We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.

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1 RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation loss, we want you to have everything that you will need to ensure that if a loss occurs you can get your employee taken care of quickly and that you have access to the people and resources that can provide assistance. Attached you will find the Workers Compensation Reporting Kit which contains the Arizona state-mandated forms, and a step-by-step process to follow in case an employee sustains an injury. For claims handling, we have selected Pinnacle Risk Management as our claims servicing administrator. If you report claims, your claims adjusting team at Pinnacle s Phoenix, Arizona office will make contact with you to get additional information about the injury and your employee and to answer any questions that you might have regarding the Arizona workers compensation process. We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees. The following state forms have been included with your claims kit packet: 1. Arizona Form 101- Employer s Report of Injury- The employee has one year to file a report of injury, while the employer has ten (10) days to report a claim. 2. Arizona Form 407- Workers Report of Injury- The employee can utilize this form to report an injury. 3. Arizona Form 102- Workers and Physician s Report of Injury (obtained in Physicians Office) This can be filed by workers physician or worker him/herself. This form is not included in the claims kit and can be obtained from the workers physician s office. 4. Wage Statement- Please complete and send a copy of employees Wage Statement to Pinnacle Risk Management at the time of injury. 5. Medical Authorization- Please have the injured employee fill out and sign this form and send to Pinnacle Risk Management at the time of an injury. Very truly yours, Tower Group Companies

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 Arizona Form 101- Employer s Report of Injury- and submit the form via one of the following: the completed form to This is the preferred method of reporting an injury. Fax to Pinnacle Risk Management at Call the Pinnacle Risk Management Reporting Hotline at By contacting your broker directly and providing the appropriate first report information. Your claim will be handled by Pinnacle Risk Management: Office Location and Mailing Address: Pinnacle Risk Management 7500 N. Dreamy Draw Suite 135 Phoenix AZ Phone: Fax: IN02 08/08

3 INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE ONLY OF INDUSTRIAL INJURY P.O. BOX PHOENIX, ARIZONA COMPLETE AND MAIL THIS REPORT WITHIN 10 FOR OSHA PURPOSES ONLY DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS. MAIL TO: (CARRIER NAME & ADDRESS) OSHA Case #: Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise our of or in the course of employment. ARIZONA REVISED STATUTES & RECORDABLE INJURY NON-RECORDABLE INJURY EMPLOYEE 1. LAST NAME FIRST M.I. 2. SOCIAL SECURITY NUMBER 3. BIRTH DATE 4. HOME ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 5. TELEPHONE 6. SEX MALE 7. MARITAL STATUS: FEMALE SINGLE MARRIED EMPLOYER 9. POLICY NUMBER 10. NATURE OF BUSINESS (MANUFACTURING, ETC.) DIVORCED WIDOWED 11. OFFICE ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 12. TELEPHONE ACCIDENT 13. DATE OF INJURY OR ILLNESS 14. TIME OF EVENT 15. TIME EMPLOYEE BEGAN WORK 16. DATE EMPLOYER NOTIFIED OF INJURY 17. LAST DAY OF WORK AFTER INJURY 18. DATE OF RETURN TO WORK 19. A.M. P.M. A.M. P.M. 20. CLASS CODE ON PAYROLL REPORT 22. DEPARTMENT NUMBER 23. DID INJURY OCCUR ON EMPLOYER PREMISES? YES NO 24. ADDRESS OR LOCATION OF ACCIDENT CITY COUNTY STATE ZIP CODE 25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specifiexamples: 26. PART OF BODY INJURED 27. FATAL 29. WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM? YES NO 30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT? YES NO 31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON YES NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL IF HOSPITALIZED, HOSPITAL NAME NO 28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH ADDRESS (STREET, CITY, STATE & ZIP CODE) ADDRESS (STREET, CITY, STATE & ZIP CODE) CAUSE OF ACCIDENT 32. WHAT HAPPENED? Tell us how the injury occurred. Examples: 33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: If this question does not apply to the incident, leave it blank. 34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS EMPLO WAGE DATA IMPORTANT 36. WAS WORKER IN YOUR EMPLOY WHEN INJURED? YES NO 43. NUMBER OF MONTHS EMPLOYMENT AVAILABLE DURING THE YEAR IF WORK LOSS IS EXPECTED TO EXCEED SEVEN CALENDAR DAYS, COMPLETE ITEMS 40 THRU HOURS PER DAY EMPLOYEE WORKED 38. WAS EMPLOYEE ON OVERTIME WHEN INJURED? YES NO FROM A.M. P.M. THRU A.M. P.M. HOUR DAY WEEK MONTH 40. DATE OF LAST HIRE 41. WAS WORKER PAID FOR DAY OF INJURY? YES NO IF YES, 39. NUMBER OF DAYS PER WEEK USUALLY WORKED EMPLOYEE COMPANY 42. WAS EMPLOYEE HIRED FOR PERMANENT EMPLOYMENT? YES NO 45. IS EMPLOYEE FURNISHED VALUE PER LODGING BOARD BOTH 46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY (EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7) 47. DOES EMPLOYEE CLAIM DEPENDENTS? YES NO IMPORTANT IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF PAYMENT? PER HOUR 49. NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER WEEK 50. GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY 51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY FROM THRU FROM THRU 52. DATE OF LAST WAGE INCREASE IF WITHIN 12 MONTHS PRIOR TO INJURY 53. WAGE BEFORE INCREASE 54. WAGE AFTER INCREASE 55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY AUTHORIZED SIGNATURE DATE AUTHORIZED SIGNATURE TITLE NOTE TO EMPLOYER: 1. Mail one copy to the Industrial Commission within 10 days. 2. Mail one copy to your insurance carrier within 10 days. 3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. Form ICA (Rev. 7/01) THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

4 WORKER S REPORT OF INJURY MAIL TO: Industrial Commission of Arizona, P.O. Box 19070, Phoenix, AZ Copies of the Arizona Workers Compensation Laws and Arizona Workers Compensation Practice and Procedure and information about the Industrial Commission of Arizona claims and hearing process are available at the Industrial Commission offices and through the ICA web-site located at: ANSWER ALL QUESTIONS FULLY (Use the back of this form to indicate any further information.) 1. NAME OF INJURED WORKER: LAST FIRST M.I. SOCIAL SECURITY # *: BIRTH DATE: PHONE #: ( ) 2. ADDRESS: CITY STATE ZIP CODE 3. MARITAL STATUS: SINGLE MARRIED DIVORCED DEPENDENTS AT TIME OF INJURY: YES NO 4. EMPLOYER S FULL NAME: PHONE #: 5. ADDRESS: CITY STATE ZIP CODE 6. DATE HIRED: WHERE HIRED: OCCUPATION: 7. HOURS WORKED PER DAY: PER WEEK: HOURLY WAGE: 8. DID YOU RECEIVE FOOD OR LODGING IN ADDITION TO WAGE? YES NO 9. DATE OF INJURY (MO/DAY/YEAR): TIME OF INJURY: AM PM 10. ADDRESS OR LOCATION OF ACCIDENT: 11. DID YOU STOP WORK IMMEDIATELY? WHEN DID YOU STOP? 12. WHEN DID YOU REPORT THE INJURY? TO WHOM? TITLE: 13. WHEN DID YOU RETURN TO WORK? REGULAR WORK OTHER WORK 14. NAMES OF PERSONS WHO SAW THE ACCIDENT. 1. NAME: ADDRESS: PHONE #: 2. NAME: ADDRESS: PHONE #: 15. WAS ACCIDENT CAUSED BY ANOTHER PERSON? IF SO, BY WHOM? 16. NAME OF MACHINE OR TOOL WHICH MAY HAVE CAUSED THE ACCIDENT: 17. STATE HOW ACCIDENT HAPPENED: 18. BODY PART INJURED: DESCRIBE THE INJURY (CUT, BRUISE, ETC.): 19. WHERE WERE YOU FIRST TREATED: NAME: ADDRESS: 20. WHO TREATED YOU FOR THIS INJURY: NAME: ADDRESS: 21. OTHER THAN THIS INJURY, HAVE YOU LOST TIME FROM WORK DUE TO AN ACCIDENT IN THE PAST 12 MONTHS? YES NO NAME OF STATE WHERE ACCIDENT HAPPENED: WORK INJURY: YES NO 22. OTHER THAN THIS INJURY, HAVE YOU EVER RECEIVED ANY PERMANENT DISABLING INJURY? YES NO DATE OF INJURY: WORK INJURY: YES NO NAME OF STATE WHERE ACCIDENT HAPPENED: 23. OTHER THAN THIS INJURY, ARE YOU RECEIVING COMPENSATION FOR ANY DISABLING CONDITIONS? YES NO IF SO, FROM WHOM? AMOUNT? WHY? I make application for all benefits to which I may be entitled under the law. I certify, with full knowledge that it is a crime to make willful, false statements to obtain compensation and that all of my statements on this form are true, accurate and complete. Signature of injured worker or injured worker s authorized representative is REQUIRED. Date The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission s forms, prescribed under the Commission s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT CLAIMS AT ( ). ICA REV 5/02

5 W AGE S TATEMENT Employer: Employee: Please provide the 52 weeks of wages prior to the date of injury of Date employee ceased to work: Number of Hours employee is scheduled to work per week: Is employee paid by hour, day, week or month Date Hired Claim Number At what rate: Does Employee work Overtime Yes No If yes, is Overtime mandatory Yes No State the date and amount of any pay increases during the past 52 weeks Date Amount Date Amount Date Amount Date Amount Dates Incl of each Week Pd Hrs Wkd Regular Overtime Dates Incl of each Week Pd From To Yr From To Yr Hrs Wkd Regular Overtime SUBTOTAL SUBTOTAL GRAND TOTAL This is a correct statement of Employee s earnings as actually taken from roll Records Employer s Signature Title Date

6 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

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