Claims Kit Pennsylvania

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1 Representing Financial Strength & Integrity Claims Kit Pennsylvania Contents: BHHC Claims Kit Introductory Letter 10/29/2013 BHHC Instructions for PA Postings and Notices 10/14/2013 PA Form LIBC Workers Compensation Insurance Posting 05/2009 BHHC PA Form - Workers' Compensation Information 10/14/2013 BHHC PA Form - Medical Provider Panels Poster 10/28/2013 BHHC PA Medical Provider Panels 10/28/2013 PA Form IA-1 - First Report of Injury or Illness 01/01/2002 BHHC PA Employee Accident Report 10/14/2013 BHHC PA Treating Physician Designation 10/28/2013 BHHC General Supervisor Accident Report 10/03/2013 BHHC General Witness Accident Report 10/03/2013 BHHC Workers Compensation Fraud Poster (English & Spanish) 10/09/2013

2 Dear Policyholder: P.O. Box , San Francisco, CA Phone: (888) bhhc.com Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC). We look forward to working with you to fulfill all your workers compensation needs. Enclosed you will find documentation necessary for the processing and administration of a claim in the event of a workplace injury, as well as important information regarding workers compensation requirements for your state (i.e. posting notices, compliance laws, etc). Please utilize the documents included to collect valid information regarding the injured employee and incident, and send the documents in when reporting the claim or upon request. Any completed document should be sent directly to BHHC using mail, , or fax. The assigned claims professional will forward necessary documentation onto the appropriate state entity. It is critical that you promptly report all new claims using one of the following methods: Phone: (800) Fax: (800) newclaim@bhhc.com Online: 1. Go to our website: 2. Highlight Workers Comp in the menu 3. Highlight Claims Center 4. Click Report a Claim State law requires that employers authorize initial medical treatment within 24 hours of knowledge that an occupational injury of illness has been sustained or reported, regardless of the legitimacy of the claim. Failure to comply may result in the loss of medical control and a significant increase in the potential claim cost. We will attempt to contact you and the injured worker within 24 hours of receiving the First Report of Injury. Your cooperation in allowing the injured employee to speak with one of our Claims Professionals is appreciated. Should you have any questions regarding the contents of this kit, a claim, or claim reporting, please contact our Customer Care Center at (888) Questions regarding your insurance policy or coverage should be directed to your broker or agent. We thank you for choosing BHHC as your workers compensation carrier and look forward to providing you superior customer service and compassionate care for your injured workers. BERKSHIRE HATHAWAY HOMESTATE COMPANIES BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY BROOKWOOD INSURANCE COMPANY CONTINENTAL DIVIDE INSURANCE COMPANY CYPRESS INSURANCE COMPANY OAK RIVER INSURANCE COMPANY REDWOOD FIRE AND CASUALTY INSURANCE COMPANY

3 Workers Compensation Posting and Notices Requirements REQUIREMENTS FOR FORM LIBC WORKERS COMPENSATION INSURANCE POSTING Post in one or more conspicuous places readily accessible to all employees at all business locations and work sites o Must be posted in the areas used for the treatment or administration of first aid to injured employees Must contain the insurer/carrier contact information Print on 8.5 x 11 paper Text must be in at least 11-point font-size To complete the form, please enter the following information in the spaces provided: Your company name Date posted Name of your designated insurance company The Bureau Code assigned to your designated insurance company o The Bureau publishes a listing of the Bureau Codes assigned to authorized insurers on their website at For your convenience, our other contact information has been entered on the Poster. Please note, the form fields are designed to populate text meeting the statutory font-size requirement. (Pennsylvania Workers Compensation Act 305(e)) REQUIREMENTS FOR WORKERS COMPENSATION INFORMATION DOCUMENT Must be provided to all employees: o At the time of hire o Immediately after a work accident or injury or as soon as possible thereafter Print on 8.5 x 11 paper Text must be in at least 11-point font-size Please note, the text of this document meets the statutory font-size requirement. (34 Pennsylvania Administrative Code 121.3b) REQUIREMENTS FOR MEDICAL PROVIDER PANELS POSTER Must be provided to all employees: o At the time of hire o Immediately after a work accident or injury or as soon as possible thereafter Print on 8.5 x 11 paper To complete the form, please enter the following information in the spaces provided: Location Name Name of an employer representative to provide copies of panel list Physician and provider contacts including: physician name, specialty, clinic name, address, and phone (34 Pennsylvania Administrative Code )

4 REMEMBER: It is Important to Tell Your Employer about Your Injury The name, address and telephone number of your employer s workers compensation insurance company, third-party administrator (TPA), or person handling workers compensation claims for your company, are shown below. Employer Name: IF INSURED: (Complete all applicable spaces) Name of Insurance Company: Date Posted: IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) Name of TPA (Claims administrator): Address: Address: Telephone Number: Telephone Number: Insurer s Bureau Code: IF SELF-INSURED: (Complete all applicable spaces) Name of person handling claims at the self-insured: IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) Name of TPA (Claims administrator): Address: Address: Telephone Number: Telephone Number: Self-Insured Bureau Code: Department of Labor & Industry Bureau of Workers Compensation 1171 S. Cameron Street, Room 103 Harrisburg, PA LIBC-500 REV 5-09 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

5 WORKERS COMPENSATION INFORMATION v The workers' compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. v Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers' compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid. v You should report immediately any injury or work-related illness to your employer. v Your benefits could be delayed or denied if you do not notify your employer immediately. v If your claim is denied by your employer, you have the right to request a hearing before a workers' compensation judge. v The Bureau of Workers' Compensation cannot provide legal advice. However, you may contact the Bureau of Workers' Compensation for additional general information at: Bureau of Workers' Compensation 1171 South Cameron Street, Room 103, Harrisburg, Pennsylvania Telephone number within Pennsylvania (800) Telephone number outside of this Commonwealth (717) TTY (800) (for hearing and speech impaired only) PA Keyword: workers comp I have read this document and fully understand its entire contents. I have asked questions about anything that was not clear to me and I am satisfied with the answers I have received. I understand that I have a right to receive a copy of this acknowledgment upon my request. Employee Name Employee Signature Date 34 Pa. Code 121.3b

6 LOCATION NAME NOTICE: MEDICAL TREATMENT FOR YOUR WORK INJURY OR OCCUPATIONAL ILLNESS Your employer has selected a list of 6 or more physicians and other health care providers who are available to treat your work-related injuries and illnesses during the first 90 days of treatment. This list is posted below for you to review. Also, you may get a copy of this list from. If you are injured at work or suffer an occupational illness, you have certain legal RIGHTS and DUTIES under Section 306(f.1)(1)(i) of the Workers Compensation Act regarding your medical treatment. These rights and duties are summarized below. MEDICAL TREATMENT: DURING THE FIRST 90 DAYS = You have the RIGHT to receive reasonable and necessary medical treatment for your work injury or occupational illness. Your employer must pay for the treatment, as long as the treatment is by one of the listed providers. You have the RIGHT to choose which of the listed providers will treat you for your work injury or illness. You have the RIGHT to switch among any of the listed providers when you receive treatment; and if a listed provider refers you to a provider not on your employer s list, you have the RIGHT to receive treatment from the referral provider. If a listed provider prescribes surgery for you, you have the RIGHT to receive a second opinion from any provider of your choice. If that opinion is different from the opinion of the listed provider, you have the RIGHT to choose which course of treatment to follow. If you choose the treatment prescribed in the second opinion, you must receive the treatment from a listed provider for a period of 90 days after the date of your visit to the provider of the second opinion. You have the DUTY to visit one or more of the listed providers for the first 90 days of treatment for your work injury of illness if you expect your employer to pay for the medical treatment you receive. If you seek treatment for your work injury of illness from a provider who is not on the list, your employer may not have to pay for this medical treatment during this 90-day period. Therefore, you should talk to your employer before seeking treatment from a provider who is not on the list. If a listed provider prescribes surgery for you, you have the RIGHT to receive a second opinion from any provider IMPORTANT: The requirements your employer must meet to have a valid list of at least 6 providers are shown on the reverse side of this form. If the list does not meet these requirements, it is not a valid list, and you have the right to seek medical treatment for your work injury or occupational illness from any health care provider of your choice. MEDICAL TREATMENT: AFTER THE FIRST 90 DAYS You have the RIGHT to receive treatment from any physician or other health care provider of your choice, whether or not they are listed by your employer. Your employer must pay for this treatment as long as it is reasonable and necessary for your work injury or occupational illness and has been properly documented by the physician or other health care provider. You have the DUTY to notify your employer if you receive treatment from a physician or other health care provider who is not listed by your employer. You must notify your employer within five days of the first visit to any provider who is not on your employer s list. The employer may not be required to pay for the treatment received until you have given this notice. Your signature on this form indicates that you have been informed of and you understand these rights and duties. If you have questions, be sure you have your rights and duties explained to you before signing this form. I HAVE BEEN INFORMED OF MY MEDICAL TREATMENT RIGHTS AND DUTIES WITH REGARD TO WORK-RELATED INJURIES AND OCCUPATIONAL ILLNESSES. THIS NOTICE WAS PRESENTED TO ME AT [Check one]: TIME OF HIRE WHEN I WAS INJURED OTHER EMPLOYEE: EMPLOYER REPRESENTATIVE: DATE: DATE: Physician Name Specialty Clinic Name Address Phone Physician Name Specialty Clinic Name Address Phone Physician Name Specialty Clinic Name Address Phone Physician Name Specialty Clinic Name Address Phone Physician Name Specialty Clinic Name Address Phone Physician Name Specialty Clinic Name Address Phone (OVER)

7 REQUIREMENT FOR EMPLOYER S LIST OF HEALTH CARE PROVIDERS 1. There must be at least 6 health care providers on the list, but there may be more than 6 listed. 2. At least 3 of the health care providers on the list must be physicians. 3. No more than 4 of the health care providers on the list may be coordinated care organizations (CCOs). 4. The names, addresses, phone numbers and areas of medical specialties of all health care providers must be included on the list. 5. The health care providers on the list must be geographically accessible and must have specialties that are appropriate based on the anticipated work-related medical problems of the employees. 6. Your employer must specify on the list if any of the health care providers on the list are employed, owned or controlled by your employer or its workers compensation insurance company. NOTE: Your employer s list of health care providers must meet all of the above requirements. If the list does not meet all of these requirements, you do not have to choose a medical provider from the list. Instead, you have the right to seek medical treatment with any health care provider of your choice. BUREAU OF WORKERS COMPENSATION HELPLINE INFORMATION CENTER (800) (long-distance calls inside PA) (717) (local and calls outside PA)

8 Pennsylvania Medical Provider Panels Treating physicians can have a significant impact on a claim s medical cost. A key component to controlling these costs and reaching a satisfactory resolution of a claim for all parties involved is ensuring that the claimant receives quality medical care from a competent physician. In the state of Pennsylvania, employers have a single option, in the form of provider panels, for asserting some influence on the selection of the treating physician. Pursuant to PA WC Act 306(f.1) and 34 Pa. Code (a), excluding denied claims and emergencies, the establishment and maintenance of a valid medical provider panel may limit an injured worker s initial physician choice to medical providers designated within the panel for the first 90 days of treatment. The first 90 days of a claim is a crucial period in the life of a claim which may set the tone for the remaining days of a claim. Please note, the failure to authorize initial medical treatment upon notice of an employee s work injury may result in a waiver of panel rights. This document contains a summary of the essential elements for the creation and maintenance of an enforceable medical provider panel. MEDICAL PROVIDER PANEL REQUIREMENTS Notice to Workers The law requires employers to provide notice of their medical provider panel to all employees. Notice should be given prior to and upon knowledge of an employee s work injury. Posting: Employers are required to post the panel listing in prominent and readily accessible places at all business locations and work sites. Each panel must include required notices contained within 34 Pa. Code (b). Our Medical Provider Panels Poster may be used to comply with the requirements. o Print on legal sized paper (8.5 x 14 ) o Must be posted in the areas used for the treatment or administration of first aid to injured employees Acknowledgement Form: The use of an acknowledgement form to be signed by all employees to show that they have been notified of the panel and its use is also required. Employees must receive the acknowledgement form at the time of hire and upon notice of accident or injury. Our Medical Provider Panels Poster contains an area to obtain an employee s signature and acknowledgement. Number of Providers A panel must include a minimum of at least 6 health care providers within a reasonable distance. o No more than 4 providers may be affiliated or within a coordinated care organization. Coordinated care organizations only count as one of the provider choices o Physicians and providers that are employed by, owned, or controlled by the employer may not be used unless such employment, ownership, or control is disclosed. o At least 3 physicians must be included Specialty Recommendations: orthopedics, neurology, general surgeon, occupational medicine, and ophthalmology. PANEL PERIOD In general, a valid and enforceable panel restricts a claimant s provider choice to one or more health care providers within a panel for up to 90 days from the of the first visit for the treatment of the work injury or illness. PANEL MAINTENANCE To guarantee panel validity over time, routine maintenance is recommended. o Every six months to a year, each physician or provider on a panel should be contacted to confirm that their contact information is up-to-date and that they are still accepting and treating workers compensation patients. PHYSICIAN SELECTION AND CHANGES Excluding denied claims and emergencies, an injured worker is required to select the authorized treating physician from the panel list. o Obtain the injured worker s initial selection in writing. Our Treating Physician Designation Form may be used for this purpose. o Please note, exceptions may apply if a physician prescribes a surgical procedure. Please refer to the Medical Provider Panels Poster document for more information. Injured workers have the right to change to another provider listed on the panel without prior approval. CLAIM PROCEDURES All work accidents and injuries must be reported to us as soon as possible so that we are able to begin the claim investigation promptly. Please have the injured worker complete our Pennsylvania Employee Accident Report. When reporting the claim, please make sure to provide a copy of your posted physician panel and a copy of the injured worker s signed panel acknowledgment. This allows the Claims Professional to enforce panel use.

9 WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER EMPLOYER S LOCATION ADDRESS (IF DIFFERENT) LOCATION # INDUSTRY CODE EMPLOYER FEIN PHONE # CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) TO CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS (INCL ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE M MALE U UNMARRIED SINGLE/DIVORCED EMPLOYMENT STATUS F FEMALE M MARRIED U UNKNOWN S SEPARATED PHONE # OF DEPENDENTS K UNKNOWN NCCI CLASS CODE RATE PER: OCCURRENCE/TREATMENT DAY WEEK MONTH OTHER: DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? TIME EMPLOYEE BEGAN WORK AM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE DATE EMPLOYER NOTIFIED PM ( ) CANNOT BE DETERMINED PM CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED YES YES NO NO DATE DISABILITY BEGAN DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER S TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE PREMISES? YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) YES NO YES NO INITIAL TREATMENT 0 NO MEDICAL TREATMENT 1 MINOR: BY EMPLOYER 2 MINOR CLINIC/HOSP OTHER WITNESSES (NAME & PHONE #) EMERGENCY CARE HOSPITALIZED > 24 HOURS FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER S NAME & TITLE PHONE NUMBER FORM IA-1(r ) SEE BACK FOR IMPORTANT INFORMATION IAIABC 2002

10 EMPLOYER S INSTRUCTIONS DO NOT ENTER DATA IN SHADED FIELDS DATES: Enter all dates in MM/DD/YY format. INDUSTRY CODE: This is the code which represents the nature of the employer s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget. CARRIER: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. CLAIMS ADMINISTRATOR: Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. AGENT NAME & CODE NUMBER: Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy. OCCUPATION/JOB TITLE: This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS: Indicate the employee s work status. The valid choices are: Full-Time On Strike Unknown Volunteer Part-Time Disabled Apprenticeship Full-Time Seasonal Not Employed Retired Apprenticeship Part-Time Piece Worker DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employer s premises to be contacted for additional information. TYPE OF INJURY/ILLNESS: Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm). PART OF BODY AFFECTED: Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back). DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Maintenance Department or Client s office at 452 Monroe St., Washington, DC 26210) If the accident or illness exposure did not occur on the employer s premises, enter address or location. Be specific. FORM IA-1(r ) IAIABC 2002

11 EMPLOYER S INSTRUCTIONS cont d ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Acetylene cutting torch, metal plate) List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator s scaffolding, electric sander, paintbrush, and paint. Enter NA for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee s injury or illness. SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Cutting metal plate for flooring) Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter NA for not applicable if employee was not engaged in a work process (eg. walking along a hallway). HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL: (Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.) Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker s right wrist was broken in the fall. DATE RETURN(ED) TO WORK: Enter the date following to most recent disability period on which the employee returned to work. FORM IA-1(r ) IAIABC 2002

12 EMPLOYEE S ACCIDENT REPORT To be completed by the injured worker Employee name Employer name Date of accident Time of accident Time you began work on day of accident Location of accident (specify if off-site address) How did the injury occur? What job duties were you performing? Please describe in your own words. What part(s) of your body was injured (indicating right and/or left)? Have you sought any medical treatment for these injuries? If so, specify where and when. Have you ever injured this part of your body before (yes or no)? If so, please describe how and when the previous injury(s) occurred. What witnesses were present when the accident occurred? Please provide names if applicable. Who did you report the injury to? When was the injury reported? Please provide name(s) and job title(s). What did you do after the accident occurred? By signing this document, I am certifying that my employer provided me with a copy of their official posted panel and has reviewed the purpose of the panel with me. The above report is true and correct: SIGNATURE: DATE FORM COMPLETED:

13 Treating Physician Designation By signing this document, I acknowledge my employer s posted physician panel. I understand that I must select a medical provider from the panel list to provide medical care for my work injury for the first 90 days of treatment. I also understand that my employer may not be required to pay for any medical treatment that I obtain from a medical provider that is not included on the panel. I further understand that, if I am not satisfied with the first physician that I select from the panel, I have the right to change to another physician listed on the same panel. INITIAL TREATING PHYSICIAN SELECTION: I hereby select the following physician to provide medical services and treatment for my work injury or illness: NAME FACILITY ADDRESS PHONE I have read this form and fully understand its entire contents. I have asked questions about anything that was not clear to me and I am satisfied with the answers I have received. I understand that I have a right to receive a copy of this document upon my request. PRINTED NAME SIGNATURE DATE

14 SUPERVISOR S REPORT OF EMPLOYEE ACCIDENT Employee name Employer name Date of accident Time of accident Date accident reported Did the employee report the accident immediately? YES NO Location of accident (specify if off-site address) How did the injury occur? What job duties was the employee performing? What part(s) of the employee s body were reported as injured? Has the employee sought any medical treatment for these injuries? If so, specify where and when. What witnesses were present when the accident occurred (including self)? Do you have any reason to question the legitimacy of the accident? If so, please explain: Indicate working conditions present that led to accident (please check all that apply): Unused/unavailable lifting equipment Unused/unavailable PPE (gloves, hardhat, goggles, etc.) Unused/unavailable sharps container Unguarded or improperly guarded equipment Electrical exposure Obstructed view Lack of training Defective tools or equipment Wet/slippery floor Poor housekeeping Interaction with co-worker Interaction with patient or resident Interaction with customer Chemical exposure Motor vehicle accident Other: What changes could be made to eliminate or reduce the hazard(s) identified above? The above report is true and correct: Prepared by: Title: Date prepared:

15 WITNESS REPORT/STATEMENT OF EMPLOYEE ACCIDENT Employee name Witness name & phone number Witness Address Date of accident Time of accident Location of accident (specify if off-site address) Did you witness the above-reported accident? If so, how did the injury occur? What job duties was the employee performing? What part(s) of the employee s body were injured? Describe the type of injury (strain, bruise, etc.) What did the injured employee say at the time of injury? Did the injured employee complain of pain at the time of injury? If they complained of pain, please specify the body part(s). What did the employee do after the accident occurred? Were any other witnesses present at the time of the accident? If so, please list them below. The above report is true and correct: Signature of witness: Date signed: NOTE: Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties.

16 BERKSHIRE HATHAWAY HOMESTATE COMPANIES OFFERS: REWARD WORKERS COMPENSATION CLAIMS FRAUD $1,000 FOR INFORMATION LEADING TO THE ARREST AND CONVICTION OF ANY CO-WORKER, HEALTH CARE PROFESSIONAL, OR ATTORNEY REPRESENTING A FRAUDULENT WORKERS COMPENSATION CLAIM TO BERKSHIRE HATHAWAY HOMESTATE COMPANIES* Most states make it a FELONY to make or cause to be made a knowingly false or fraudulent material statement in order to obtain Workers Compensation benefits. Berkshire Hathaway Homestate Companies believes that any party engaging in such fraud should be prosecuted to the fullest extent of the law, including JAIL SENTENCES. Please do your part to help. Putting these criminals out of operation benefits all of us, including keeping your employer s premium rates reasonable. Call our TOLL-FREE FRAUD HOTLINE immediately if you have information on a fraudulent claim. You, and all of us, reap the rewards of reducing Workers Compensation Fraud. TOLL FREE: JAIL BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY BROOKWOOD INSURANCE COMPANY CONTINENTAL DIVIDE INSURANCE COMPANY CYPRESS INSURANCE COMPANY OAK RIVER INSURANCE COMPANY REDWOOD FIRE AND CASUALTY INSURANCE COMPANY *Maximum reward of $1,000 per conviction. In the event more than one individual submits information regarding the same fraudulent claim, Berkshire Hathaway will equally divide the reward among those providing information used in obtaining the conviction. Berkshire Hathaway reserves the right to determine what information, if any, will be provided to the appropriate law enforcement agency. Criminal prosecutions are the sole responsibility of the authorities and may or may not be pursued at their discretion. Any issues regarding the interpretation of this policy shall be resolved by Berkshire Hathaway Homestate Companies at their sole discretion. Program subject to change or termination without prior notice.

17 LA COMPAÑIA DE SEGUROS BERKSHIRE HATHAWAY OFRECE: RECOMPENSA DEMANDAS FRAUDULENTAS DE COMPENSACION DE TRABAJADORES $1,000 INFORMACIÓN QUE LLEVA AL ARRESTO Y A LA CONDENA DE CUALQUIER COMPAÑERO DE TRABAJO, PROFESIONAL DE CUIDADO MEDICO, O ABOGADO QUE REPRESENTE UN RECLAMO FRAUDULENTO EN CONTRA DE BERKSHIRE HATHAWAY HOMESTATE COMPANIES* En la mayoría de los estados es un delito grave hacer que se haga una declaración de material fraudulento para obtener beneficios de Compensación al Trabajador. Berkshire Hathaway Homestate Companies cree que cualquier persona que se involucre en tal fraude debe ser procesado con todo el rigor de la ley, incluyendo SER SENTENCIADO A LA CARCEL. Ayúdenos de su parte. El poner a estos delincuentes fuera de operaciones nos beneficia a todos, incluso esto ayuda a mantener los réditos bajos de la aseguranza de su empleador. Si usted tiene información sobre un reclamo fraudulento por favor llame de inmediato a nuestra LINEA GRATUITA DE FRAUDE. Usted y todos nosotros no beneficiamos cuando reducimos los casos fraudulentos de Compensación al Trabajador. LLAMADA GRATIS: JAIL BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY BROOKWOOD INSURANCE COMPANY CONTINENTAL DIVIDE INSURANCE COMPANY CYPRESS INSURANCE COMPANY OAK RIVER INSURANCE COMPANY REDWOOD FIRE AND CASUALTY INSURANCE COMPANY *La recompensa máxima es de $1,000 por convicción. En caso de que más de una persona presente informaciones sobre la misma demando fraudulenta, Berkshire Hathaway dividirá la recompensa por partes iguales entre aquellas persones que aportaron informaciones para obtener la convicción. Berkshire Hathaway se reserva el derecho de determinar qué informacion presentará a la agencia judicial correspondiente. El proceso de crímenes es la responsibilidad exclusiva de las autoridades, que pueden decidir si el proceso debe entablarse or no. Cualquier disputa que pudiera surgir en la interpretación de esta ofreta será resuelta por la propia Compañia de Seguros Berkshire Hathaway. Este programa está sujeto a cambios a cancelación sin aviso previo.

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