CLAIM REPORTING GUIDE

Transcription

1 CLAIM REPORTING GUIDE

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)

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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)

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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.