2 CLAIMS REPORTING GUIDE TABLE OF CONTENTS INTRODUCTION LMC CLAIM STAFF DIRECTORY CLAIM REPORTING INSTRUCTIONS WORKERS COMPENSATION WHAT TO DO IN THE EVENT OF A WORKERS COMP LOSS BEST PRACTICES BEFORE A WORKERS COMPENSATION LOSS BEST PRACTICES AFTER A WORKERS COMPENSATION LOSS SAMPLE INJURY MANAGEMENT PROGRAM PROPERTY WHAT TO DO IN THE EVENT OF A PROPERTY LOSS PROPERTY LOSS REPORTING FORM AUTOMOBILE WHAT TO DO IN THE EVENT OF A CLAIM AUTOMOBILE ACCIDENT CLAIM REPORTING FORM AUTO ACCIDENT DIAGRAM DRIVER S STATEMENT FORM LIABILITY WHAT TO DO IN THE EVENT OF A CLAIM LIABILITY WORKSHEET WITNESS STATEMENT D&O EPLI WHAT TO DO IN THE EVENT OF A CLAIM WHAT TO DO IN THE EVENT OF A CLAIM FIDUCIARY WHAT TO DO IN THE EVENT OF A CLAIM CRIME WHAT TO DO IN THE EVENT OF A LOSS GLOSSARY OF CLAIM TECHNOLOGY
3 INTRODUCTION Welcome to LMC Risk Management Services. Our claim department team is comprised of trained professionals ready to assist you in the event of a property, general liability, automobile loss or injury to an employee. This handbook is custom designed for our customers as a reference guide for reporting claims. Included is information to help you in gathering key information on various types of claims associated with your business operations. To help expedite the claims reporting process, each section of this handbook contains forms that can be used to collect loss information. We are committed to providing excellent claims service and invite you to call us if there is a question about how to handle a claim situation. Updates will be forwarded to you should any of the information included in this book change.
4 LMC CLAIMS DEPARTMENT STAFF DIRECTORY PHONE (515) OR (800) FAX (515) Kay Dilks, AIS P&C Claims Specialist (515) Jess Baker, AINS, AIS WC Claim Consultant (515) Markie Lamer, AIC, SCLA Claim Department Manager (515)
5 CLAIM REPORTING INSTRUCTIONS WORKERS COMPENSATION All Workers Compensation claims are to be reported directly to Policy Number: Your LMC WC Claim Consul tant is: Phone: or direct Fax: All other claims are to be reported to your LMC Claims Specialist: Kay Dilks, AIS, Claims Specialist Phone: or direct Fax:
6 WHAT TO DO IN THE EVENT OF A WC CLAIM WORKERS COMPENSATION If you are at the scene of the accident when it happens, administer first aid as needed and seek emergency medical assistance for the injured person(s), if necessary. For non-emergency cases, refer the employee to the designated treating physician if your state allows the employer to direct medical care. All work-related accidents must be investigated as soon after the occurrence as possible. Employees should be instructed to report all work-related injuries to their supervisors or the designated claims coordinator immediately. Complete an accident investigation using the form provided in this packet. Submit a state first report of injury form or call the claim in to the workers comp insurance carrier. The claim will be assigned to an adjuster who may call you and begin with adjustment of the claim. Most states have deadlines for reporting lost time injuries so it s important to avoid delay. OSHA requires reporting for work-related incidents resulting in the death of an employee or in-patient hospitalization of three or more employees. The employer must report such incidents in person or by phone within 8 hours of the incident. The OSHA toll-free telephone number is After the injured worker has seen a doctor, they should provide you with a return to work slip indicating work restrictions in terms of lifting maximums, bending limitations or hours on the job in a given day. It is usually in your best interest to provide modified work until the employee is released to full duty. If the employee is physically unable to return to work, they should have something in writing from the doctor verifying this. Submit all medical bills related to the accident, to the insurance carrier as soon as you receive them. The carrier will adjust the price based on usual and customary or the state fee schedule. If you have any problem with the adjustment of the claim or payments being made, call LaMair- Mulock-Condon Co. (800)
7 BEST PRACTICES BEFORE A WORKERS COMPENSATION LOSS 1. COMMITMENT Make a commitment company-wide to implement Best Practices to promote the health and safety of each employee while reducing the costs associated with workplace injury. 2. HIRING PRACTICES Have formal hiring practices in place. Perform reviews of all jobs and establish the basic requirements of each job to assist in selecting the best candidate. Consider utilizing post offer pre hire testing to test new hires on their ability to meet these requirements. 3. ACCOUNTABILITY - Establish accountability throughout the management chain so the entire organization has an external incentive to act with safety as a priority. Make Safety an element of all employees performance reviews. Over a period of time, external incentives become part of the culture and become internal incentives. 4. FORMAL SAFETY COMMITTEE Create a Formal Safety Committee made up of a diverse group of employees including Senior Management, Safety/HR/Operations, line employees and supervisors. The Committee is most effective when it has real authority to effect change. Some examples of areas the Safety Committee can implement/monitor: a. Safety Orientation program for new hires b. Annual safety training calendar including training priorities c. Accident Investigation (including near-miss investigations) d. Safety Audits e. Recommendations made and implemented to improve safety f. Loss Reviews with agent/insurer as needed g. Monitor and review repeat violators h. Return to Work Program i. Drug Testing Program 5. LIGHT DUTY JOB REVIEWS Perform reviews on all job tasks and identify jobs in each department that would qualify for light duty. Identifying light duty jobs prior to needing them will decrease the amount of lost time away from work. 6. APPROPRIATE MEDICAL CARE Identify a health clinic that specializes in occupational medicine and channel care as possible. Communicate this choice to supervisors and employees so they know where to go in the event of an injury. The emergency room should only be used for true emergencies. 7. CULTURE OF WELLNESS Establish a formal Wellness program, which will make a difference in Workers Comp costs over the long run. Studies are showing an increased correlation between healthy employees and improved Workers Compensation results.
8 BEST PRACTICES AFTER A WORKERS COMPENSATION LOSS 1. IMMEDIATE NOTICE Report claims within 24 hours of the injury. Require employees to report incidents within that timeframe and report them to your insurer immediately even if for Notice Only on medical only claims. Statistics overwhelmingly confirm that claim costs are reduced if this step is followed. 2. APPROPRIATE MEDICAL CARE - Utilize the established medical provider whenever possible. 3. DOCUMENT THE INJURY Require the employee to provide a detailed, written account of how the incident occurred, then have them sign and date it. Also, have any eye-witnesses provide their own written accounts of the accident. 4. DRUG/ALCOHOL TEST AT TIME OF INJURY Include a statement in your employee handbook requiring drug testing at a certified hospital/clinic at the time of injury. A formal, written program should be in place. 5. RETURN TO WORK PROGRAM Bring employees back to work in whatever capacity they are able within their restrictions. Employees feel valued if they are needed back at work in any capacity. Light duty work also reinforces good attendance, strong work habits, and decreases lost time benefits. 6. RETRAINING Prevent a recurrence of injuries by retraining employees on the correct way to perform tasks. Use the information developed by the Formal Safety Committee. 7. COMMUNICATION 3 Points of Contact Communicate with the injured employee. Stay in touch if they are NOT on light duty. Have them come to work if at all possible. Communicate with the Medical Providers to make sure they understand the job requirements and light duty s available. Follow up with to ensure that the appointments are kept. Communicate with the insurance carrier regularly. Difficult injuries and claims have long return to work curves so its important to stay involved in the process. Involve your claim staff at LMC at any time for assistance or with questions.
9 INJURY MANAGEMENT A post injury procedure designed to ensure quality medical care, contain medical costs, reduce opportunities for litigation and return injured employees back to work in the earliest possible time. Prepared By: LaMair-Mulock-Condon Co. Des Moines, IA
10 INJURY MANAGEMENT Page 1 A. INTRODUCTION An injury management program is a post injury procedure designed to ensure quality medical care, contain medical costs, reduce opportunities for litigation and return injured employees back to work in the earliest possible time. B. MANAGEMENT'S ROLE The cost of Workers' Compensation insurance to our company will be contained. Rather than accepting injury related expenses as a fixed cost of doing business, we will be proactive in this program and focus our resources on: Educating our employees Loss reporting Utilization of medical providers Return to work (RTW) Documentation The success of this program is dependent on a strong partnership between our management staff, employees, medical care providers and our insurance company. C. IMPLEMENTATION Educating Our Employers Fear and uncertainty are primary reasons for injured employees to delay reporting injuries and to seek assistance from attorneys. This may be due to concern over medical bills, lost income or even the loss of employment. We will take whatever action is necessary to alleviate these fears, specifically: - All employees will be provided with an explanation of the Workers' Compensation system and benefits it will provide. - The work force will be instructed in accident reporting procedures. - We will direct injured employees to our selected medical care providers where state law permits. - Company directed/recommended providers will have their names, telephone numbers and addresses posted on bulletin boards. - Workers will be educated on our return-to-work program.
11 INJURY MANAGEMENT Page 2 Loss Reporting - We will establish procedures which will give all employees the responsibility and incentive to report all accidents and near-miss incidents to their supervisor immediately. - The state required First Report of Injury will be prepared and reported to the insurance company within 24 hours by fax or by telephone. Follow state requirement for distribution of hard copies. Utilization of Medical Providers The selection of physicians, clinics or hospitals is an important injury management decision. We will either directly or indirectly manage the medical care provided to our injured employees to the maximum extent permitted by our state's Workers' Compensation regulations. - We will use Preferred Provider Organizations (PPO) if available to us. - Chosen medical facilities must provide quality care, effective service and pricing to fit our needs. - Whenever possible, we will encourage physicians treating our employees to visit the company to observe our operations to better understand the way we conduct our business. Return to Work (RTW) To effectively manage the costs incurred as a result of work related injuries, the following eight point plan will be closely followed and monitored: 1. Ensure that initial treatment is provided. Immediately following an injury, provide necessary first aid and send the employee to a medical provider as required. Document all details including the date and time of the injury, the type of first aid provided and the name of the physician, clinic or hospital where the employee received treatment. 2. Notify Claims. Contact our carrier's claim office following an injury. 3. Provide the job function evaluation form to the treating physician. (refer to Exhibit A). This information should include: A description of the employee's current job, with details on postures (standing, sitting, walking) and physical demands (lifting-weight and frequency, hours worked, tool usage, etc.)
12 INJURY MANAGEMENT Page 3 A copy of the injury report describing how the injury occurred if available. A statement of our company's position on returning injured employees to work. 4. Attending physician's report (refer to Exhibit B). It is critical to obtain the treating physician's response to any work restrictions our injured worker may have. If the doctor has the job function evaluation as a guide, an informed response should be obtainable. 5. Contact the employee. Employee contact should be made in person or by phone within 24 hours of their initial medical treatment/review. Reassure the employee of our company's commitment to their well-being. Assess the employee's understanding of the treatment he or she received. Ask if the employee has any specific questions about future plans, treatment, etc. 6. Follow up with the physician. Within 24 hours of initial treatment obtain details regarding recommended additional treatment, return-to-work expectations and specific job restrictions. Discuss a specific timetable for the employee's return to work. 7. Maintain contact with the employee, physician and the claims handler. During the employee's absence from work, we will continue to monitor progress: Contact the employee at least once every week to inquire about their recovery and express our concern for their return to good health. Contact the physician periodically to discuss recovery progress and any changes in the timetable for the employee's return to work. Keep our carrier's claim handler informed about the employee's return to work status. 8. Establish an injury management record. (Refer to the Injury Management Checklist File Exhibit C.) For each case involving lost time and/or follow up medical treatment, establish an injury management record. At a minimum, this record should include: A copy of the injury report Documentation of initial treatment Copies of medical bills
13 INJURY MANAGEMENT Page 4 A log of all phone conversations with the employee, physician and claim representative Progress reports from the physician All activities regarding treatment and recovery should be logged and documented whenever possible. Explain any progress toward return to work and discuss this with our claim representative and the physician or other parties involved. Indicate the date the employee returned to work and in what capacity (full duty, part-time, limited physical activity, etc.)
14 EXHIBIT A Page 5 JOB FUNCTION EVALUATION EMPLOYEE NAME DATE COMPANY DEPARTMENT JOB TITLE I. EMPLOYEE'S JOB FUNCTION (provide a basic description of the job duties) CHECK ONE: CURRENT JOB [ ] ALTERNATIVE JOB [ ] II. WORK LOCATION Indoors [ ] Heated [ ] Yes Personal protective [ ] Yes Outside [ ] [ ] No Equipment required [ ] No Below Ground [ ] Elevated areas [ ] Temp. extremes [ ] Yes [ ] No Describe III. IV. WORK POSTURES Work is performed in which posture? Indicate frequency. Standing [ ] Continuous [ ] Frequent [ ] Infrequent [ ] Sitting [ ] Continuous [ ] Frequent [ ] Infrequent [ ] Walking [ ] Continuous [ ] Frequent [ ] Infrequent [ ] Climbing [ ] Continuous [ ] Frequent [ ] Infrequent [ ] Kneeling [ ] Continuous [ ] Frequent [ ] Infrequent [ ] 6-8 Hrs./Day 2-6 Hrs./Day 0-2 Hrs./Day PHYSICAL DEMANDS LIFTING Describe materials Weight of materials How frequently lifted Position of lift CARRYING Describe materials Weight Distance carried TOOL USAGE Describe or list tools Forceful grip required? [ ] Yes [ ] No Frequency of usage WORK HOURS Number and length of breaks or rest periods MISC. Indicate any other special or unusual job demands
15 EXHIBIT B Page 6 ATTENDING PHYSICIAN'S REPORT Employer Patient's Name Claim # SSN Dear Doctor: Please provide the following information related to this injury/illness. This will assist us in returning our employee to work. Our company has an extensive and comprehensive Return to Work program for the injured/ill employee. 1. Employee may return to normal work duties at once. 2. Employee may return with the following restrictions: Hours/Day: No restrictions 8 hours 6 hours 4 hours other Days/Week: No restrictions 5 days 4 days 3 days other Lifting: No restrictions 40 lbs. 30 lbs. 20 lbs. 10 lbs. other. Movement: No restrictions limited stooping limited bending limited overhead reaching other Other (please specify): days, OR employee will be re- Length of restrictions: Resume regular duties after evaluated on (date). 3. The employee is totally incapacitated at this time. Employee will be re-evaluated on (date). 4. Notice to physician and employee: This report must be returned to Employee's Employer and the Insurance Claims Department within 24 hours of this office visit. I saw the patient on: (date) and have made the following diagnosis: DX: 5. Comments: Physician's signature Date
16 INJURY MANAGEMENT CHECKLIST FILE Page 7 A. INTRODUCTION A medical case file (see Injury Management Checklist) should be maintained on every employee injury requiring medical treatment due to a workplace accident. These medical files should be separated from standard employee files and secured apart from all other file information being maintained on the injured employee. B. MEDICAL FILE CONTENTS All documentation concerning the treatment of an employee injury should be maintained in this file. This includes a copy of the Employer's First Report of Injury, copy of the Employee's First Report of Injury (if required by the state), medical bills received, medical bills paid, and correspondence to and from all parties involved until the injured worker returns to full gainful employment without medical restrictions. C. PURPOSE There are several good business reasons to maintain a medical case management file. These include: The securing of data necessary to manage the claim. Providing a checklist for the company representative managing the case which documents actions taken to protect the rights of the company and the injured employee. Provides for a monitoring system to keep company management current on the status of the injured employee and progress being made on getting that individual back into the normal workflow. D. MAINTENANCE INSTRUCTIONS As soon as management becomes aware of an employee accident, report it to our insurance carrier's claims office by telephone or FAX. Follow the activity instructions including the date and time the activities are complete as shown on Exhibit C1. The monitor (Exhibit C2) should be used as a day-to-day diary of all activity taking place in managing the claims process.
17 EXHIBIT C1 Page 8 INJURY MANAGEMENT CHECKLIST WHEN AN EMPLOYEE HAS REPORTED AN INJURY OR ILLNESS WHICH REQUIRES MEDICAL ATTENTION, THE FOLLOWING ACTIONS SHOULD BE TAKEN: ACTIVITY DATE/TIME INITIAL MEDICAL TREATMENT PROVIDED BY: Name of physician Phone NOTIFY CLAIMS: Phone Fax PROVIDE INFORMATION TO THE PHYSICIAN: Duties/tasks of injured employee Accommodations for return to work CALL THE EMPLOYEE WITHIN 24 HOURS: Phone Ask about treatment received FOLLOW-UP WITH PHYSICIAN WITHIN 24 HOURS: Discuss employee's job duties and options for accommodating his/her restrictions Circumstances of injury occurrence Express committment to care and recovery Ask about special needs/concerns Discuss timetable for employee's return to work AFTER TAKING THE INITIAL ACTIONS LISTED ABOVE, THE FOLLOWING ACTIVITIES SHOULD BE COMPLETED REGULARLY AND DOCUMENTED ON THE INSIDE FRONT COVERAGE OF THIS RECORD: While the employee remains away from work, continue to monitor progress with the employee and physician at least every two weeks. Keep your claim handler informed regarding initial treatment and subsequent progress toward return to work.
18 EXHIBIT C2 Page 9 MONITOR DATE ACTIVITY RESULTS
19 WHAT TO DO IN THE EVENT OF A PROPERTY CLAIM BUILDING OR BUSINESS PERSONAL PROPERTY DAMAGE Damage to property you own must be reported under the Building and Business Personal Property coverage. Fire, wind, hail and theft are typical property damage claims. These claims may also include business interruption and extra expense losses if this coverage is also included in your policy. If you discover a fire in progress at your business that cannot be contained by using a fire extinguisher, call for help immediately. Use 911 service if available. Never risk any person s safety, including yours, to save your property from damage. All theft losses must be reported to the police. Once the danger has passed, you must protect the property from further damage. Proceed with reasonable temporary repairs and move personal property as needed. For example, if the wind blows a hole in the roof and it is raining, call a contractor to cover the hole with plywood or tarps and move any contents away from water that may be dripping into the building. Keep good documentation on all expenses incurred. You will eventually need to get at least one contractor s bid for building repairs and you will need to provide an inventory of damaged business personal property, if any. Report the loss to L-M-C as soon as possible. We will make sure the insurance carrier assigns an adjuster right away. We will review your property coverage and advise you on how to proceed with the claim. (800)
20 WORKSHEET FOR PROPERTY TELEPHONE REPORTING ACCOUNT INFORMATION CALLER S PHONE NUMBER & EXTENSION CALLER S TITLE AND NAME LOSS STATE (STATE WHERE LOSS OCCURRED) SUBSIDIARY NAME AND ADDRESS SUBSIDIARY MAILING ADDRESS (IF DIFFERENT FROM ABOVE) DID THE LOSS OCCUR AT THE LOCATION ADDRESS? (IF NO, ADDRESS WHERE LOSS OCCURRED) YES NO PARENT COMPANY/INSURED S NAME LOCATION CODE POLICY SYMBOL AND NUMBER LOSS INFORMATION DATE AND TIME OF LOSS FULL DESCRIPTION OF LOSS (INCLUDE SPECIFICS OF WHERE IT OCCURRED, SUCH AS A WAREHOUSE, STOCKROOM, DEPARTMENT) DID THE LOSS INVOLVE: BUILDING (REAL PROPERTY) DAMAGE? IF YES, DESCRIPTION OF DAMAGE TO BUILDING IS ANY INTERIOR SECTION OF THE BUILDING NOW EXPOSED TO THE OUTDOORS AND UNPROTECTED? CAN THE BUILDING BE OCCUPIED? DO YOU HAVE A WRITTEN ESTIMATE OR REPAIR BILL FOR BUILDING? IF YES, AMOUNT CONTENTS (PERSONAL PROPERTY) DAMAGE? IF YES, DESCRIPTION OF DAMAGE TO CONTENTS DO YOU HAVE A WRITTEN ESTIMATE OR REPAIR BILL FOR BUILDING? IF YES, AMOUNT ONLY GLASS OR SIGN DAMAGE? BUSINESS INTERRUPTION? WITNESSES (NAMES, ADDRESSES, AND PHONE NUMBERS) AUTHORITIES (NAME, REPORT/CASE NUMBER, COUNTY, ANY VIOLATIONS/CITATIONS) CONTACT INFORMATION CONTACT NAME AND PHONE NUMBER, BEST TIME TO CONTACT AND WHERE TO CONTACT ADDITIONAL NOTES/COMMENTS OR CUSTOMER SPECIFIC INFORMATION C Rev. 9-99
21 WHAT TO DO IN THE EVENT OF AN AUTO CLAIM AUTOMOBILE All auto accidents must be investigated. Vehicle accidents may occur with company owned vehicles or with non-owned vehicles. If an employee owns the vehicle involved, and the accident happens while the employee is on company business, a complete investigation must still be conducted. Always respond IMMEDIATELY to all notices of claims. Employees should be instructed to report all accidents to their immediate supervisor and/or to the company claims coordinator. Never admit fault until after a complete investigation has been completed. Simply tell the person making the claim that you need to discuss the situation with your Risk Manager and that someone will be contacting them soon. If you are at the scene of the accident when it happens, administer first aid as needed and seek professional medical assistance for the injured person(s), if necessary. Call local law enforcement and have them investigate when necessary. Always do this if bodily injury has occurred. Get the names of investigating officials, such as police, fire department and other state officials. Get the names of doctors or repair contractors the claimant is using. Record the name, address and phone number of all who are involved in the accident. (Driver, owner, driver s employer, passengers) Include names of all witnesses. Record exact date, time and place of the accident. Record description of the other vehicle(s) and their plate number(s). Get a description of the injury or property damage. Make note of environmental conditions such as weather, temperature, wind, sun, etc. Take photos of the property damage and of the section of road or street where the accident occurred, as soon as possible. Notify LAMAIR-MULOCK-CONDON COMPANY IMMEDIATELY after gathering the initial information. (800)
26 WHAT TO DO IN THE EVENT OF A LIABILITY CLAIM GENERAL LIABILITY Two common types of general liability claims that occur are premises liability and products/completed operations liability claims. Premises liability claims are generated when a customer is injured while doing business in your buildings or on your property. Examples of premises liability claims are as follows: a customer slips and falls on slick walking surfaces, a customer trips on something and falls, something falls on the customer or their property. Always respond IMMEDIATELY to all notices of claims. Employees should be instructed to report all accidents to their immediate supervisor and/or to the company claims coordinator. Never admit fault until after a complete investigation has been completed. Simply tell the person making the claim that you need to discuss the situation with your Risk Manager and that someone will be contacting them soon. If you are at the scene of the accident when it happens, administer first aid as needed and seek professional medical assistance for the injured person(s), if necessary. Get name, address and phone number of all who are involved in the accident. Include names of all witnesses. Get the names of doctors or repair contractors the claimant is using. Record exact date, time and place of the accident. Take photos of the area where the accident occurred. Focus attention on walking surfaces or other items that allegedly caused the accident. Photograph any damaged property and record a detailed description of the property. Products liability/completed operation claims are generated when a consumer claims injury or property damage as a result of a defect in a product manufactured, packaged, distributed or sold by your company. In addition to the above suggestions, you should also do the following: Verify and record the name of the product, proof of purchase, sample of actual product, product label with directions for use and written warnings. Get a copy of the original invoice. Preserve the evidence by labeling and storing the product in question, taking photos and getting serial numbers. Never discard or destroy evidence until you receive permission in writing from your insurance carrier or from your lawyer. Find out how the product was being used. Were there other things that may have contributed to the accident? Get a description of the injury or property damage. Make note of environmental conditions such as weather, temperature, wind, etc. Get the names of investigating officials, such as police, fire department and other state officials. Get the names of doctors or repair contractors the claimant is using. Notify LAMAIR-MULOCK-CONDON COMPANY IMMEDIATELY after gathering the initial information. (800)
27 WORKSHEET FOR GENERAL LIABILITY TELEPHONE REPORTING ACCOUNT INFORMATION CALLER S PHONE NUMBER & EXTENSION CALLER S TITLE AND NAME ACCIDENT STATE (STATE WHERE ACCIDENT OCCURRED) SUBSIDIARY NAME AND ADDRESS SUBSIDIARY MAILING ADDRESS (IF DIFFERENT FROM ABOVE) DID THE LOSS OCCUR AT THE LOCATION ADDRESS? (IF NO, ADDRESS WHERE LOSS OCCURRED) YES NO DATE AND TIME OF LOSS FULL DESCRIPTION OF LOSS PARENT COMPANY/INSURED S NAME LOCATION CODE POLICY SYMBOL AND NUMBER INJURIES WERE THERE ANY INJURIES? IF YES BE PREPARED TO PROVIDE THE FOLLOWING INFORMATION FOR EACH INJURED PERSON: NAME BUSINESS AND HOME PHONE NUMBERS ADDRESS DATE OF BIRTH GENDER DESCRIPTION OF INJURY MEDICAL FACILITY (IF TREATMENT RECEIVED) ATTORNEY INFORMATION (IF REPRESENTED) PROPERTY DAMAGE IS THERE DAMAGE TO THE PROPERTY OF OTHERS? IF YES, DID THE LOSS INVOLVE: BUSINESS DAMAGE? IF YES, PROVIDE THE FOLLOWING INFORMATION: NAME BUSINESS AND HOME PHONE NUMBERS ADDRESS DESCRIPTION OF DAMAGED PROPERTY IS THE INTERIOR OF BUILDING NOW EXPOSED TO OUTDOORS AND UNPROTECTED? CAN THE BUILDING BE OCCUPIED? IS THERE A WRITTEN ESTIMATE OR REPLACEMENT/BILL FOR THE DAMAGE? IF YES, AMOUNT ATTORNEY INFORMATION (IF REPRESENTED) C Rev. 9-99
28 PROPERTY DAMAGE (CONTINUED) IS THERE DAMAGE TO THE PROPERTY OF OTHERS? IF YES, DID THE LOSS INVOLVE: OTHER/CONTENTS DAMAGE? IF YES, PROVIDE THE FOLLOWING INFORMATION: NAME BUSINESS AND/OR HOME PHONE NUMBERS ADDRESS DESCRIPTION OF DAMAGED PROPERTY LOCATION OF DAMAGED PROPERTY INCLUDING ADDRESS IS A WRITTEN ESTIMATE OR REPAIR/REPLACEMENT BILL FOR THE DAMAGE AVAILABLE? IF YES, AMOUNT ATTORNEY INFORMATION (IF REPRESENTED) WITNESSES (NAMES, ADDRESSES, AND PHONE NUMBERS) CONTACT INFORMATION CONTACT NAME AND PHONE NUMBER, BEST TIME TO CONTACT AND WHERE TO CONTACT ADDITIONAL NOTES/COMMENTS OR CUSTOMER SPECIFIC INFORMATION C (Back)
30 WHAT TO DO IN THE EVENT OF A D&O CLAIM DIRECTORS & OFFICERS The Directors and Officers (D&O) policy provides liability coverage for directors and officers of the corporation for wrongful acts which includes but is not limited to breach of duty, neglect, error, misstatement, misleading statement, omission or other act done or wrongfully attempted by the directors or officers. The corporation itself may also be covered if the option for entity coverage was chosen. This policy provides claims made coverage and applies only to claims first made during the policy period or any extended reporting period. A claim is defined as any written notice of intent to hold any director or officer responsible for a wrongful act. Written notice may include but is not limited to letters from attorneys or civil lawsuit. It is important that the claim be reported before any defense costs are incurred, as these costs will reduce the limit of liability and will also be applied against the deductible or retention. Failure to notify the carrier will result in a denial of coverage for fees already incurred.
Employer s Handbook Workers Compensation Workers Compensation 101 Table of Contents Contact Information. 3 What is Workers Compensation?... 4-5 What is your role?... 6-7 Workers Compensation Benefits 8-9
rightlawyers.com RIGHT Lawyers Right Lawyers has successfully represented numerous clients in the areas of car accidents, work injuries, and slip and falls. The goal of this guide is to provide you answers
DELAWARE COUNTY Subject Self- Program Effective June 28, 2004 Supersedes June 15, 1988, March 22, 1999 This Sheet 1 Total 5 Purpose To provide a written document explaining the Self- Program, preferred
Quick Guide to Workers Compensation What Is Workers Compensation Insurance? Workers compensation insurance covers businesses for their statutory and legal obligations for employee expenses that are a direct
Pillar Income Asset Management, Inc. Incident Reporting Manual For use in reporting: Property Losses General Liability Incidents Workers Compensation Incidents Commercial Auto Incidents Prepared by: The
Session 1B: Insurance, What you do not know can hurt you! Notes: June 10, 2015 Session 1B page 1 Session 1B: Insurance, What you do not know can hurt you! Notes: June 10, 2015 Session 1B page 2 June 10,
BUSINESS INSURANCE FAQ Q: What is Business Insurance? A: We strive to understand your risk tolerance and financial ability to withstand the spectrum of potential losses and develop insurance programs to
Insurance basics for nonprofit organizations Updated: July 2012 This document is intended as general and abbreviated guidance for nonprofit organizations. Because every organization s insurance needs are
WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured? 3. How can I get help? 4. What information should I gather at the
A Stock Insurance Company, herein called the Company PUBLIC ENTITY POLICY LAW ENFORCEMENT LIABILITY COVERAGE FORM OCCURRENCE COVERAGE Various provisions in this policy restrict coverage. Please read the
Understanding the Claims Handling Process About This Brochure This brochure was designed to answer frequently asked questions about the claim handling process. If you have other questions or would like
February 15, 2016 Professional Practice 544 Tort Law and Insurance Michael J. Hanahan Schiff Hardin LLP 233 S. Wacker, Ste. 6600 Chicago, IL 60606 312-258-5701 email@example.com Schiff Hardin LLP.
19. Injury, Accident, and Loss Reporting Overview This section discusses the following topics: Where to Report Claims Reporting Workers Compensation Illnesses and Injuries Reporting Automobile Accidents
EL PASO COUNTY DEPARTMENT OF HUMAN RESOURCES Workers Compensation Policy and Procedure Revised Date: March 21, 2016 I. Purpose The County of El Paso provides workers compensation benefits for incidental
UNDERSTANDING YOUR PROPERTY DAMAGE CLAIM A LET US EMPOWER YOU This brochure will empower you with the knowledge and tools necessary to complete your own property damage claim. One of the biggest inconveniences
Volunteer Return to Work Volunteer Modified Duty Handbook Workers Compensation Fund toll-free: 1.800.446.2667 web: www.wcfgroup.com Although preventing injuries is the best way to control workers compensation
T H E S TAT E B A R O F C A L I F O R N I A WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? GET THE L E G A L F A C T S O F L I F E What should I do if I have an 1 a u t o a c c i d e n t? If I have an auto
Page 1 of 5 Approved By: Cabinet Effective Date: January 2, 2013 Category: Contact: Human Resources Assistant Vice President for Human Resources (585) 245-5516 I. PURPOSE This document outlines the policies
Information for Worker s Compensation Clients Overview of the Worker s Compensation Act Indiana Worker s Compensation cases are governed by a State law known as the Worker s Compensation Act. The legislature
Premiums paid here, stay here to keep Wisconsin strong. Controlling WWWWoer Workers Compensation Claims Presented By: Sheila K. McGraw Director of Claims To The: Wisconsin Towns Associations Annual Convention
July 2003 Workers Compensation Program Review and Approval Authority Prepared and Edited by: Assistant Director Date UM Workers Compensation Manager Date Reviewed and Approved by: Chair - UM E, H & S Operations
SPECIAL REPORT TRAIN INJURY CASE Protect Your Rights: 7 Mistakes That Can Derail Your Train Injury Case If you are employed in the train industry, you should be aware of what to do should you become injured
INDEMNIFICATION AND INSURANCE REQUIREMENTS FOR LOS ANGELES COUNTY SERVICE AGREEMENTS Include Section I and Section II.(A. - F.) in all County service agreements. I. Indemnification: Contractor shall indemnify,
Nebraska Workers Compensation Court Information Sheet: Rights & Obligations under the Nebraska Workers Compensation Law NEBRASKA WORKERS COMPENSATION COURT OFFICIAL SEAL What is workers compensation? Workers
SMALL COMMERCIAL INSURANCE Copyright 2015 by The Hartford. All rights reserved. No part of this document may be reproduced, published or posted without the permission of The Hartford. Agenda 1. The Basics:
INSURANCE (A) GENERAL CONSIDERATIONS This document presents the minimum insurance requirements as set forth by the United States Trustee Program (USTP). A standing trustee must purchase property insurance
What to Do When an Accident Occurs - Work Comp Procedures Immediate Response Non-emergency Respond with onsite first aid/cpr responders. Employee must select a physician from the Panel of Physicians form
EXHIBIT "B" CRITERIA AND BILLING FOR EXTRA SERVICES The following Extra Services to the Agreement shall be performed by Architect if needed and if authorized or requested by the District: 1. Making revisions
FOSTER PARENT LIABILITY PROGRAM I. THE PROGRAM The following provisions set forth the exclusive terms and conditions of the State of New Jersey's Foster Parent Liability Program (hereinafter referred to
INJURED ON THE JOB? A SUMMARY OF THE RIGHTS AND BENEFITS AVAILABLE TO INJURED WORKERS UNDER ILLINOIS LAW Law Offices ANESI, OZMON, RODIN, NOVAK & KOHEN, LTD 161 NORTH CLARK STREET AT RANDOLPH 21ST FLOOR
16 An Employee s Guide to the South Dakota Workers Compensation System Division of Labor and Management Phone: (605) 773-3681 www.sdjobs.org Department of Labor and Regulation 700 Governors Drive Pierre,
Chapter 1 Chapter Objectives Your learning objectives are as follows: Understand the mechanism of insurance. Understand the difference between property and casualty insurance. Learn the parts of the insurance
EMPLOYER AGREEMENT Pace Vanpool Incentive Program - (VIP) SHUTTLE SERVICE THIS AGREEMENT made this day of, 200 by and between Pace, the Suburban Bus Division of the RTA ("Pace"), and ( Employer ) whose
ONYX BUSINESS AUTO POLICY COVERAGE Various provisions in this policy restrict overage Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this policy
POLICY NUMBER: CL CG 04 57 07 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYMENT-RELATED PRACTICES LIABILITY ENDORSEMENT This endorsement modifies insurance provided under the
Insurance for Libraries Christine Lind Hage, Director, Rochester Hills (MI) Public Library 2014 by United for Libraries: The Association of Library Trustees, Advocates, Friends and Foundations. This toolkit
Lowcountry Injury Law 1917 Lovejoy Street Post Office Drawer 850 Beaufort, South Carolina 29901 Personal Injury Phone (843) 524-9445 Auto Accidents Fax (843) 524-6981 Workers Comp Lawyer@LowcountryLaw.com
Insurance 101 Sally Becker CPCU ARM 1 Statutes Texas Tort Claims Act CPRC 101 Indemnification CPRC 104 Limitation of Liability CPRC 108 2 Definition: A contractual relationship that exists when one party
SMALL BUSINESS INSURANCE CONSIDERATIONS Philadelphia LawWorks, a project of Philadelphia VIP, contributes to Philadelphia s economic development by ensuring that homeowners, nonprofits and small business
Managed Return to Work Date Effective April 15, 2011 City Manager Revision Date Effective Code Number HR 23 Human Resources Responsible Key Business Objective: The City of Charlotte seeks to ensure the
Table of Contents Job Description ORM-C600... 4 Claims Adjuster 1-4... 4 INTRODUCTION ORM-C601... 7 SET UP NEW CLAIM FILE ORM-C602... 8 Litigated Claims... 8 Medical Record Review... 9 Investigation...
City and County of Denver Workers Compensation Procedure Issued September 10, 2001 Revised 2/1/2013 Workplace Safety 201 West Colfax Avenue Dept. 1105 Denver, CO 80202 Risk.Management@Denvergov.org Workplace
FLORIDA KEYS AQUEDUCT AUTHORITY BOARD OF DIRECTORS MEETING OPEN TO THE PUBLIC A G E N D A FLORIDA KEYS AQUEDUCT AUTHORITY BOARD ROOM 1100 Kennedy Drive Key West, Florida 33040 WEDNESDAY, MAY 14, 2014 10:00
STATE OF WISCONSIN Frequently Asked Questions Auto Insurance OFFICE OF THE COMMISSIONER OF INSURANCE PI-233 (C 03/2015) The Automobile Insurance Policy (page 1) Wisconsin's Financial Responsibility Law
PUBLIC ENTITY RISK MANAGEMENT AUTHORITY MEMORANDUM OF WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE FOR THE PERIOD JULY 1, 2015 TO JUNE 30, 2016 EFFECTIVE: JULY 1, 2015 PUBLIC ENTITY RISK MANAGEMENT
Mailing Address: P.O. Box 34538 Seattle, WA 98124-1538 Maritime Injury Cases The following are the questions most frequently asked by our clients about Maritime injury cases. Obviously, the questions and
Guide to Commercial Insurance Introduction Operating a successful business today requires knowledge in many different areas, and one of the most important things to consider are the types and amounts of
Managing the Care and Return to Work of Injured Workers (and controlling your Workers Compensation Costs) This Guide was developed to provide you with valuable information regarding our managed care program,
COWLEY COUNTY, KANSAS REQUEST FOR PROPOSAL General Property & Liability Insurance SUBMITTAL DEADLINE June 28, 2013 RFP NUMBER 13-001 CONTACT Jeremy Willmoth, County Administrator GENERAL REQUIREMENTS 1.
QUESTIONS AND ANSWERS ABOUT ILLINOIS AUTOMOBILE INSURANCE AND ACCIDENTS What types of coverages are available? Generally, automobile insurance policies provide Bodily Injury and Property Damage Liability
INDEPENDENT CONTRACTOR AGREEMENT (ICA) (This agreement is not a construction contract within the meaning of Civil Code section 2783, and is not an agreement for the provision of construction services within
An Employee s Guide to the Missouri Workers Compensation System Missouri Department of Labor and Industrial Relations Division of Workers Compensation Important Information You may want to put names and
Schedule Q (Revised 1/5/15) CONSTRUCTION CONTRACTOR INSURANCE REQUIREMENTS Section 0.0 Introduction of the Owner-Controlled Insurance Program The City of Oakland (City) has implemented an Owner-Controlled
Bowdoin College Salary Continuation Plan for Administrative Staff Benefits under the Short Term Disability Salary Continuation Plan described in the following pages are provided and funded by the Employer.
Workers' Compensation Insurance, Crime Insurance, Commercial Umbrella Liability, and Bonds A. Workers Compensation Laws (a.k.a. State Industrial) can be monopolistic and compulsory (required) in some states.
SAMPLE CONSTRUCTION INSURANCE REQUIREMENTS A. In General The shall purchase and continuously maintain in full force and effect for the policy periods specified below the insurance policies specified in
Mailing Address: 711 High Street Des Moines, IA 50392-0410 Principal Life Insurance Company Disability Claim Notice Instructions For Filing A Claim Please indicate the type of policy and the policy(ies)
Glossary of Insurance Terms: (obtained from website: http://www.iii.org/individuals/glossary/alfa.l/) ACTUAL CASH VALUE A form of insurance that pays damages equal to the replacement value of damaged property
Consumer Legal Guide Your Guide to Automobile Insurance and Accidents WHAT TYPES OF COVERAGES ARE AVAILABLE? Generally, automobile insurance policies provide Bodily Injury and Property Damage Liability
Workers Compensation 101 Dave Young EMC Insurance Companies Outline I. Brief history of Workers Compensation Insurance II. What does Workers Compensation do? III. Calculation of the Workers Compensation
NOTE 15: RISK MANAGEMENT AND INSURANCE A. Public Entity Risk Pool Public School Insurance Fund The Public School Insurance Fund (the Fund) is a public entity risk pool reported within the enterprise funds.
Guide for Injured Workers This is a guide to Oklahoma workers' compensation law and rules. It is based on laws and rules in effect in 2015. Laws and rules can change by acts of the Legislature, rulemaking
Call Us Now (813) 269-7421 FREE Consultation Your Quick Reference for Florida Auto Accident Law At the Law Offices of Martin Schwartz, we are here to take care of your legal needs in the aftermath of an
Local Rule 1301 Scope. Compulsory Arbitration Local Rule 1301 Scope. (1) The following civil actions shall first be submitted to and heard by a Board of Arbitrators: (a) (b) (c) (d) Civil actions, proceedings
the the the GOOD UGLY BAD& What A Nonprofit Organization Needs To Know About Insurance Susan R. Smith Beehive Insurance Agency, Inc. c o n t e n t s Introduction 1 General Liability 2 Professional Liability
THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) TODAY'S DATE PERSONAL INFORMATION: DATE OF ACCIDENT NAME HOME ADDRESS CITY STATE ZIP HOME TELEPHONE ( ) DATE OF BIRTH
Zurich Handbook Managed Care Arrangement program summary A Managed Care Arrangement (MCA) is being used to ensure that employees receive timely and proper medical treatment with respect to work-related
For over 100 years people in Connecticut have relied on the law firm now known as. Today, the law firm s Connecticut injury attorneys focus their experience and resources on helping injured people recover
The Essentials of Church Insurance By Jerry J. Sparks www.agfinancial.org/insurance 866.662.8210 The Essentials of Church Insurance What coverage does your church need? Churches have become increasingly
GUIDELINES FOR PURCHASING INSURANCE For ELCA LEADERS Developed By Willis is pleased to provide the following information to help ELCA congregations and synods in evaluating different insurance programs
CORNERSTONE A-SIDE MANAGEMENT LIABILITY INSURANCE COVERAGE FORM THIS IS A CLAIMS MADE POLICY WITH DEFENSE EXPENSES INCLUDED IN THE LIMIT OF LIABILITY. PLEASE READ AND REVIEW THE POLICY CAREFULLY. In consideration
Employment Practices Liability Insurance and Insurance Coverage for Employee Dishonesty Michael Conley, Esq. (267) 216-2707 firstname.lastname@example.org AAPA Port Administration and Legal Issues Seminar Baltimore,
Workers' Compensation in Oklahoma Employee s Rights & Responsibilities Workers Compensation Court Counselor Program 1915 N. Stiles Avenue, Oklahoma City, OK 73105 210 Kerr State Office Bldg., 440 S. Houston,
Workers' Compensation in Oklahoma Employee s Rights & Responsibilities The information provided in this pamphlet is general in nature and for informational purposes only. It is not intended to be a legal
Workmen s Compensation Policy Number: 7390 Effective Date: All employees of Snake River School District 52 are covered by Workmen's Compensation insurance for bodily injury, disease, or death caused by
WORKERS COMPENSATION GLOSSARY ACCIDENT An unplanned and unexpected event which occurs suddenly and at a definite place resulting in injury and/or damage. ACCIDENT FREQUENCY The rate of the occurrence of
SPECIAL REPORT MANAGING THE RISK OF INDEPENDENT CONTRACTORS WORKING IN YOUR BUILDING (04-04-14) This Special Report was written by Daniel P. Hale, J.D., CPCU, ARM, CRM, LIC, AIC, AIS, API of Marsh & McLennan
COMMERCIAL GENERAL LIABILITY CG 00 34 12 07 LIQUOR LIABILITY COVERAGE FORM THIS FORM PROVIDES CLAIMS-MADE COVERAGE. PLEASE READ THE ENTIRE FORM CAREFULLY. Various provisions in this policy restrict coverage.
Workers Compensation Instructions for Filing a Claim Please complete following steps within 24 48 hours of the incident: Report the incident to your supervisor immediately or, if a medical emergency, dial