complete the attached Employer s Report of Occupational Injury of Illness form and forward to us in any manner noted below. By Fax: To report a claim by Fax: Fax the completed Employer s Report of Occupational Injury of Illness form for our First Report fax line at By To report a claim by - Please the completed Employer s Report of Occupational Injury of Illness form to By Phone: To report a claim by phone Call By Mail: To report a claim by mail Please forward the completed Employer s Report of Occupational Injury of Illness form to: Tower Group Companies Claims Department P.O. Box Irvine, CA, If at any time you have questions about the reporting process or how to complete the Employer s Report of Occupational injury or Illness form, please feel free to contact our claims department at

3 Workers Compensation Injury Reporting Kit (These materials are to be used to report an on-job-injury of illness.) Injuries must be reported within 24 hours! 1. Employee Claim Form (DWC-1) The Employer provides this form to the injured employee within 24 hours of knowledge of injury. a. Employee completely reads and fills in # s 1-8 b. Employee retains a copy and returns the form to the employer c. The employer completes # s 9-18 (*Note # 14 is Tower Group Companies) d. The employer provides a dated copy of the completed form to the employee, sends a copy to Tower Group Companies and keeps a copy on file. 2. Employer provides injured employee with the following additional items in the appropriate language a. Name of treating physician or authorized industrial clinic b. Informational pamphlet c. Name, telephone number and P.O. Box our First Report Unit in Irvine, California. 3. Employer s Report of Occupational Injury or Illness (Form 5020) 4. Medical Care a. Employer fills out lines # s 1-39 b. At the bottom of form 5020, print the name and title of the person who if filling the Report of Occupational Injury or Illness. c. Employer dates and signs Form 5020 in the space provided at the bottom of the form, sends the completed form to Tower Group Companies and keeps a copy on file. In an emergency, please contact 911. Otherwise, refer the employee to your industrial clinic. 5. Report of Occupational Injury of Illness Form (5020) Within 24 hours of your knowledge of injury or illness, report the claim to the Tower First Report unit by calling You will need to be prepared to provide them with the information necessary to complete the California Employer s Report of Occupational Injury of Illness (Form 5020). A sample is enclosed for your reference. ***Remember, a copy of item #1 and #3 MUST be sent to Tower Group Companies***

4 Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibilty Formulario de Reclamo de Compeiisación de Trabajadores (DWC 1) y Notlfieación de Posible Elegibildad v'~"-:"... ~ :\,,~; '.... If you are injured or become ill, either physically or mentally. because of your job, including injuries resulting from a workplace crime, you may be entitled to workers' compensation benefits. Attached is the fonn for filing a workers' compensation claim with your employer. You should read all of the information below. Keep this sheet and all othcr papers for your records. You may be eligible for some or all of the benefits listed depending on the nature of your claim. If required you will be notified by the claims administrator, who is responsible for handling your claim, about your eligibility for benefits. To fie a claim, complete the "Employee" section of the fomi, keep one copy and give the rest to your employer. Your employer will then complete the "Employer" section, give you a dated copy, keep one copy and send one to the claims administrator. Bencfits can't start until the claims administrator knows of the injury, so complete the form as soon as possible. Medical Care: Your claims administrator will pay all rcasonable and necessary medical care for your work injuiy or illness. Medical benefits may include treatment by a doctor, hospital services, physical therapy, lab tests, x-rays, and medicines. Your claims administrator will pay the costs directly so you should never see a bill. There is a limit on some medical services. The Priman Treating Phvsician cptpi is the doctor with the overall responsibility for treatmcnt of your injury or illness. Generally your employer selects the PTP you will see for the first 30 days, however, in specified conditions, you may be treated by your predesignated doctor or mcdical group. If a doctor says you still need treatment after 30 days, you may be able to switch to the doctor of your choice. Different rules apply if your employer is using a Health Care Organization (HCO) or a Medical Provider Network (MPN). A MPN is a selected network of health care providers to provide treatment to workers injured on the job. You should receive infoimation from your employer if you are covered by an Ileo or a MPN. Contact your employer for more inforniation. If your employer has not put up a poster describing your rights to workcrs' compensation, you may choose your own doctor immediately. Within one working day after you file a claim form, your employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for the alleged injury and shall continue to be liable for up to $~ 0,000 in treatment until the claim is accepted or rejected. Disclosure of Medical Records: After you make a claim for workers' compensation benefits, your medical records will not have the same level of privacy that you usually cxpect. If you don't agree to voluntarily release medical records, a work.ors' compensation judge may decide what records will be released. If you request privacy, the judge may "scal" (keep private) certain medical records. Payment for Teßlllolan Disabilty (Lost Wa~: If you can't work while you are recovering from ajob injury or illness, for most il\iuries you will receive temporary disability payments for a limited pciiod of time. These payments may change or stop when your doctor says you are able to rdum to work. These benefits arc tax-free. Temporary disability payments are two-thirds of your average weekly pay, within minimums and maximums set by state law. Paynients arc not made for thc first three days you are ott the job unless you are hospitalized overnight or cannot work for more than 14 days. Return to Work: To help you to return to work as soon as possible, you should actively communicate with your treating doctor, claims administrator, and employer about the kinds of work you can do while recovering. They may coordinate efforts to return you to modified duty or other work that is medically appropriate. This modified or other duty may Si Ud. se lesiona 0 se enferma, ya sea fisieamente 0 mental mente, debido a su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es posible que Ud. tenga derecho a beneticios de compensaeión de trabajadores. Se adjunta el formulario para presentar un reclamo de compensación de trabajadores COll su ernpleador. UII. debe leer toda la información a continuación. Guarde esta hoja y todos los del1ás documentos para sus archivos. Es posible que usted reúna los requisitos para todos los beneficios, 0 parte de éstos, que se enurneran, dependiendo de la indole de su reclamo. Si se requiere, el administrador de reclamos, quien es responsable pol' el manejo de su reclamo, Ie notificará sobre su elegibilidad para beneficios. Para prescntar un reclaiio, Ilene la sección del foriiiulario designada para el "Empleado," guarde una copia, y déle el restn a su empleador. Entonces, su empleador completará la sección designada para el "Empleador," Ie dará a Ud. una copia fechada, guardará una copia, y enviará una al administrador de reclamos. Los benefieios no pueden comenzar hasta, que el administrador de reclamos se entere de la lesión, asi que complete el formulario 10 antes posible. Atención Médica: Su administrador de reclamos pagará toda ia atención médica razonable y necesaria, para su!esión 0 enfennedad relacionada con el trabajo. Es posible que los beneficios médieos incluyan ci tratamiento pol' parte de un médico, los scrvicios de hospital, la tcrapia fisica, los análisis de laboratorio y las medicinas. Su administrador de reclamos pagará directamentc los costos, de manera que usted nunca verá un eobro. Hay un Iímite para ciertos servicios médicos. EI Mcdico Primario que Ie Atiende-Pri11flrr TI'ellifll! PIll sicioii PTP es d médico con la responsabilidad total para tratar su lesión 0 enfermedad. Gcneralmcnte, su ernpleaclor selecciona al P7ï' que Ud. verá durante los primeros 30 dias. Sin embargo, en condiciones especificas, es posible que usted pueda ser tratado poi' su médico 0 grupo médico previaiiente designado. Si el doctor dice que usted aún necesita tratamiento después de 30 dias, es posible que Ud. pueda cambial' al médico de su prefèrencia. Hay reglas differentes que se aplican cuando su empleador usa una Organización de Cuidado Médico (HCO) 0 una Red de Proveedores Mcclicos (MPN). Una MPN es una red de proveedores de asistencia médica seleccionados para dar tratamiento a los trabajadores lesionaclos en cl trabajo. Usted dcbe recibir infonnaeión de su empleador si su tratamiento es cubieiio pol' una HCO 0 una MPN. Hable con su empleador para más infolliación. Si su einpleador no ha colocado un caiiel describiendo sus derechos para la compensaeión de trabajadores, Ud. puede seleecionar a su propio incdico inmediatamente. Dentm de un día despucs de que Ud. Presente un formulario de reclaino, su empleador autorizará to do tratamiento iiédieo de acuerdo eon las pautas de trataiiiento aplicables a la presunta lesión y será responsable pol' $ I 0,000 en tratamiento hasta que el reclamo sea aceptado 0 rechazado. Divulgación de Exiiedieiites Mcdicos: Después de que Ud. presente un reclamo para beneficios de compensaeión de trabajadores, sus expedientes médicos no tendrán el misino nivel cle piivacidad que usted noimalrnente espera. Si Ud. no está dc aeuerdo en divulgar voluntarial1ente los expedientes médicos, un juez cle comp(;nsación de trabajadores posiblel1ente deeida qu6 expedientes se revelarán. Si Ud. solicita privacidad, es posible que el juez "selle" (inantenga privados) ciertos expedientes inédicos. Pa:.o por Incapacidad Temporal (Sneldos Perdidos): Si Ud. nl) puede trabajar, rnientras se está recuperando de una lesión 0 enfennedad relacionada con el trabajo. Ud. recibirú pagos pol' incapacidad temporal para la mayoria de las lesions poi' un period limitaclo. Es posible que estos pagos cambien 0 paren, wando su inédi~o diga que Ud. está en condiciones de regresar a trabajar. Estos beneficios son libres de inipuestos. Los pagos Rev. 6110

5 Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibilty Formultll'io tie Reclamo tie Compeiistlcióll tie Trabajadol'es (DWC 1) Y Notifcacióii tie Posible Elegibildall i~~;::. Il~~. ~~..._:... be temporary or may be extended depending on the nature of your injury or illness. Pai ment for Permanent Disabilii: If a doctor says your injury or illness results in a permanent disability, you may receive additional payments. The amount will depend on the type of injury, your age, occupation, and date of injury. Supplemental Job DiSllljlcement Benefit isjdb!: If you were injured after 1/1/04 and you have a permanent disability that prevents you from returning to work within 60 days after your temporary disability ends, and your employer does not offer modified or alternative work, you may qualify for a nontransferable voucher payable to a school for retraining and/or skil enhancement. If you qualify, thc claims administrator will pay the costs up to the maximum set by state law based on your percentage of perrnanent disabi Ii ty. Death Benefits: If the injury or illness causes death, paymcnts may be made to relatives or household members who were financially dependent on the deceased worker. It is iie::al for,'our emiilover to punish or tíre you for having a job injury or illness, for fiing a claim, or testifying in another person's workers' compensation case (Labor Code 132a). If proven, you may receive lost wages, job reinstatement, increased benetíts, and costs and expenscs up to limits set by the state. You have the right to disagree with decisions affecting your claim. ifyou have a disagreement, contact your claims administrator first to sec if you can resolve it. If you are not receiving benefits, you may be able to get State Disability Insurance (SOI) benefits. Call State Employment Development Depar1ment at (800) You can obtain free infonnation from an information and assistance offcer of the State Division of Workers' Compensation (DWC), or you can hear recorded information and a list of local oftces by calling (800) You may also go to the DWC website at Yon can eonsiilt with an attorney. Most attorneys otter one frte consultation. If you dccide to hire an attorney, his or her fcc will be taken out of some of your benefits. For names of workers' compensation attorieys, eall tht: State Bar of Calítornia at (415) or go to their web site at pol' ineapacidad temporal son dos tercios de su rago semanal promedio, con eantidades Ilínimas y Iláximas establecidas pol' las Icyes estatales. Los pagos no se haccn durante los primeros Ires dias en que ljd. no trabaje, a men os que Ud. sea hospitalizado una noche 0 no pueda trabajar durante más de 14 días. Regreso al Tmbajo: Para ayudarle a regresar a trabajar 10 antes pçisible, ljd. debe cornunicarse de manera aetiva con el médieo que Ie atienda, el administrador de reclamos y el empleador, con respeeto a las clases de trabajo que ljd. puede hacer rnientras se recupera. Es posible que ellos coordinen esfuerzos para regresarle a un trabajo modificado, 0 a otro trabajo, que sea apropiado desde el punto de vista médico. Este trabajo modificado u otro trabajo podna ser temporal 0 podria extenderse dependiendo de la índole de su lesión 0 enfennedad. Pa"o poi. Ineaiiacidad Permanente: Si el doctor dice que su lesión 0 enfermedad resulta en una ineapacidad pernianente, es posible que ljd. reeiba pagos adicionales. La cariidad dependerá de la clase de lesión, su edad, su ocupación y la fecha de la lesión. Beneficio SIi"lementario 1101' Dcs(llazamicnto de Ti'abalo: Si ljd. Se lesionó después del 111/04 y tiene una incaracidad peniianente que Ie impide regrcsar al trabajo dentro de 60 dlas después de que los pagos pol' ineapacidad temporal terminen, y su empleador no ofrcce un trabajo modificado 0 alternativo, es posiblc que usted reúna los requisitos para reeibir un vale no-transferible pagadero a una escuda para recibir un nuevo entrenamiento y/o inejorar su habilrdad. Si Ud. reúiie los requisitios, el administrador de reclainos pagará los gastos hasta un máximo establecido pol' las leyes estatales basado en su porcentaje de incapacidad pennanente. Bcnctìcios por Miierte: Si la lesión 0 enferinedad causa la muerte, es po,ible que los pagos se hagan a los parientes 0 a las personas que viven en el hogar y que dependían econ6niicameiite del trabajador difunto. Es ilcgal que sll cmpleador Ie castigue 0 despidii, pol' sufrir una lesión 0 erilènnedad en el trabajo, pol' presentar un reclaino 0 pol' testificar cn cl caso de compensaeión de trabajadores de otra persona. (El Codigo I.aboral seceión 132a.) De ser rrobado, usted puede recibir pagos por pérdida de sueldos, reposicióii del trabajo, aumento de beneficios y gastos hasta los líniites establecidos poi' ei estado. Ud. tiene derecho a no cstar de aeuerdo con las decisiones que afecten su reclamo. Si Ud. tiene un desacuerdo, priinero comuníquese con su aclministrador dt: reclainos para vel' si usted puede resolverlo. Si usted no está recibiendo beiiefieios, es posible que Ud. pueda obtener beiieficios del Seguro Estatal de Incapacidad (SOL). Llame al Departamento Estatal del Desarrollo del Einpleo (EDD) al (800) Ud. puede obtener infoimación gratis, de un oficial de infonnación y asistencia, de la Divisióii Estatal de Coripensación de Trabajadores (Division oj Workers' Compensation -- DWC) 0 puede escuchar información grabada, asi como una lista de oficinas locales liamando al (800) Ud. tambiéri ruede consultar con la pagina Web de la DWC en Vd. (liicdc eonsultar con un abo:,ado. La mayoría de los abogados ofrecen una consulta gratis. Si Ud. decidc contra tar a un abogado, los honorarios serán toinados de algunos de sus beneficios. Para obtener nombres de abogados dc compensación de trabajadores, liame a la Asoeiaci6n Estatal de Abogados de Califoiiia (State Bar) al (415) , ó consulte con la pagina Web en Hev 6/tO

6 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. "ny person who makes or causes to he made any knowingly false or fraudulent material statement or materiiil representation for the purpose of obtaining or denying workers' compensa1on benefits or payineni~ is guilty of a felony. Estado de California Departamento de Relacioiies liidustriales DlVlSlON DE COMPENSAC/ÓN AL TRi\BJlADOR PETITION DEL EMPLEADO PARA DE eompensación DEL TRABAJADOR (DWe I) Empfeado: Complete la sección "Empleado" y eiitregue la forma a su empleador. Qiiédese con la copia designada "Recibo Temporal del Empfeado" l10sm que Vd. reciba la copiafirmada y fechada de su empleador. Vd. puede llamar a la Division de Compensación al Trabajadoral (800) para oil' informución gravada. En la hoja ciibierta de esta forma esla la explicatión de los beneficios de compensación al tmbajador. Vd. también debería haber recibido de su empleador unfolleiu describiendo los benjïcios de compelisació/i al tmbajador lesion ado y los procedimieiiios para obtenerlos. Toda aquella persona que a propósito haga 0 calise que se produr.ca ciialquler declaraciiín 0 representación material fal~a 0 fraudulenta eim el fin de obtener 0 negar beneficios 0 pagos de ciimpensación a lraba.ladores lesionados es culpable de un crimen ma~'or "relonia". Employee--omplete this section and see note above Empleado-complete esta sección y note fa notacióii arriba. i. Name. Nombre. Today's Date. Fecha de Hoy. 2. Home Address. Direccióii Residencial. 3. City. Ciudad. State. Estado. Zip. Código Postal. 4. Date of Injury. F echa de la lesión (accidente). Time of Injury. Hom en que ocurrió.. a.m. 5. Address and description of where injury happened. DirecCIônllugar dônde occiirió 1'1 accidenti'. p.m. 6. Describe injury and part of body affected. Descriha la lesión y parte del cueljjo afectada. 7. Social Security Number. Número de Seguro Social del Empleado. 8. Signature of employee. Firmlt del empleado. Employer--omplete this section and see note below. Empfeiidor-complete estii sección y 1/ote (ll1/otació1/ abiijo. 9. Name of employer. Nombre del empleador. 10. Address. Dirección. I i. Date employer first knew of injury. Fecha eii que el empleador supo poi' primera vez de la lesión 0 accidente. 12. Date claim form was provided to employee. Fecha en que se Ie entregô al empleado la peticiôn. 13. Date employer received claim form. Fedia en que el empleado devo!i'ió la peticiôn al empleador. _ Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros 0 agencia adminslradora de seguros. 15. Insurance Policy Number. EI niírnero de la l'óliza de Seguro. 16. Signature of employer representative. Firma del representante del empleador. 17. Title. Titulo. 18. Telephone. Teléfono. Employer: You are required to daic tbis form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the elaim within one working dav of receipt of the form from the employee. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABn~ITY Empleador: Se requiere que Ud.feche estaforma y que provéa copias a su compalïa de seguros. administrador de reclamos, 0 dependienielrepresentanie de reclanws y al empleado que hayan presemado esta peticiôn demro del plaza de un día hábil desde elmomento de haher sido recibida lafomia del empleado. EL FIRMAR ESTA FORMA NO SlGNIFlCi\ ADMTSTON DE RESPONSABlLlDAD o Employer copylcopia dd Emp/mdor o Eniployte copy! Copia del Emplt'ado o Claims Admini:-trator/.4dmil1is/mdOl de Reclaiios 0 Temporary Receipt/Ri.'cibo del Emplcado 6/10 Rev.

7 I ~,.tc ei t.a i exni_..s. comp.cto n ",~"c".llype i possjblo r.', ""0 copias 0: EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS Any person who makes or causes to be made.ny knowingly false 01' fraudulent material staement or material representation for the purpose of obtaining or denying workers compensation benefis or payments Is gul~y of a f.lony. OSHA CASE NO. FATALITY 0 California law requires employers to report within five days of knowledge every occupational injury or illness whicl results in lost time beyond the date of the incident OR requires medicallreatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness. the employer must fie within five days of knowledge an amended report indicaling death. In addition, every serious injury, illness. or death must be reported immediately by telephone or telegraph 10 the nearest office of the California Division of Occupational Safety and Heallh. 1. FIRM NAME ia. Polloy Numb.r Please do not use this column E 2. MAIUNG ADDRESS: (Numb.r, Str..t, City, Zip) M P L 3. LOCATION W din.rent rom Mailing Addr.ss (Fiui6.r, Str..i, City and lip! o ~ 4. NATURE OF BUSINESS; e.g.. P.ainting cqltraelrl wholes:;lagrcxer, sawmil, hotel, etc. R 211. Phone Number 3a. LocatIon Cõde 5. TYPEOFEMPLOY"R: D D DOD D Pnv:i Stole County ily Sohool Di'lr~1 Oler Go"~ Spei/;: (mm/dd/yy) ~ AM PM -6. State unemployment Insuranco aeclno 7, DATE OF INJRY I ONST OF ILLNESS 8. TIME INJURYA~,ILLNESS oecupmrred 9. TIfI EMPLOYEE BEGAN WORK 11o.IF EMPLOYEE DIED, DATE OF DEATH (mmlddlyy) 11: ~~~e.le TO WORK FM ÄhiíãY ön'l 12 DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) _~~~~~ 1 FUll DA YAFT~ OF INJURY?. DYes UNO 14..I._F S..TlLl OFDF WORK, CHECK THIS BOX: 16. PAID FUll DAYS WAGES FOR DATE OF 15. SALARY BEING CONTINUED? 17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 118. DATE EMPLOYEE WAS PROViDED CLAIM FORM ~~~~ig:ki:~?t 0 Yes ONO DYes DNa INJURynllNESS (mmldd/yy) FORM (mm/ddjy) I9.SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS ~.v.ii.ble, e.g.. sëooñddeiree burns on right arm, tendonitis on leltelbow, lead poisoning CASE NUMBER OWNERSHIP INDUSTRY OCCUPATION SEX AGE I ~ 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, Crt, Zip) U R Y 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURREO, e.g. Shipping department, maohineshop. 20a. COUNTY 21. ON EI,'PLOYER'S PREMISES7 DYes DNa DYes DNO l' 3. OtherWorkcrs Injured or II in this event? Z;:'EciuiPMENT;MATÉRIALS AND CHEMICALS THE EMPLOYEE WAS USING WHËÑEVÊr.T OR EXPÓŠURE,:iCCÜRREOÐ,Ãëetylen., weíding lorch, farm tractor, soaffold o R 26. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, '.g.. Welding seams of metal forms, loading boxes onto truok. DAILY HOURS DAYS PER WEEK WEEKLY HOURS I L L ig. HOW INJURynLLNEsS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIREêiü PRõö-ûèËö THE injurylilness;e.g.. Work.r stepped iìi to inspet work N and suppe on serap m;;terial. As he fell, he brushed against fresh weld, and burne right hand. USE SEPARATE SHEET IF NECESSARY E S S WEEKLY WAGE COUNTY 27. Nam~ 8~d add..;;; of physician (numbel"~ sin~et. cii~\... :iip) J 279. Phone Nuinber NATURE OF INJURY IZll.llospitølind as an inpatient o"erni2ht'~ D No Dyes Ify 's then,iiame and address ofhospiial (numbe.., street, cit)'~ zip) Ti8a. lho-;e Niwibl PART OF BODY 29. Emplo)t' Crcatl'd In em('r ciii:y room? ~ IIIYcs ONn ATIENTION 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 --URCE while the information is being used for occupational safety and health purposes. See CCR Tille (b)(6)-10) & (bX2)(E)2. Note: Shtidcd boxes indicnte confidencial employee informacion as listed in CCR Title (b)(2)(E) EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. IlATEOf BIRTH (mmjddly)) EVENT E 33. 1I0ME,\DORESS (Sumber. Sireel, Ciiy,Zip) M P L 34. SEX o D Male D Female Yt= ~ - E 37. EMPLOYEE USUALLY WORKS E _ hours per day, 38. GROSS WAGES/SALARY 33.. PIlO!'E NUMBER 35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers) 36. DATE 01' IIRE (mm/ddiyyl days per week, per total weekty hours 37.. EMPLOYMENT STATUS Dreguiafi fult-tlme Dtemporary Dpar1.tlme Dse.sonai DYes ONe 37b. UNDER WHAtCLASS CODE OF YOUR POUCY WHERE WAGES ASSIGNED 3'. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)? SECONDARY SOURCE -ËXTENT OF INJURY Completed By (type or print) Signature & Title Dale (mm/ddlyyl. Confidenti;ll i"fonn~tion may be disclosed only to the em pi yee, fonner employee, or their personal represenbtive (CCR Title ), to othcrs for the purpose 0' processing ii workers' compensation or other insurance claim; and under certain circumstnces to ii public health or law enforcement agency or to a consultant hired by the employer (CCR True ). CCR TiUe requires provtsion upon request to certin state and federal workplace safety agencies. FORM 5020 (Rev7l June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF liability

8 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.

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