Sedgwick Claims Kit New Jersey

Transcription

1 Sedgwick Claims Kit New Jersey 2014 v2 P.O. Box Lexington, KY T: F: Toll Free:

2 Dear Insured: We would like to welcome you as a policyholder of Freestone Insurance Company. Sedgwick is your Claims Administrator and we are pleased to be able to provide you with workers compensation claims handling services. Please follow the below instructions for filing a new claim and note the claim kit attachment. Sedgwick Claim Kit Attachments Employer s First Report of Injury Form (Form IA-1) A Worker s Guide to Workers Compensation in New Jersey A Worker s Guide to Workers Compensation in New Jersey (Spanish) Authorization for Release and Use of Medical Information Claim Office Directory Provider Search Tool Job Aid Atlas General First Fill Temporary Pharmacy Card Atlas General Pharmacy Card To Report a Claim Phone: (855-7ATLAS7) atlasgeneralinsurance@sedgwickcms.com Fax: Questions Linda Pettitt Client Services Associate Direct: Loss Runs lossruns@atlas.us.com Medical Provider Search User Name: client@sedgwickcms.com Password: SedgwickCMS_123 (case sensitive) We appreciate your business and believe that communication is critical for successful claims administration. We encourage you to contact us if you have any questions.

3 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

4 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

5 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

6 Atlantic City District Office Directory 1333 Atlantic Avenue 4th Flr. (609) Atlantic City, NJ (Atlantic and Cape May counties) Bridgeton 40 East Broad Street (856) Suite 203 Bridgeton, NJ (Cumberland & Salem counties) Camden 2 Riverside Dr., 3rd Flr. (856) Camden, NJ (Camden & Gloucester counties) Elizabeth 295 North Broad St., 2nd Fl. (908) Elizabeth, NJ (Union county) Freehold 2 Paragon Way (732) Freehold, NJ (Monmouth county) Hackensack 60 State Street (201) Hackensack, NJ (Bergen county) Jersey City 438 Summit Ave., 3rd Fl. (201) Jersey City, NJ (Hudson county) Lebanon Hunterdon Hills Plaza (908) Rt. 22 W. Lebanon, NJ (Hunterdon, lower Warren, Somerset counties) Mt. Arlington 100 Valley Rd., Suite 100 (973) Mt. Arlington, NJ (Morris, Sussex and upper Warren counties) Mt. Holly 555 High Street (609) Fairground Plaza Mt. Holly, NJ (Burlington county) Newark 124 Halsey Street, 2nd Floor (973) Newark, NJ (Essex county) New Brunswick 550 Jersey Avenue (732) New Brunswick, NJ (Middlesex county) Paterson 100 Hamilton Plaza (973) th Floor Clark Street Paterson, NJ (Passaic county) Toms River 954 Route 166 (732) Toms River, NJ (Ocean county) Trenton Station Plaza 4 (609) PO Box 958 Trenton, NJ (Mercer county) For more information about Workers Comp, visit us online at nj.gov/labor, then click on Workers' Compensation. New Jersey Department of Labor and Workforce Development is an equal opportunity employer with equal opportunity programs. Auxiliary aids and services are available upon request to individuals with disabilities. This pamphlet is published for general information only and does not have the status of law or regulation. For specific wording of the law see the New Jersey Workers Compensation Act (NJSA 34:15-1 et seq.) or consult your attorney. Rate in effect on the date of accident or exposure/manifestation in cases of occupational disease. Effective Date 01/01/ % of wages to maximum of $691 $691 minimum of $184 $ 35 01/01/ % of wages to maximum of $711 $711 minimum of $190 $ 35 01/01/ % of wages to maximum of $742 $742 minimum of $198 $ 35 01/01/ % of wages to maximum of $773 $773 minimum of $206 $ 35 01/01/ % of wages to maximum of $794 $794 minimum of $212 $ 35 01/01/ % of wages to maximum of $792 $792 minimum of $211 $ 35 01/01/ % of wages to maximum of $810 $810 minimum of $216 $ 35 01/01/ % of wages to maximum of $826 $826 minimum of $220 $ 35 WC(G)-338 (1/13) Benefits Temporary & Permanent Total Permanent Partial STATE OF NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION P.O. BOX 381 TRENTON, NEW JERSEY

7 What is Workers Compensation? Workers Compensation is a system created by the New Jersey Legislature that provides benefits to workers who are injured or who contract an occupational disease while working. The benefits include medical care, temporary disability payments, and compensation for a resulting permanent disability. In the event of the death of an injured worker, benefits are payable to the family of the worker. Benefits may be paid voluntarily or it may be necessary to apply to the Workers Compensation Courts for relief. Who is covered? Virtually every worker who performs services for wages is covered by the law, regardless of the number of workers employed by the employer. Under New Jersey law, domestic and farm workers are covered. However, workers considered to be independent contractors, rather than employees, are not covered. Seamen, maritime workers, railroad workers, and federal employees are covered under federal workers compensation law. What must a worker do if injured? The worker should notify the employer as soon as possible, but not later than 90 days from the date of the accident. The notice may be given to the supervisor, personnel office, or anyone in authority at the employer s place of business. Notice need not be in writing. If the worker needs medical treatment, a request should be made to the employer as soon as possible. What if an employer refuses to provide medical services and/or temporary disability benefits? The injured worker should seek the services of an attorney who will file a formal claim petition and a motion for medical and temporary benefits with the Division of Workers Compensation. Attorneys are prohibited by law from charging a fee in advance for such services. Fees will be fixed by the court only if a compensation award is made. Important: There is a two-year statute of limitations. A formal Claim Petition must be filed within two years of the date of the injury or the last payment of compensation, whichever is later. Medical treatment authorized by the employer is considered a payment of compensation. In cases of occupational illness, the Claim Petition must be filed within two years from the date the worker first became aware of the condition and its relationship to employment. The statute of limitations applies to minors also. An injured worker may also file an application for an informal hearing before a Judge of Compensation. At the informal hearing a representative of the employer or the employer s insurance carrier is usually present. The suggestions made by the judge at an informal hearing are, however, not binding on either party. The filing of an application for an informal hearing does not stop the two-year statute of limitations from running. What happens after a claim is reported? The employer or the employer s insurance carrier will investigate the claim. If the claim is found compensable, they will pay for necessary and reasonable medical treatment, loss of wages during the period of rehabilitation, and, when documented, benefits for permanent disability. Within 21 days of receiving notice of the accident, the insurance carrier should file a First Report of Injury form with the Division. This form gives the Division initial information about the accident and injuries. Another form, called the Subsequent Report of Injury, must be filed with the Division within 26 weeks after the worker returns to work or has reached maximum medical improvement. At that time, the worker should receive a letter from the insurance carrier explaining the benefits paid to date on their claim. The information from these forms helps the Division ensure that workers receive fair and timely benefits for work-related injuries. Can an employer take action against a worker for filing a claim? The Workers Compensation Statute prohibits the employer from discharging or discriminating in any manner against an employee because the employee has claimed or attempted to claim workers compensation benefits, or has testified, or is about to testify, in a workers compensation case. Does the Workers Compensation Law give special consideration to minors? Yes. If a minor, employed in violation of the Child Labor Law, suffers a disability because of a jobrelated injury or illness, benefits will be double the amount ordinarily awarded. Benefits Available Through Workers Compensation Medical Benefits All necessary medical treatment and hospitalization services should be provided by the employer or the employer s insurance carrier. The employer has the right to choose the treating physician. If the employer refuses to provide medical treatment, the injured worker is free to choose the treating physician. However, in the case of an emergency, an injured worker may obtain medical or hospital treatment without specific authorization from the employer, but the employer should be notified as soon as possible concerning the treatment being received. Temporary Disability Benefits If there is lost time which extends beyond seven calendar days due to the injury, temporary disability benefits become payable starting with the first day lost. The benefit amount is 70 percent of gross weekly wages received at the time of the injury, up to a maximum established annually by the Commissioner of Labor and Workforce Development.* Permanent Partial Benefits When a job-related injury or illness results in a permanent partial disability, benefits are based upon a percentage of certain scheduled or nonscheduled losses. A scheduled loss is one involving arms, hands, fingers, legs, feet, toes, eyes, ears, or teeth. A nonscheduled loss is one involving the back, heart, lungs, etc. Permanent Total Benefits When a job-related injury results in permanent total disability, the injured worker is entitled to payments for 450 weeks which will be continued thereafter for as long as the total disability exists. However, after the 450 weeks, these payments are subject to reduction for wages earned from employment. Weekly payments for permanent total disability are 70 percent of the gross weekly wage at the time of the injury up to a maximum established annually by the Commissioner of Labor and Workforce Development.* Permanent total disability is presumed when the worker has lost two major members or a combination of members of the body such as eyes, arms, hands, legs or feet. However, permanent total disability can result from other injuries that render the worker unemployable. Death Benefits When a job-related accident or illness results in the worker s death, benefits are payable to the dependents of the worker as defined by the law. The weekly benefit payment is 70 percent of wages, but the maximum total benefit payable to all of the worker s dependents cannot exceed the maximum established annually by the Commissioner of Labor and Workforce Development.* A surviving spouse or civil union partner and natural children who were a part of decedent s household at the time of death are conclusively presumed to be dependents. A surviving spouse or civil union partner and natural children who were not a part of decendent s household at the time of death and all other alleged dependents (parents, grandparents, grandchildren, brothers, sisters, etc.) must prove actual dependency. Children who are deemed to be dependents remain so until the age of 18 years or, if a full-time student, until the age of 23 years. If a child is physically or mentally disabled he/she may be eligible for further benefits. The employer or the employer s insurance carrier is responsible to pay up to $3,500 in funeral expenses for a job-related death. These funds are payable to whomever is liable for the funeral bill, be it the estate or an individual. * Maximum weekly rates for the past eight years are shown on the reverse.

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9 AN EMPLOYER S GUIDE TO WORKERS COMPENSATION IN NEW JERSEY I. WHAT IS WORKERS COMPENSATION?... 2 II. WORKERS COMPENSATION BENEFITS... 3 III. INSURANCE REQUIREMENTS... 4 Types of Coverage Definition of Employee Obtaining Workers Compensation Coverage Insurance Premium Rates What a Workers Compensation Policy Covers Penalties for Failure to Insure IV. BEFORE AN INJURY OCCURS... 9 Posting Notice Establish Clear Procedures for Employees and Managers V. REPORTING WORK ACCIDENTS AND OCCUPATIONAL EXPOSURES VI. HOW TO REDUCE WORKERS COMPENSATION COSTS...11 Establish a Safety Program Establish Return-to-Work Programs Establish and Maintain Good Communication with Your Injured Employees Ensure Prompt Treatment from the Right Medical Providers VII. CLAIM PETITIONS IN WORKERS COMPENSATION VIII. WHAT ELSE DOES AN EMPLOYER NEED TO KNOW? Discrimination Complaints Second Injury Fund Workers Compensation Web site Contacts for Questions 1

10 I. WHAT IS WORKERS COMPENSATION? Workers compensation is a no fault insurance program that provides medical treatment, wage replacement, and permanent disability compensation to employees who suffer job-related injuries or illnesses. It also provides death benefits to dependents of workers who have died as a result of their employment. An injured employee will receive benefits regardless of who was at fault. In exchange for these guaranteed benefits, the worker does not have the right to bring a civil action against the employer for pain and suffering or other damages, except in cases of intentional acts. The Division of Workers Compensation is responsible for the administration of the New Jersey Workers Compensation Act (N.J.S.A. 34:15-1 et seq.). This is accomplished by: ensuring that workers receive fair and timely workers compensation benefits for work-related injuries from their employers and/or insurance carriers; enforcing the law that requires employers to secure workers compensation insurance coverage from commercial insurance carriers or self-insurance programs; providing certain benefit payments to injured workers who are totally and permanently disabled as a result of their last work-related injury combined with the worker s pre-existing disabilities. These benefits commence at the conclusion of the payment of benefits from the worker s employer. The Division of Workers Compensation does not have jurisdiction over insurance premium rate setting. That responsibility falls under the jurisdiction of the Compensation Rating and Inspection Bureau of the Department of Banking and Insurance. 2

11 AN EMPLOYER S GUIDE TO WORKERS COMPENSATION IN NEW JERSEY I. WHAT IS WORKERS COMPENSATION?... 2 II. WORKERS COMPENSATION BENEFITS... 3 III. INSURANCE REQUIREMENTS... 4 Types of Coverage Definition of Employee Obtaining Workers Compensation Coverage Insurance Premium Rates What a Workers Compensation Policy Covers Penalties for Failure to Insure IV. BEFORE AN INJURY OCCURS... 9 Posting Notice Establish Clear Procedures for Employees and Managers V. REPORTING WORK ACCIDENTS AND OCCUPATIONAL EXPOSURES VI. HOW TO REDUCE WORKERS COMPENSATION COSTS...11 Establish a Safety Program Establish Return-to-Work Programs Establish and Maintain Good Communication with Your Injured Employees Ensure Prompt Treatment from the Right Medical Providers VII. CLAIM PETITIONS IN WORKERS COMPENSATION VIII. WHAT ELSE DOES AN EMPLOYER NEED TO KNOW? Discrimination Complaints Second Injury Fund Workers Compensation Web site Contacts for Questions 3

12 II. WORKERS COMPENSATION BENEFITS Medical Benefits: Necessary and reasonable medical treatment, prescriptions, and hospital services related to the work injury are paid by the employer s insurance carrier or directly by the employer if selfinsured. The employer and/or its insurance carrier have the right to designate medical providers for all work-related injuries. Temporary Total Benefits: If an injured worker is disabled for a period of more than seven days, he or she will be eligible to receive temporary total benefit, retroactive to the first day of lost time. The benefit will be paid at a rate of 70% of the worker s average weekly wage, not to exceed the statutory maximum rate or fall below the statutory minimum rate established annually by the Commissioner of Labor and Workforce Development. These benefits are provided until the worker has returned to work, has reached maximum medical improvement, or has reached the statutory 400-week maximum. Permanent Partial Benefits: When a job-related injury or illness results in a permanent bodily impairment, benefits are based on the individual s functional loss. These benefits are paid weekly and are due after the date temporary disability ends. Permanent Total Benefits: When a work injury or illness prevents a worker from returning to any type of gainful employment, he or she may be entitled to receive permanent total disability benefits. These weekly benefits are provided initially for a period of 450 weeks. Benefits continue beyond the initial 450 weeks provided that the injured worker is able to show that he or she remains totally disabled. The benefits are paid weekly and are based upon 70% of the average weekly wage, not to exceed the statutory maximum or fall below the statutory minimum. Death Benefits: Dependents of a worker who dies as a result of a workrelated injury or illness may be eligible to receive death benefits and funeral expenses up to $3,500. The weekly benefits are 70% of the wage of the deceased worker, not to exceed the statutory maximum. 4

13 III. INSURANCE REQUIREMENTS TYPES OF COVERAGE New Jersey law requires that all New Jersey employers not covered by federal programs have workers compensation coverage or be approved for self-insurance. Even out-of-state employers may need workers compensation coverage if a contract of employment is entered into in New Jersey or if work is performed in New Jersey. Coverage may be obtained in one of two ways: Workers Compensation Insurance Policy written by a mutual or stock carrier authorized to write insurance in New Jersey. Premiums for such insurance are based on the classification(s) of the work being performed by employees, the claims experience of the employer, and the payroll of the employer. Self-Insurance through application to and approval by the Commissioner of the Department of Banking and Insurance. Approval for self-insurance is based upon the financial ability of the employer to meet its obligations under the law and the permanence of the business. The posting of security for such obligations may be required. A self-insured employer has the option of administering its own workers compensation claims or contracting with a thirdparty administrator (TPA) to provide these services. For more information about self-insurance, please refer to N.J.S.A. 34:15-77 of the New Jersey Workers Compensation statute or contact the Department of Banking and Insurance at (609) , ext Note: Governmental agencies are required to provide workers compensation benefits to their employees but are not required to purchase insurance or receive approval as a self-insurer. They generally either 1) obtain an insurance policy, 2) participate in an insurance pool, or 3) maintain a separate appropriation for workers compensation. 5

14 The following employing entities must have workers compensation insurance in effect: Corporations All corporations operating in New Jersey must maintain workers compensation insurance or be approved for self-insurance so long as any one or more individuals, including corporate officers, perform services for the corporation for prior, current or anticipated financial consideration.* Partnerships/LLCs All partnerships and limited liability companies (LLCs) operating in New Jersey must maintain workers compensation insurance or be approved for selfinsurance so long as any one or more individuals, excluding partners or members of the LLC, perform services for the partnership or LLC for prior, current or anticipated financial consideration.* Sole Proprietorship All sole proprietorships operating in New Jersey must maintain workers compensation insurance or be approved for self-insurance so long as any one or more individuals, excluding the principal owner, performs services for the business for prior, current or anticipated financial consideration.* *Financial consideration means any remuneration for services and includes cash or other remuneration in lieu of cash such as products, services, shares of or options to buy corporate stock, meals or lodging, etc. DEFINITION OF EMPLOYEE The New Jersey Workers Compensation Act is liberally interpreted with respect to the definition of employee and is broader than the Internal Revenue Code and Unemployment Compensation statute. A variety of working relationships have been determined to be that of an employer-employee, including some that would not appear to be a typical employment situation. Further, a contract or other agreement as to whether an individual is an employee is not binding in determining whether an employee employer situation is present. 6

15 New Jersey courts, in deciding this issue, have developed two tests: the control test and the relative nature of the work test. Under the control test, the relationship between a business and the individual is reviewed. There is employment if the business retains the right to supervise the individual and control what is done as well as how it shall be done. Under the relative nature of the work test, there is employment if an individual relies on income from the business and the work performed by the individual is an integral part of the activities of the business. If any or both of these tests are met, an employee employer relationship is established. OBTAINING WORKERS COMPENSATION COVERAGE The New Jersey Compensation Rating and Inspection Bureau (NJCRIB), an agency in the New Jersey Department of Banking and Insurance, is responsible for establishing and maintaining regulations and premium rates for workers compensation and employers liability insurance. Workers compensation insurance coverage can be obtained from any of the more than 400 private licensed insurance companies authorized to sell workers compensation policies in New Jersey. A policy can be purchased directly from an insurance carrier, an insurance agent, or an insurance broker. For assistance with obtaining coverage, please contact: New Jersey Compensation Rating and Inspection Bureau 60 Park Place Newark, NJ (973)

16 INSURANCE PREMIUM RATES The primary device used to determine workers compensation insurance premiums is the classification system, which groups New Jersey businesses into various classifications. The purpose of this system is to bring together, within each classification, employers engaged in the same type of business. Accompanying each classification is a rate that represents the average work-injury experience for that classification. This rate is adjusted annually according to the latest available work-injury experience data. It is also recognized that no two employers, although they may be in the same business, have exactly the same operations or identical conditions of employment. Within any given classification, there are employers with better-than-average work injury experience and those with worsethan-average work injury experience. To account for such differences, an additional refinement to the classification system is offered through another program known as the Experience Rating Plan. In this plan, an employer s own work injury experience is used to modify its premium, higher or lower, by comparing it to the average work-injury experience of all employers in the classification to which the employer is assigned. For more information on how rates are established, you may wish to read the WC Reference Guide available on NJCRIB s Web site (www. njcrib.com/referenceguide/cribcnst.asp). WHAT A WORKERS COMPENSATION POLICY COVERS A workers compensation policy covers the following: For injured employees: Reasonable medical services necessary to treat the job injury or illness Temporary disability benefits to help replace lost wages up to statutory maximum Permanent disability benefits to compensate for the continued effects of the injury Burial and death benefits for dependents in cases of fatal injury 8

17 For employers: Coverage of financial liabilities for work-related injuries and illnesses Legal representation PENALTIES FOR FAILURE TO INSURE The consequences for failure to provide workers compensation coverage can be very significant, even without a work-related injury. Specifically, the law provides that failing to insure is a disorderly persons offense and, if determined to be knowing, a crime of the fourth degree. Moreover, penalties for such failure can be assessed up to $5,000 for the first 10 days with additional assessments of $5,000 for each 10-day period of failure to insure thereafter. In the case of a corporation, liability for failure to insure can extend to the corporate officers individually. Penalties assessed for failure to insure are not dischargeable in bankruptcy. Where a work-related injury or death has occurred, the employer, including individual corporate officers, partners or members of an LLC, is directly liable for medical expenses, temporary disability, and permanent disability or dependency benefits. In addition to awards for medical expenses and other benefits, New Jersey law also provides for civil penalties against the employer and its officers where failure to insure is determined. Awards and penalties arising from these claims can become liens against the uninsured employer and its officers, which are generally enforceable in the New Jersey Superior Court against any assets belonging to the uninsured employer and its officers. 9

18 HOW UNINSURED EMPLOYERS ARE IDENTIFIED State employer records are compared, or cross-matched, with the database at the Department of Banking and Insurance s Compensation Rating and Inspection Bureau (NJCRIB) on a regular basis to identify uninsured employers. When an employer is identified through this cross-match as a possibly uninsured employer, a letter and a cross-match response form is issued. Mandatory insurance should be immediately obtained if an employer is uninsured and verification of insurance must be provided. Penalties may still be assessed for failure to have insurance at the time of the cross-match. If you are an employer that has insurance and has received this form, you should provide the information requested about your workers compensation coverage as soon as possible to ensure that penalties are not improperly assessed against you. Also, if you are aware of an uninsured employer, you may provide this information to the Division of Workers Compensation by (oscf@dol.state.nj.us), by calling (609) or by completing and submitting a Report of Non-Compliance form, available on the Web site of the Division of Workers Compensation. You need not identify yourself but you should be prepared to provide the name and exact address of the employer and, if possible, the names of the principle operators of the business. IV. BEFORE AN INJURY OCCURS POSTING NOTICE New Jersey law requires every employer to post and maintain, in a conspicuous place or places in and about the worksite, a form prescribed by the Commissioner of the Department of Banking and Insurance, stating that the employer has secured workers compensation insurance coverage or has qualified with the Department of Banking and Insurance as a self-insured employer. For insured employers, the notice must include the name of the insurance carrier and other items as required by the Department of Banking and Insurance. To obtain copies of this notice, employers should contact their insurer. 10

19 ESTABLISH CLEAR PROCEDURES FOR EMPLOYEES AND MANAGERS At the time of hire and periodically thereafter, employees should be provided the following information: An explanation of their workers compensation coverage and benefits How, when, and to whom to report an injury Where to go for medical treatment if injured while working The Division of Workers Compensation has a general brochure on workers compensation available for injured workers, called A Worker s Guide to Workers Compensation. The brochure, which can be downloaded for distribution to employees from the division s Web site ( is available in English and Spanish. V. REPORTING WORK ACCIDENTS AND OCCUPATIONAL EXPOSURES Every work accident or occupational exposure should be recorded on an accident report form. Such documentation should prompt an immediate investigation, which not only assists in determining the cause of the accident or exposure, but is also important in the prevention of future accidents. When an employer receives notice about a work-related accident or occupational exposure, it should notify its insurance carrier or thirdparty administrator (TPA) immediately so that a First Report of Injury form can be filed by the carrier or TPA with the state of New Jersey. This form, which is filed electronically, gives the Division of Workers Compensation initial information about the work accident or exposure and any resulting injuries. A copy of this report is sent by the carrier or TPA to the employer for verification of the information submitted. Within 26 weeks after the worker has reached maximum medical improvement or has returned to work, the insurance carrier or TPA must electronically file a second report, called a Subsequent Report of Injury, with the state. Information from this report, including an explanation of any benefits paid on the claim, is also sent to the injured worker. 11

20 Note: If you are a self-administered self-insurer or governmental entity, you will be required to file these two reports directly with the state. For more information on how to file, please visit the Division of Workers Compensation s Electronic Data Interchange (EDI) Web page at labor/wc/wcedi.html. VI. HOW TO REDUCE WORKERS COMPENSATION COSTS ESTABLISH A SAFETY PROGRAM The best way for an employer to lower workers compensation costs is to prevent injuries from happening in the first place. Involve your employees in identifying hazardous work practices and potentially harmful situations, areas, or equipment. Safety teams and company incentives play a role in reducing costs. Most importantly, management must be willing to listen and put into practice appropriate recommendations. Many insurance companies offer free advice to policyholders about how to establish and maintain safe workplaces. You can also use the New Jersey Department of Labor and Workforce Development s free On-Site Consultation Service to find out about potential hazards at your worksites and improve your occupational safety and health management systems. Information on this service can be obtained by contacting: New Jersey Department of Labor and Workforce Development Division of Public Safety and Occupational Safety and Health P.O. Box 953 Trenton, NJ (609)

21 ESTABLISH RETURN-TO-WORK PROGRAMS Creating return-to-work programs that include appropriate light-duty or modified jobs can encourage workers to return to employment sooner and lower business costs. In addition, employers can partner with medical professionals and managed care specialists to design jobs that will not aggravate or reinjure workers who have recovered enough to return to work, but need additional time before resuming regular duties. The employer should provide an injured worker s job description to his or her medical care provider. Such information may facilitate early release of the worker to some type of modified duty. Researchers have found that in companies offering return-to-work programs, workers felt more satisfied with the care they received. ESTABLISH AND MAINTAIN GOOD COMMUNICATION WITH INJURED EMPLOYEES Pre-Injury: Frequently communicate workers compensation-related information to employees in plain, straightforward language. Publicize company procedures for job-related injuries or illnesses and encourage early reporting of such injuries. Let workers know which doctors they must see for work-related claims. When workers receive prior communication about what to do when a work-related injury or illness occurs, they are more likely to follow the employer s established procedures. When the same information is received after an injury has already occurred, employee reaction and response may be less positive. Post-Injury: Employers should actively become involved in every workers compensation case. Communicate on a regular basis with your employees who are disabled with work related injuries. The communication, whether it is by telephone or in person, should be positive and upbeat. If your company conducts an accident investigation, keep in mind that an important purpose of such an investigation should be to determine how the accident occurred so that such occurrences can be prevented in the future. 13

22 Studies have shown that prior communication and post-injury demonstrations of concern by the employer can result in higher levels of worker satisfaction and reduced time lost from work factors that contribute to lower program costs. ENSURE PROMPT TREATMENT FROM THE RIGHT MEDICAL PROVIDERS Helping the injured worker get immediate medical attention pays off for both worker and employer on several levels. Typically, the sooner injured workers receive proper treatment, the sooner they may return to work. Under the New Jersey workers compensation law, the employer and/ or its insurance carrier select the medical providers to treat injured workers for work-related injuries. Such control of medical treatment is an important employer right and obligation. When a workplace accident or occupational exposure occurs, the injured worker should be offered prompt medical treatment. Employers should keep in mind that providing medical coverage is not considered an admission of liability (N.J.S.A. 34:15-15). VII. CLAIM PETITIONS IN WORKERS COMPENSATION Employees who are injured on the job may file a workers compensation claim petition with the New Jersey Division of Workers Compensation. Issues may include compensability of the claim (whether the injury/ illness is considered work related), the type and extent of medical treatment, and/or the payment of temporary disability benefits. Further, a claim petition may seek permanent disability benefits and, in cases of alleged job-related death, dependency benefits. Workers are generally represented by an attorney but they may file a claim petition on their own (pro se). An insurance carrier will usually provide a legal defense on behalf of a covered employer. If you are a self-insured corporation, it is required that you or your third-party administrator obtain legal representation to defend your interests. The vast majority of claim petitions are settled by mutual agreement as to the amount of benefits due and extent of disability. In cases where an agreement is not reached, a workers compensation judge will resolve the disputed issues. 14

23 An insurance carrier, drawing on their extensive knowledge of the law and taking into consideration all the pertinent facts of the case, can make a decision to accept or deny a claim. Stay aware of whether claims are investigated timely, whether benefits are being paid on time, and whether claims are being disputed or accepted. The employer plays a key role in working with the carrier and the injured worker to ensure that the system works smoothly and fairly. VIII. WHAT ELSE DOES AN EMPLOYER NEED TO KNOW? DISCRIMINATION COMPLAINTS It is unlawful for any employer to discharge or otherwise discriminate against an employee because the employee claimed or attempted to claim workers compensation benefits or because the employee testified or is about to testify in a workers compensation matter. The Division of Workers Compensation is responsible for investigating such claims. SECOND INJURY FUND The Second Injury Fund (SIF), which is administered by the Division of Workers Compensation, makes benefit payments to injured workers who are totally and permanently disabled as a result of work-related injuries combined with pre-existing disabilities. The Second Injury Fund was established to encourage employers to hire disabled workers. The employer only pays for the work-related aspect of the total disability award. DIVISION OF WORKERS COMPENSATION WEB SITE The Division of Workers Compensation maintains an Internet Web site that contains the latest information on New Jersey workers compensation, including legal and administrative procedures, forms and brochures, statistical data, and program details. The Web address is 15

24 CONTACTS FOR QUESTIONS If you have questions about New Jersey s workers compensation program, please contact: New Jersey Department of Labor and Workforce Development Division of Workers Compensation P.O. Box 381 Trenton, NJ (609) Fax: (609) dwc@dol.state.nj.us If you have questions about workers compensation insurance rates or obtaining coverage, please contact: New Jersey Compensation Rating and Inspection Bureau 60 Park Place Newark, NJ (973)

25 New Jersey Department of Labor and Workforce Development Division of Workers Compensation P.O. Box 381 Trenton, NJ (609) Fax: (609) WC-373 (7/10) 17

26 NEW JERSEY BENEFIT STATUS LETTER Medical Only [Claim Administrator Letterhead] [Claim Administrator Address] Date of notice: To: [NAME OF INJURED EMPLOYEE] [ADDRESS] [CITY, STATE, ZIP] Date of Injury: Insurance Claim #: Agency Claim #: Dear [Injured Worker Name], I am handling your claim for workers compensation benefits. In accordance with [Jurisdiction {New Jersey}] law, I am sending you a summary of your claim and benefits paid to date. The information contained in this notice has already been provided to the state in an electronic format. According to our records, your injury occurred while you were working for: Name of Employer: Employer s Address: Your claim has been acknowledged as a medical only claim. ****If there is a value of 350,360 or 370 in DN0095 Paid to Date/Reduced Earnings/Recoveries Code (for release 1) or DN0216 Other Benefit type Code (for Release 3), insert this paragraph and Benefit section: To date, we have paid the following benefits in relation to your work related injury: Benefit Description Paid to Date If you do not agree with the information contained in this letter or if you have any questions, please contact me via one of the methods below: Adjuster s Name: Telephone #: Fax #: Address: Or you may write to the NJ Division of Workers Compensation at PO Box 381, Trenton, NJ , Attn: EDI Coordinator. A copy of your letter must be sent to the insurance carrier.

27 NEW JERSEY BENEFIT STATUS LETTER Indemnity [Claim Administrator Letterhead] [Claim Administrator Address] Date of notice: TO: [NAME OF INJURED EMPLOYEE] [ADDRESS] [CITY, STATE, ZIP] Date of Injury: Insurance Claim #: Agency Claim #: Dear [Injured Worker Name], I am handling your claim for workers compensation benefits. In accordance with [Jurisdiction {New Jersey}] law, I am sending you a summary of your claim and benefits paid to date. The information contained in this notice has been provided to the state in an electronic format. Only the boxes checked or information provided applies to your workers compensation claim. This notice is with reference to the following status of your workers compensation claim: ( ) You were released to return to work on ( ) Your injury reached maximum medical improvement status on ( ) Your injury was assigned a permanent impairment rating as follows: [Permanent Impairment Percent] of the [Permanent Impairment Body Part] ( ) This workers compensation claim involves a fatality that occurred on and we [have/have not] been providing death benefits on this claim. According to our records, your injury occurred while you were working for: Name of Employer: Employer s Address: At the time of the injury, your average weekly wage was $ Items such as overtime, lodging, uniforms, etc. [were/were not] applicable to the average weekly wage calculation, pursuant to jurisdictional requirements. Based on your average weekly wage, your weekly benefit rate was calculated at $ ****If maximum medical improvement box was checked above, insert this paragraph: Once maximum medical improvement has been reached, you are no longer eligible for temporary disability benefits; but if you sustained a permanent disability, you may be entitled to permanent benefits. The weekly benefit is defined by statute with a value based upon degree of impairment. ****If the employer continued salary during the temporary disability benefit period (Release 1: DN0067 Salary Continued Y/N = Yes or Release 3: DN0273 Employer Paid Salary in Lieu of Compensation=Y). Include the following paragraph. Your employer elected to continue paying your salary during your temporary disability period and in lieu of workers compensation benefits except for the following benefits we provided and that are listed below.

28 To date, we have provided the following workers compensation indemnity benefits for your injury: Benefit Description Paid To Date From/Through Dates # Weeks # Days (*****insert printout of benefits paid by benefit type*****) If you do not agree with the information contained in this letter, please contact me via one of the methods below: Adjuster s Name: Telephone #: Fax #: Address: Or you may write to the NJ Division of Workers Compensation at PO Box 381, Trenton, NJ , attn: EDI Coordinator. A copy of your letter must be sent to the insurance carrier.

29 SPECIAL NOTE There is a specific limitation to the release duration for this state, which is incorporated at number 3 on the release form. Scroll to Next Page for Release Form 1

30 AUTHORIZATION FOR RELEASE AND USE OF MEDICAL INFORMATION I authorize each of the parties identified below to use and disclose any and all of my individually identifiable medical or health information, as described below, for purposes of administering my claim or request for reasonable accommodation. I understand that the information about me that I authorize to be used or disclosed may be redisclosed in accordance with the terms of this Authorization by the recipient thereof and may no longer be protected by federal or state privacy laws or regulations. I specifically authorize physicians, nurses and hospitals to communicate my individually identifiable medical or health information by any means, including written or telephonic communications or by direct interview, whether or not I am present during, or notified of, such communications, and I hereby authorize Sedgwick Claims Management Services, Inc. ("Sedgwick") to initiate and conduct such communications whether or not I am present or have received notice thereof. 1. What Information is covered by this Authorization? This authorization applies to all medical, health, psychological, and/or psychiatric information, records and reports, including information regarding pre-existing health or medical conditions or illnesses (a) that are in existence while this authorization is valid (see Item 3) and (b) that are related to any of the following: my request for reasonable accommodation; my workers compensation claim; my claim for disability benefits; my claim for bodily injury; my claim for personal injury; my claim for FMLA or my claim for dental benefits. My claim or request for reasonable accommodation involves the following condition: My information to be disclosed may include, but is not limited to, medical or health history, chart notes, prescriptions, diagnostic test results, x-ray reports, and records received from other health care providers. If directly related to my claimed condition or illness, this information may include the following, Please check yes or no and initial: HIV test results, HIV or AIDS information. YES NO Initial here Psychiatric information. YES NO Initial here Information related to drug or alcohol abuse. YES NO Initial here The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic information as defined by GINA, includes an individual s family medical history, the results of an individual s or family member s genetic tests, the fact that an individual or an individual s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. 2. Who may disclose and receive Information under this Authorization? A. Any person or facility that attends, treats or examines me, including but not limited to (specific name, if needed) is to make this information available to Sedgwick or any of its agents, representatives or independent contractors; and B. When relevant to my claim, Sedgwick may re-disclose (without my further authorization) any and all of my individually identifiable medical or health information (whether obtained pursuant to this authorization or otherwise from any person or entity) to any of the following, (a) Any person or facility that attends, treats or examines me; (b) Any person or facility that impacts determination of my claim or that coordinates my benefits; (c) My employer and its affiliates and their representatives, independent contractors and service providers that may receive any such information from my employer to the extent permitted by state or federal law; or (d) The Social Security Administration or a social security or vocational rehabilitation vendor. Sedgwick may use my information obtained pursuant to this authorization in any other claim matter that Sedgwick may administer or handle related to me. 3. How Long this Authorization is Valid? This authorization is valid during the duration of my claim(s) and any future related claims, unless a different period is required under applicable federal or state law (Release in connection with a claim for benefits for health insurance may not remain valid longer than the term of coverage of the policy; or for the duration of the claim for all other insurance claims). 4. Revocation of this Authorization. Unless otherwise provided by federal or state law, I understand that I may revoke this authorization at any time by notifying, in writing, Sedgwick at of my revocation and that my revocation shall be effective upon Sedgwick receipt of my notice of revocation. I also understand that my revocation of this Authorization will not have any effect on any actions taken by Sedgwick before its receives my revocation. 2

31 5. Processing of Claims. I understand that this Authorization is generally necessary for the processing of my claim or request for reasonable accommodation. Failure to sign this Authorization may impair or impede the processing of my claim or request for reasonable accommodation. 6. Refusal To Sign. I further understand my health care providers will not condition my treatment, payment, enrollment or eligibility on my refusal to sign this Authorization. I understand that I have the right to request and receive a copy of this authorization. I understand that I have the right to inspect the disclosed information at any time. A photocopy of this authorization shall be valid and is to be accepted with the same effect as the original. Signature of Patient or Patient s Representative Printed Name of Patient or Patient s Representative Representative s Relationship to Patient, if applicable Date Signed Sedgwick 7/2013 Patient s Address Patient s Social Security Number First Day Absent Date of Birth Sedgwick Claims Management Services, Inc. NOTICE OF STATE FRAUD REQUIREMENTS Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. 3

32 AUTORIZACIÓN PARA USO Y DIVULGACIÓN DE INFORMACIÓN MÉDICA Yo, autorizo a cada una de las partes identificadas a continuación, para usar y divulgar cualquier y toda información médica y de salud inidentificable individualmente como mía, como se describe más adelante, para propósitos de administración de mi solicitud o petición para un acomodo razonable. Entiendo que la información sobre mí, que yo autorizo para uso y divulgación, puede estar sujeta a divulgación posterior, de acuerdo con los términos de esta Autorización, por parte del destinatario de ésta y que es posible que ya no esté protegida por las leyes y regulaciones federales o del estado sobre privacidad. Autorizo, específicamente, a médicos, enfermeras y hospitales para comunicar la información de salud o médica identificable individualmente como mía, a través de cualquier medio, incluidas comunicaciones escritas o telefónicas, o por entrevista directa, sea que este presente o se me haya notificado o no, de dichas comunicaciones, y por la presente, autorizo a Sedgwick Claims Management Services, Inc. ("Sedgwick") para iniciar y realizar dichas comunicaciones, sea que este presente o haya recibido notificación de esto o no. 1. Qué información está incluida en esta Autorización? Esta autorización se aplica a toda la información, registros e informes médicos, de salud, sicológicos y/o psiquiátricos, incluida información sobre condiciones o enfermedades médicas o de salud preexistentes (a) que estén en existencia durante la validez de esta autorización (ver Punto 3) y (b) que estén relacionadas con cualquiera de las siguientes solicitudes: mi solicitud de acomodo razonable, mi solicitud de compensación del trabajador; mi solicitud de prestación por invalidez, mi solicitud por lesión corporal, mi solicitud por accidentes personales, mi solicitud de FMLA o mi solicitud de prestaciones dentales. Mi solicitud o petición para acomodo razonable involucra las siguientes condiciones: Mi información, que será divulgada, puede incluir, pero no se limita a, historia médica o de salud registros médicos, prescripciones, resultados de evaluaciones de diagnóstico, informes de rayos X y registros recibidos de otros prestadores de salud. Esta información puede incluir lo siguiente, si está directamente relacionada con las condiciones o enfermedades demandadas. Por favor, marque sí o no e inicial: resultados de pruebas de VIH, información sobre VIH o SIDA SÍ NO Inicial aquí Información siquiátrica. SÍ NO Inicial aquí Información relacionada con abuso de drogas o alcohol. SÍ NO Inicial aquí La Ley contra la discriminación de información genética de 2008 (GINA, por sus siglas en inglés) prohíbe a los empleadores y otras entidades que abarca el Título II de la GINA solicitar o requerir información genética de un individuo o miembro de la familia del individuo, excepto en los casos específicamente permitidos por esta ley. Para cumplir con esta ley, le solicitamos no brindar ninguna información genética cuando responda a esta solicitud de información médica. Información genética, como lo define la GINA, incluye la historia médica de la familia de un individuo, los resultados de pruebas genéticas del individuo o la de un miembro de su familia, el hecho de que un individuo o un miembro de la familia del individuo buscó o recibió servicio genéticos e información genética de un feto que el individuo o un miembro de la familia del individuo está gestando o un embrión en el vientre legalmente en el individuo o un miembro de la familia del individuo que recibe servicios reproductivos de asistencia. 2. Quién puede divulgar y recibir información bajo esta Autorización? A. Cualquier persona o entidad que me atienda, trate o examine, incluida, pero no limitada a (nombre específico, si es necesario) para poner esta información a disposición de Sedgwick o cualquiera de sus funcionarios, representantes o contratistas independientes; y B. Cuando sea pertinente a mi solicitud, Sedgwick puede divulgar posteriormente (sin autorización ulterior) cualquier o toda información médica o de salud identificada individualmente como mía (fuese obtenida de acuerdo con esta autorización o, de lo contrario, de otra persona o entidad) a cualquiera de los siguientes: (a) cualquier persona o institución que me atienda, trate o examine; (b) cualquier persona o institución que influya en la determinación de mi solicitud o que coordine mis beneficios; (c) mi empleador y sus afiliados y sus representantes, contratistas independientes y prestadores de servicios que puedan recibir tal información de mi empleador hasta al grado que permite la ley federal o estatal, o (d) la Dirección del Seguro Social o el proveedor de seguro social o rehabilitación vocacional. Sedgwick puede usar mi información, obtenida de acuerdo con esta autorización, en cualquier otra materia de solicitud que Sedgwick pueda administrar o manejar en relación a mí. 3. Por cuánto tiempo es válida esta Autorización? Esta autorización es válida por el período de duración de mi(s) petición(es) y de cualquier petición relacionada futura; a menos que se requiera un período diferente de acuerdo con la ley federal o estatal correspondiente..(la revelación de información con relación a un reclamo de beneficios del seguro de salud no podrá tener una validez mayor al plazo de cobertura de la póliza, o a la duración del reclamo para todos los demás reclamos del seguro). 4

33 4. Revocación de esta Autorización. A menos que la ley federal o estatal establezca otra cosa, entiendo que puedo revocar esta autorización en cualquier momento al notificar, por escrito, a Sedgwick a de mi revocación y que ésta entrará en efecto una vez que Sedgwick haya recibido mi notificación de revocación. También entiendo que mi revocación de esta Autorización no tendrá ningún efecto sobre las acciones tomadas por Sedgwick antes del recibo de mi revocación. 5. Procesamiento de una Solicitud. Entiendo que esta Autorización, generalmente, es necesaria para el procesamiento de una solicitud o petición de acomodo razonable. El no firmar esta autorización puede perjudicar o impedir el procesamiento de mi solicitud o petición de acomodo razonable. 6. Denegación de Firma Además, entiendo que mis prestadores de atención médica no condicionarán mi tratamiento, pago, inscripción o elegibilidad, en caso de negarme a firmar esta Autorización. Entiendo que tengo derecho a solicitar y recibir una copia de esta autorización. Entiendo que tengo derecho de inspeccionar la información divulgada en cualquier momento. Una fotocopia de esta autorización será válida y aceptada con el mismo efecto que el original. Firma del Paciente o Su Representante Dirección del Paciente: Nombre del Paciente o Su Representante Parentesco del Representante con el Paciente, si corresponde Día de Firma Sedgwick 7/2013 Número del Seguro Social del Paciente Primer Día Ausente Fecha de Nacimiento Sedgwick Claims Management Services, Inc. AVISO DE REQUISITOS DE FRAUDE ESTATAL Toda persona que intencionalmente presenta una declaración que contenga información falsa o engañosa está sujeta a sanciones penales y civiles. Toda persona que incluya información falsa o engañosa en la solicitud de una póliza de seguro está sujeta a sanciones penales y civiles. 5

34 To Report a Claim T: 855-7ATLAS7 ( ) F: AtlasGeneralInsurance@sedgwickcms.com Sedgwick Customer Service Linda Pettitt T: Linda.pettitt@sedgwickcms.com States Serviced Service Office / Contact Office Information Alabama Dallas National program Teresa Carden, Asst. Manager T: F: Teresa.carden@sedgwickcms.com Sedgwick CMS P.O. Box Lexington, KY Arizona Republic Underwriters program Arkansas Dallas National program California Republic Underwriters program Georgia Dallas National program Illinois Dallas National program Indiana Dallas National program Mississippi Dallas National program William Herring, Claims Director T: F: William.herring@sedgwickcms.com Teresa Carden, Asst. Manager T: F: Teresa.carden@sedgwickcms.com Christopher Perez, AVP T: F: Christopher.perez@sedgwickcms.com Teresa Carden, Asst. Manager T: F: Teresa.carden@sedgwickcms.com Jennifer Krikie, Claims Director T: F: Jennifer.krikie@sedgwickcms.com Jennifer Krikie, Claims Director T: F: Jennifer.krikie@sedgwickcms.com Teresa Carden, Asst. Manager T: F: Teresa.carden@sedgwickcms.com Sedgwick CMS P.O. Box Lexington, KY Sedgwick CMS P.O. Box Lexington, KY Sedgwick CMS P.O. Box Lexington, KY Sedgwick CMS P.O. Box Lexington, KY Sedgwick CMS P.O. Box Lexington, KY Sedgwick CMS P.O. Box Lexington, KY Sedgwick CMS P.O. Box Lexington, KY /5/2014