On behalf of the A.I.M. Mutual Insurance Companies, I welcome you as a policyholder.

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1 A.I.M. Mutual Insurance Company Associated Employers Insurance Company Massachusetts Employers Insurance Company New Hampshire Employers Insurance Company Claim Kit in partnership with you

2 On behalf of the A.I.M. Mutual Insurance Companies, I welcome you as a policyholder. As your new workers compensation insurance carrier, we ask that you report all accidents to us as soon as possible after they occur. Your prompt notification together with a complete accident report will help us to handle your claims fairly and efficiently. Enclosed is a supply of the necessary forms along with instructions for their use. Please feel free to contact us at any time with your questions or service requests. Sincerely, Laura Parsons, WCLA, FCLA Claim Technical Director

3 54 Third Avenue, Burlington, MA Workers Compensation New Hampshire Claim Reporting Options In the event of a serious accident, call us immediately at (toll free 24-hour/7 day a week claim reporting) Choose from several different ways to report your workers compensation claims to us: By Fax: For all claims, complete and fax the Employers First Report of Occupational Injury or Disease form (Form 8WC) into us at Form 8WC should be filed as soon as possible after knowledge of an employee s job-related injury or disease but no later than five days thereafter. We will file Form 8WC with the State of New Hampshire Department of Labor. If this or any injury results in an employee being disabled for four or more calendar days, complete and fax the Form 13 WCA (Employers Supplemental Report of Injury) to us at It must be filed as soon as possible after date of knowledge of an occupational injury or disease, but no later than ten days thereafter. We will file this form with the New Hampshire Department of Labor. On-Line, over the Internet: Sign on to and click Report A Claim. Select To Report A Claim Online and then click on New Hampshire. You will be prompted to answer a series of questions similar to the information necessary to complete a Form 8WC. After answering all of the questions and clicking on SEND, you will receive a message stating your claim has been submitted. It will also state that a Claim Acknowledgement letter containing the claim number and assigned claim representative will be mailed to your company after registration has been completed. Click Print for a copy of the information you sent. We will file Form 8WC (and Form 13WCA if appropriate) with the State of New Hampshire Department of Labor. If the claim is originally reported to us as a Medical Only claim but the injured employee is then disabled for four (4) or more calendar days, please notify us by faxing or mailing Form 13 WCA to us, which we will then file with the Department of Labor. By Phone: Report claims by calling toll free: This line is established for reporting new claims only, and facilitates the initial claim reporting process. Please have your claim number on hand prior to calling. You will receive a completed Form 8WC and a confirmation letter, followed by a claim acknowledgment letter including the name of the Claim Representative assigned to your case. We will file Form 8WC (and Form 13WCA, if appropriate) with the Department of Labor. If the claim is originally reported to us as a Medical Only claim but the injured employee is then disabled for four (4) or more calendar days, please notify us by faxing or mailing Form 13 WCA to us which we will then file with the Department of Labor.. After the initial claim report: Please direct ongoing claim and service inquiries to your Claim Representative at our toll free telephone number: By Mail: Please refer to the Claim Reporting Procedures in your Claims Folder for instructions.

4 A.I.M. Mutual Insurance Companies New Hampshire Internet Claim Reporting --

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6 State of New Hampshire Workers Compensation Claim Reporting Procedures IT IS IMPORTANT THE INSTRUCTIONS IN THESE PROCEDURES BE FOLLOWED EXACTLY AS OUTLINED. Prompt filing of the correct forms with all the necessary information helps speed necessary claim investigations and the proper payments of benefits when due. LATE FILINGS OR LATE PAYMENTS MAY ALSO RESULT IN PENALTIES IMPOSED ON YOUR COMPANY AND/OR A.I.M. MUTUAL INSURANCE COMPANIES AS YOUR INSURER. Keep in mind: If it s a serious accident, call us immediately: We will file the Form 8WC and Form 13WCA, if applicable, with the State of New Hampshire Department of Labor. If you need additional forms, they may be requested from A.I.M. Mutual Insurance Companies at , Claim Services Department or downloaded from the New Hampshire Department of Labor (DOL) website: For any job-related claim: Applicable Forms include: 1. Form No. 8WC Employer s First Report of Occupational Injury or Disease 2. Form No. 8aWCA Notice of Accidental Injury or Occupational Disease Additional forms for any lost time claim: 1. Form No. 13 WCA Employer s Supplemental Report of Injury 2. Form No. 76 WCA Wage Schedule 1

7 Faxing or Mailing Medical Only and/or Loss of Time Claims A. Complete Employer s First Report of Occupational Injury or Disease (Form No. 8WC) You need to complete the Employer s First Report of Occupational Injury or Disease (Form No. 8WC) as soon as possible after knowledge of an employee s job-related injury or disease, but no later than five days thereafter. The timing of the filing of Form No. 8WC is very important. Please file this report with us within five days of the injury or disease, or within five days of your receiving notice. We will file Form 8WC (and 13WCA, if needed) with the State of New Hampshire Department of Labor. If you phone in or report a new claim over the Internet, a completed Form 8WC will be sent to you. (If the claim is originally reported to us as a medical only claim but the injured employee is then disabled for four (4) or more calendar days, please notify us by faxing or mailing Form 13WCA to us which we will then file with the Department of Labor.) Form No. 8WC Employee Information Section - The injured worker s supervisor or similar person in authority should complete the information requested in areas 1 through 38. Employer Information - The injured worker s supervisor or similar person in authority should complete the information requested in areas 39 through 53 and obtain the signature of an authorized company representative (areas 54 and 55). Whenever possible, the injured employee should be asked to sign and date this form (areas 56-57). Copies of this form should be distributed as follows: 1 st Copy: A.I.M. Mutual Ins. Cos. Claim Department 54 Third Avenue P.O. Box 4070 Burlington, MA Fax: nd Copy: Employer s File Copy 3 rd Copy: Employee s Copy B. Notice of Accidental Injury or Occupational Disease (Form No. 8aWCA) This report must be completed under the same guidelines as the Employer s First Report of Occupational Injury or Disease (Form 8WC). Photocopies of this form should be mailed along with the First Report to: A.I.M. Mutual Insurance Companies 54 Third Avenue P. O. Box 4070 Burlington, MA (The original should be kept by the employer; the second copy given to the employee.) 2

8 II. LOST TIME CLAIMS A. Employer s Supplemental Report of Injury (Form No. 13 WCA) (For employee disability of four or more days. Also completed upon employee s return to work, full duty.) The Employer s Supplemental Report of Injury (Form No. 13 WCA) must be completed and filed in the event an employee s disability extends to four or more calendar days. It must be filed as soon as possible after the date of knowledge of an occupational injury or disease, but no later than ten days thereafter (per New Hampshire Workers Compensation law RSA 281-A:53). A.I.M. Mutual Ins. Cos. will file Form 13WCA with the Department of Labor. This form should be completed by the injured worker s supervisor or similar person in authority and signed by an authorized representative of the company. Copies of this form should be distributed as follows: 1 st Copy: A.I.M. Mutual Ins. Cos. Claim Department 54 Third Avenue P.O. Box 4070 Burlington, MA Fax: nd Copy: Employer s File Copy 3 rd Copy: Employee Copy B. WAGE SCHEDULE (Form No. 76 WCA) The Wage Schedule must be completed and submitted to A.I.M. Mutual Ins. Cos. together with the Employer s Supplemental Report of Injury (Form No. 13 WCA), but no later than the employee s fifteenth day of disability resulting from an industrial accident. Note: Two copies of Form No. 76 WCA must be sent to A.I.M. Mutual Ins. Cos. with Form No. 13 WCA. Copies of Form No. 76 WCA should be distributed as follows: Two Copies: A.I.M. Mutual Ins. Cos. Claim Department 54 Third Avenue P.O. Box 4070 Burlington, MA Additional Copies: For Employee and for Employer File 3

9 Alternative Work Duties New Hampshire Workers Compensation law (RSA 281-A:23-b) mandates that employers give injured employees the opportunity to work in an alternative capacity. The law applies to employers with five or more employees. Specifically, employers must identify and design alternative job duties with the intent of returning the injured employee to his/her original job as quickly as possible. Working directly with the injured employee, the health care provider and your A.I.M. Mutual Insurance Companies Claim Representative will determine the best way to develop alternative job duties that meet the needs of all involved. 4

10 Return to: EMPLOYER S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE (Form 8WC) The State of New Hampshire, Department of Labor P.O. Box 2077, Concord, NH (603) FAX: (603) NH DOL USE ONLY IMPORTANT; Every employer shall file this report as soon as possible after knowledge of any occupational injury or disease to an employee, but no later than five days thereafter. Notice of disability of four or more days shall be filed no later than seven days after date of injury on Supplemental Report Form No. 13WCA. Failure to comply with any or all of the above carries a civil penalty of up to $2, RSA 281A:53. PLEASE TYPE OR PRINT. ILLEGIBLE OR INCOMPLETE FORMS WILL BE RETURNED. 1. Name of injured: First Middle Initial Last 2. DOB: 3. Age: 4. Male 5. SS No.: 6. Address: No. & St. City/Town 7. State: 8. Zip Code: 9. Tel. No.: Female 10. Is there on file a N.H. Youth 11. Occupation when injured: 12. Was this his/her regular occupation? 13. Wages per hr.: 14. No. hrs. worked per day: Employment Certificate?: If not, state regular occupation: 15. No. days worked per week: 16. Average Weekly Earnings: 17. Was injured hired in N.H.? 18. Date employment began: 19. Date & Time of Injury: EMPLOYER INFORMATION EMPLOYEE INFORMATION 20. Date disability began: 21. Was injured paid in 22. Date supervisor/employer 23. Name of Person notified: 24. Location/Jobsite where accident occured: full for this day? was first notified: 25. Describe fully how accident occurred and describe what employee was doing when injured: 26. Name of witness(es): 27. Part(s) of body injured: 28. Estimated length of disability: 29. Has injured returned to work? 30. If so, what date? 31. At what occupation or job? 32. Returned at: Full Duty: Alternative/Light Duty: 33. Equipment causing injury: 34. Were safeguards in place? 35. Was accident caused by injured s failure to use safeguards or follow regulations? 36. Initial Treatment: (check those that apply) No medical treatment: Care provide by Employer only (on-site): Emergency care: Hospitalized: Other: (Outpatient): (Clinic): (Office Visit): (Other-explain): 37. Name of treating physician: Name of treating hospital: 38. Has injured died? If so, what date? 39. Legal Business Name and/or D/B/A or Leasing Company Name: 40. Employers Federal ID: 41. If leased or temporary worker, client s business name: 42. Business Address of No. 39 above: 43. City/State: 44. Zip: 45. Telephone Number: 46. Insurance Co. (not agent) or Self Insured Group: 47. Managed Care Program? Y or N. If yes, name Provider: 48. No. of Employees: Full-time: Part-time: 49. Is there a Written Safety Program in force? 50. Is there an active Safety Committee? 51. Business SIC Code 52. Type or Nature of Business in N.H.: 53. If report sent by Insurance Agency, state name: 54. Employer Signature: 55. Printed/Typed Name and Official Title: 56. Employee Signature (whenever possible): 57. Date of this report: Form 8WC (7-95) White Labor Department Canary Insurance Claims Office Pink Employer s Copy

11 Return to: EMPLOYER S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE (Form 8WC) The State of New Hampshire, Department of Labor P.O. Box 2077, Concord, NH (603) FAX: (603) NH DOL USE ONLY IMPORTANT; Every employer shall file this report as soon as possible after knowledge of any occupational injury or disease to an employee, but no later than five days thereafter. Notice of disability of four or more days shall be filed no later than seven days after date of injury on Supplemental Report Form No. 13WCA. Failure to comply with any or all of the above carries a civil penalty of up to $2, RSA 281A:53. PLEASE TYPE OR PRINT. ILLEGIBLE OR INCOMPLETE FORMS WILL BE RETURNED. 1. Name of injured: First Middle Initial Last 2. DOB: 3. Age: 4. Male 5. SS No.: 6. Address: No. & St. City/Town 7. State: 8. Zip Code: 9. Tel. No.: Female 10. Is there on file a N.H. Youth 11. Occupation when injured: 12. Was this his/her regular occupation? 13. Wages per hr.: 14. No. hrs. worked per day: Employment Certificate?: If not, state regular occupation: 15. No. days worked per week: 16. Average Weekly Earnings: 17. Was injured hired in N.H.? 18. Date employment began: 19. Date & Time of Injury: EMPLOYER INFORMATION EMPLOYEE INFORMATION 20. Date disability began: 21. Was injured paid in 22. Date supervisor/employer 23. Name of Person notified: 24. Location/Jobsite where accident occured: full for this day? was first notified: 25. Describe fully how accident occurred and describe what employee was doing when injured: 26. Name of witness(es): 27. Part(s) of body injured: 28. Estimated length of disability: 29. Has injured returned to work? 30. If so, what date? 31. At what occupation or job? 32. Returned at: Full Duty: Alternative/Light Duty: 33. Equipment causing injury: 34. Were safeguards in place? 35. Was accident caused by injured s failure to use safeguards or follow regulations? 36. Initial Treatment: (check those that apply) No medical treatment: Care provide by Employer only (on-site): Emergency care: Hospitalized: Other: (Outpatient): (Clinic): (Office Visit): (Other-explain): 37. Name of treating physician: Name of treating hospital: 38. Has injured died? If so, what date? 39. Legal Business Name and/or D/B/A or Leasing Company Name: 40. Employers Federal ID: 41. If leased or temporary worker, client s business name: 42. Business Address of No. 39 above: 43. City/State: 44. Zip: 45. Telephone Number: 46. Insurance Co. (not agent) or Self Insured Group: 47. Managed Care Program? Y or N. If yes, name Provider: 48. No. of Employees: Full-time: Part-time: 49. Is there a Written Safety Program in force? 50. Is there an active Safety Committee? 51. Business SIC Code 52. Type or Nature of Business in N.H.: 53. If report sent by Insurance Agency, state name: 54. Employer Signature: 55. Printed/Typed Name and Official Title: 56. Employee Signature (whenever possible): 57. Date of this report: Form 8WC (7-95) White Labor Department Canary Insurance Claims Office Pink Employer s Copy

12 THE STATE OF NEW HAMPHSIRE DEPARTMENT OF LABOR SPAULDING BUILDING 95 PLEASANT STREET CONCORD, NEW HAMPSHIRE NOTICE OF ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE 8aWCA (Please print or type) To Phone # (Name of Employer) (Business Name and Address) IN ACCORDANCE WITH RSA 281-A:20, This is to notify you that an injury occurred. SS # (Name of Injured Employee) Daytime Phone # (Address of Injured Employee) (Date of Accident or First Treatment) (Place Accident Happened) Describe your injury or disease, and how it happened. Identify the body part(s) affected. I have been unable to work since my injury. Yes No I have incurred the following medical bills. Name of Doctor Dates of Service Amount Name of Hospital Dates of Service Amount Other Dates of Service Amount (Employer s Signature) (Date) (Employee s Signature) (Date) This form can be returned to DOL with or without employer s signature. NOTICE TO EMPLOYER YOU MUST FILE AN EMPLOYER S FIRST REPORT, Form No. 8WC, WITH THE LABOR COMMISSIONER AND THE NEAREST CLAIMS OFFICE OF YOUR INSURANCE CARRIER, AS SOON AS POSSIBLE AFTER ACQUIRING KNOWLEDGE OF THE OCCURRENCE OF AN OCCUPATIONAL INJURY OR DISEASE TO ONE OF YOUR EMPLOYEES OR UPON PRESENTATION OF THIS NOTICE BY HIM, BUT NO LATER THAN FIVE DAYS THEREAFTER. FAILURE TO COMPLY CARRIES AN AUTOMATIC CIVIL PENALTY OF UP TO $2500. (RSA 281-A:53) Form No. 8aWCA (Rev. 08/01) Employer s Copy White Employee s Copy - Pink

13 THE STATE OF NEW HAMPHSIRE DEPARTMENT OF LABOR SPAULDING BUILDING 95 PLEASANT STREET CONCORD, NEW HAMPSHIRE NOTICE OF ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE 8aWCA (Please print or type) To Phone # (Name of Employer) (Business Name and Address) IN ACCORDANCE WITH RSA 281-A:20, This is to notify you that an injury occurred. SS # (Name of Injured Employee) Daytime Phone # (Address of Injured Employee) (Date of Accident or First Treatment) (Place Accident Happened) Describe your injury or disease, and how it happened. Identify the body part(s) affected. I have been unable to work since my injury. Yes No I have incurred the following medical bills. Name of Doctor Dates of Service Amount Name of Hospital Dates of Service Amount Other Dates of Service Amount (Employer s Signature) (Date) (Employee s Signature) (Date) This form can be returned to DOL with or without employer s signature. NOTICE TO EMPLOYER YOU MUST FILE AN EMPLOYER S FIRST REPORT, Form No. 8WC, WITH THE LABOR COMMISSIONER AND THE NEAREST CLAIMS OFFICE OF YOUR INSURANCE CARRIER, AS SOON AS POSSIBLE AFTER ACQUIRING KNOWLEDGE OF THE OCCURRENCE OF AN OCCUPATIONAL INJURY OR DISEASE TO ONE OF YOUR EMPLOYEES OR UPON PRESENTATION OF THIS NOTICE BY HIM, BUT NO LATER THAN FIVE DAYS THEREAFTER. FAILURE TO COMPLY CARRIES AN AUTOMATIC CIVIL PENALTY OF UP TO $2500. (RSA 281-A:53) Form No. 8aWCA (Rev. 08/01) Employer s Copy White Employee s Copy - Pink

14 THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR Employer s Supplemental Report of Injury This report, indicating disability of an employee of four or more days, shall be filed as soon as possible after date of knowledge of an occupational injury or disease, but no later than ten days thereafter. Consistent failure to make this report available to the labor commissioner and the nearest claims office of your insurance carrier carries an automatic civil penalty of up to $ (RSA 281-A:53) This report shall also be submitted upon employee s return to work. 1. Name of Employer Employer s Identification No. (9 digit number assigned by proper Federal Agency) 2. Address 3. Insured by (No. and St.) (City and State) (Zip Code) 4. Name of Employee (First Name) (Middle Initial) (Last Name) (S.S. Number) 5. Address (No. and St.) (City and State) (Zip Code) 6. Date of injury Date Disability began 19 A.M. P.M. 8. (Specific dates of disability) (Specific dates of disability) 9. Has injured returned to work? if so, date and hour A.M. P.M. 10. Is injured person earning same wages as before injury? If not, explain Date of Report Signed by Official Title Tel. No. Form No. 13 WCA (7-89) WHITE LABOR DEPT. CANARY INSURANCE CLAIMS OFFICE PINK EMPLOYER S COPY

15 THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR Employer s Supplemental Report of Injury This report, indicating disability of an employee of four or more days, shall be filed as soon as possible after date of knowledge of an occupational injury or disease, but no later than ten days thereafter. Consistent failure to make this report available to the labor commissioner and the nearest claims office of your insurance carrier carries an automatic civil penalty of up to $ (RSA 281-A:53) This report shall also be submitted upon employee s return to work. 1. Name of Employer Employer s Identification No. (9 digit number assigned by proper Federal Agency) 2. Address 3. Insured by (No. and St.) (City and State) (Zip Code) 4. Name of Employee (First Name) (Middle Initial) (Last Name) (S.S. Number) 5. Address (No. and St.) (City and State) (Zip Code) 6. Date of injury Date Disability began 19 A.M. P.M. 8. (Specific dates of disability) (Specific dates of disability) 9. Has injured returned to work? if so, date and hour A.M. P.M. 10. Is injured person earning same wages as before injury? If not, explain Date of Report Signed by Official Title Tel. No. Form No. 13 WCA (7-89) WHITE LABOR DEPT. CANARY INSURANCE CLAIMS OFFICE PINK EMPLOYER S COPY

16 THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, N.H WAGE SCHEDULE Employee (NAME) Date of hire Wages per hour Avg. wkly. earnings Employer Address (NAME) (NO.) (STREET) (CITY-STATE) EMPLOYER MUST FORWARD TO INSURANCE CARRIER BOTH COPIES OF THIS SCHEDULE AND CARRIER S COPY OF THE SUPPLEMEN- TAL REPORT FORM NO. 13 WCA NO LATER THAN EMPLOYEE S FIFTEENTH DAY OF DIS- ABILITY RESULTING FROM INDUSTRIAL AC- CIDENT. THIS WAGE SCHEDULE IS FOR 26 WEEKS PRIOR TO DATE OF INJURY AND MUST BE FILED WITH DEPARTMENT OF LABOR BY INSURANCE CARRIER TOGETHER WITH 9 WCA WEEK ENDING OTHER ADVANTAGES TOTAL GROSS EARNINGS (See Wages Definition) Columns 1 & 2 WAGES: In addition to money payments, means reasonable value of board, rent, housing, lodging, fuel or similar advantage received from the employer, and gratuities received in the course of employment from others, but not including any sum paid by the employer to cover any special expenses entailed on the employee by the nature of his employment. Please provide a brief explanation for weeks with no wages. RSA 281-A:2, Par. XV. Carrier Name Address (EMPLOYER S SIGNATURE) (TITLE) Dept. Approval 76 WCA (12-90) White Labor Dept. (Mail to Carrier) Canary Insurance Carrier (Mail to Carrier) P&P WHSE STOCK #4640 Date

17 THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, N.H WAGE SCHEDULE Employee (NAME) Date of hire Wages per hour Avg. wkly. earnings Employer Address (NAME) (NO.) (STREET) (CITY-STATE) EMPLOYER MUST FORWARD TO INSURANCE CARRIER BOTH COPIES OF THIS SCHEDULE AND CARRIER S COPY OF THE SUPPLEMEN- TAL REPORT FORM NO. 13 WCA NO LATER THAN EMPLOYEE S FIFTEENTH DAY OF DIS- ABILITY RESULTING FROM INDUSTRIAL AC- CIDENT. THIS WAGE SCHEDULE IS FOR 26 WEEKS PRIOR TO DATE OF INJURY AND MUST BE FILED WITH DEPARTMENT OF LABOR BY INSURANCE CARRIER TOGETHER WITH 9 WCA WEEK ENDING OTHER ADVANTAGES TOTAL GROSS EARNINGS (See Wages Definition) Columns 1 & 2 WAGES: In addition to money payments, means reasonable value of board, rent, housing, lodging, fuel or similar advantage received from the employer, and gratuities received in the course of employment from others, but not including any sum paid by the employer to cover any special expenses entailed on the employee by the nature of his employment. Please provide a brief explanation for weeks with no wages. RSA 281-A:2, Par. XV. Carrier Name Address (EMPLOYER S SIGNATURE) (TITLE) Dept. Approval 76 WCA (12-90) White Labor Dept. (Mail to Carrier) Canary Insurance Carrier (Mail to Carrier) P&P WHSE STOCK #4640 Date

18 NEW HAMPSHIRE WORKERS COMPENSATION MEDICAL FORM This form must be completed at each health professional visit (MD, DO, DC or DDS) and must be filed with the worker s compensation insurance carrier within 10 days of the treatment (first aid excluded). Failure to comply and complete this form shall result in the provider not being reimbursed for services rendered and may result in a civil penalty of up to $2,500. In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary alternative/transitional work opportunities to all employees temporarily disabled by a work related injury or illness. Employee SS # Occupation Date last worked W.C. insurer Employer Work telephone # Employer contact Employer address HEALTH PROFESSIONAL TO COMPLETE Initial visit Follow-up visit Date of injury Time Worker s statement of the incident Worker s complaints Diagnosis/Prognosis Treatment plan In your opinion is this injury and disability as a result of injury described above? Yes No Unclear EMPLOYEE WORK CAPABILITY Continue Working Can return to work: Yes Date No Full Duty With Modification. If so, for what duration? Employee can No Restrictions Frequently Occasionally Unable to bend kneel squat climb stand walk sit reach drive do fine motor No Wrist Elbow Shoulder Ankle repetitive Right motions Left Employee can lift/carry maximally lbs. Employee can lift/carry frequently lbs. Employee can work a maximum of # hours/day, # days /wk. What special accommodations are required? Other Has employee reached maximum medical improvement? Yes No Has injury caused permanent impairment? Yes No Undetermined ALL MEDICAL NOTES MUST BE ATTACHED TO BILL I certify that the narrative descriptions of the principal and secondary diagnosis and the major procedures performed are accurate and complete to the best of my knowledge. Provider s signature Provider s Printed name Provider s telephone# Federal ID# Date of visit MEDICAL AUTHORIZATION: The act of the worker in applying for workers compensation benefits constitutes authorization to any physician, hospital, chiropractor, or other medical vendor to supply all relevant medical information regarding the worker s occupational injury or illness to the insurer, the worker s employer, the worker s representative, and the department. Medical information relevant to a claim includes a past history of complaints of, or treatment of, a condition similar to that presented in the claim. [281-A:23 V(a)] 75 WCA-1 (06/94) White - Insurer/Managed Care Yellow - Provider Pink - Employee/Employer

19 Second Injury Fund New Hampshire s Second Injury Fund gives employers an opportunity to limit their compensation costs in the event that an impaired employee sustains a workers compensation injury which leaves him/her more disabled that the same injury would leave a non-impaired worker. The worker s original impairment can be of any type of cause work-related or not as long as it is a permanent impairment and is serious enough to pose an obstacle to the worker in obtaining employment. The intent of the Second Injury Fund is to equalize the compensation costs that the employer and its insurance company must pay for impaired and non-impaired workers alike, thereby removing a potential barrier to the employment of impaired workers. At the time of hire or as soon after hire as the information becomes known to you make note in writing of your knowledge of the employee s impairment. In the event of a Second Injury Fund claim in the future, the written record will need to be produced as evidence that you knew of the worker s impairment prior to the subsequent injury. The written record can take any form you wish (e.g. pre-placement physical examination report, a memorandum to the personnel file, interview notes signed and dated by the interviewer, or a letter from the rehabilitation counselor who knew the worker) as long as: the information is recorded in writing the record clearly identifies the employer, employee and the date that the record was created the record presents information about the worker s impairment and the limitations caused by the impairment This is the only step that the employer needs to take. In the event that the impaired worker becomes seriously disabled from a workers compensation injury in the future, the insurance company will initiate the process of applying to the Second Injury Fund, and, as part of this, will ask the employer for a copy of this record. If the record is not available, the case will not be eligible for reimbursement from the Fund. 7/09

20 SECOND INJURY FUND INFORMATION Per RSA 281 A:54, this will serve as written verification of Employer knowledge of pre existing injury or medical condition. Questions and responses shall be documented and dated IMMEDIATELY AFTER an individual has been hired. Business Name & Address Employee Name: Date of Birth: SS# PREVIOUS INJURIES AND LIMITATIONS (including non work related injuries) DOCTORS/HOSPITALS: PRE EXISTING MEDICAL CONDITIONS AND LIMITATIONS: DOCTORS/HOSPITALS: PRIOR SURGICAL PROCEDURES: DOCTORS/HOSPITALS: To be kept on file during the entire course of employment. Employee Date Employer Date* *This form is invalid if not dated. This information is to be used solely for the purpose of establishing information relevant to RSA 281 A:54.

21 What you need to know The treatment of work-related injuries requires physicians who are not only expert in the care of musculo-skeletal injuries, but also understand the importance of helping your employees return to rewarding productive lives. The quality of care your employee receivess in the first few weeks of injury will have a tremendous influence on whether he or she is able to return to work safely or sufferss from a prolonged disability. About the Best Doctors Occupatio nal Health Institute of Northern New England (BDOHI-NNE) BDOHI-NNE is a medical community of physicians and allied health professionals who have been selected by their peers for clinical excellence and an understanding of productivity issues so important to work-related injuries. The mission of BDOHI-NNE is to help your injured employees get the best care possible and to assure a safe recovery and a prompt return to productivity. How to help your employees benefit from thee Best Doctors Occupational Health Institute-NNE Identify and encourage the use of the most convenient BDOHI-NNE Primary Occupational Health Center for your employees. For emergent situations dial 911. Display the A.I.M. Mutual Insurance Companies poster with the name, address and phone number of the most convenient Primary Occupational Health Center in a public viewing area. Additional posters are available by calling The poster is available at in our Forms Library. In the event of a serious injury please call us immediately at Please report all other injuries through our website Click on Report a Claim. If your employee requires specialty care, he or she can call the assigned A.I.M. Mutual Insurance Companies claim handler at for several recommendations. Remember Employer s Guide to the Best Doctors Occupat ional Health Institute Your employees are your most importantt resource. Our mission is to help you help them when injured on the job. A.I.M. Mutual Insurance Company / New Hampshire Employers Insurance Company 54 Third Avenue, P.O. Box 4070, Burlington, MA Tel.: Fax: : Best Doctors and the Star-in-cross logo are trademarks of Best Doctors, Inc, in the United States and other countries Best Dr Instr Sheet NHEIC AIM Mut (2/12)

22 IN PARTNERSHIP WITH: New Hampshire BDOHI Credentialed Affiliates in BOLD Coos County Health Services 133 Pleasant St. Berlin, NH Tel: (603) Fax: (603) BOAC - Manchester 1 Highlander Way Manchester, NH Tel: (603) Fax: (603) Priority Care at Valley Regional Hospital 243 Elm St. Claremont, NH Tel: (603) Fax: (603) BOAC - Nashua 436 Amherst Street Nashua NH Tel: (603) Fax: (603) Merrimack Valley Occupational Health 171 Pleasant St. Concord, NH Tel: (603) Fax: (603) Saco Medical Group 7 Greenwood Ave. Conway, NH Tel: (603) Fax: (603) Occupational Health Services at Portsmouth Hospital Pease International Tradesport 26 Manchester Square Newington, NH Tel: (603) Fax: (603) Newport Health Center 11 John Stark Highway Newport, NH Tel: (603) Fax: (603) The Bakie Center at Access Occupational Medicine Access Health Building 1 Hampton Road Exeter, NH Tel: (603) ext 3001 Fax: (603) Occupational Health Services of Portsmouth Regional Hospital 55 High St, Suite 103 Hampton, NH Phone: (603) Fax: (603) Cheshire Medical Center Occupational Health 580 Court St. Keene NH Tel: (603) Fax: (603) Occupational Health at Alice Peck Day 10 Main Street Newport, NH Tel: (603) (Tues. only) Fax: (603) Access Sports Medicine & Orthopedics 155 Borthwick Ave. Portsmouth, NH Tel: (603) Fax: (603) (musculoskeltal & laceration same day treatment provided) Salem Occupational & Acute Care 13 Red Roof Lane, Suite 2 Salem, NH Tel: (603) Fax: (603) Dartmouth Hitchcock Medical Center Occupational Health Center One Medical Center Drive Lebanon, NH Tel: (603) Fax: (603) Occupational Health at Alice Peck Day 125 Mascoma St. Lebanon, NH Tel: (603) Fax: (603) SeaCoast Redicare 396 High St. #1 Somersworth, NH Tel: (603) Fax: (603) Merrimack Valley Occupational Health 614 Laconia Road, Rte 3 Tilton, NH Tel: (603) Fax: (603) Littleton Hospital Occupational Health 600 St. Johnsbury Road Littleton, NH Tel: (603) Fax: (603) Federal Street 21st Floor Boston, MA T (877) Best Doctors and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. July 2013

23 A.I.M. Works Express Scripts Pharmacy Program for Injured Workers As part of our workers compensation medical management services, we ask injured workers to use a pharmacy program through Express Scripts, Inc. (ESI). ESI is a pharmacy benefit management company that is uniquely set up to provide prescription medications for work-related injuries. Injured employees will be notified by mail about the pharmacy program and how it works shortly after their claim has been approved. They will also receive a prescription identification card; the card is valid only for prescriptions related to the specific, approved work injury. Injured employees will be asked to use an Express Scripts affiliated pharmacy to fill their injury-related prescriptions. Express Scripts also offers a mail service program, which employees will find convenient for refilling maintenance (longterm) prescription medications. I m sure you are familiar with the cost benefits of a mail order prescription program, and we ask that you encourage injured workers to take advantage of this service. Most prescriptions are filled within 48 hours of receipt and mailed directly to the injured employee s home. Injured employees can sign up for the mail service program through ESI by phone or by mail. Additional benefits of the program include 24-hour access to a registered pharmacist via a toll-free number and an extensive network of pharmacies to choose from. Express Scripts offers significant savings of up to 35% over fee schedules and usual and customary charges, and the program will expedite claim processing and payment. Injured employees will incur no out-of-pocket expenses. A list of Express Scripts affiliated pharmacies in the Northeast is included in this claim kit. Injured workers will receive a condensed list of chain pharmacies in the network on the reverse side of their prescription card information sheet. If their pharmacy is not on the list, they can call Express Scripts at to verify if their pharmacy is part of the network. While injured employees may use a non-affiliated pharmacy, we strongly recommend they use a pharmacy within the Express Scripts network and the mail order service to realize the program benefits. Please call the Express Scripts Workers Compensation Service Center at with any questions you may have. The toll free service is available 24 hours a day, seven days a week. As always, thank you for working with us to enhance our claim service. Sincerely, Robert R. Cella Vice President-Operations

24 Temporary Prescription Services Attention Injured Worker On your first visit, please give this notice to any pharmacy listed below to expedite the processing of your approved workers compensation prescriptions. (Based on the established parameters by your employer.) Questions or need assistance locating a participating pharmacy: Call the Express Scripts Contact Center at A la atención del trabajador lesionado: En su primera visita, entréguele esta notificación a cualquiera de las farmacias que se indican a continuación para acelerar el procesamiento de las recetas de compensación para los trabajadores aprobadas. (Según los parámetros establecidos por su empleador.) Si tiene alguna pregunta o si necesita asistencia para ubicar una farmacia participante, llame al Centro de Contacto de Express Scripts al Attention Supervisor: Please complete the following information for the injured worker. Express Scripts Employee Information ID #: SSN to be presented to the pharmacy at the time prescription is filled Date of Injury: / / MM/DD/CCYY Group #: A6SA Employee Date of Birth: / / MM/DD/CCYY First M Last Mailing Address Street Address or PO Box City State Zip Employer Name Attention Pharmacist Express Scripts administers this workers compensation prescription program. Follow the steps below to submit a claim. For assistance, call the Express Scripts Contact Center at Pharmacy Processing Steps Step 1 Enter bin number Step 2 Enter processor control A4 Step 3 Enter the group number as it appears above Step 4 Enter the injured worker s 9 digit ID# Step 5 Enter first name & last name Step 6 Enter the injured worker s date of injury (enter in PA field in the format ccyymmdd) Participating Pharmacy Chains (Cadenas de farmacias participantes) A & P Acme Pharmacy Albertson s Albertson s/acme Albertson s/osco Albertson s/sav On Amerisource Bergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg's Bi Lo Bi Mart BJ s Wholesale Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs Cash Wise Coborn's Costco Cub D&W Dahl's Dierbergs Discount Drugmart Doc's Drugs Dominicks Drug Emporium Drug Fair Drug Town Drug World Eckerd Econofoods EPIC Pharmacy Network FamilyMeds Farm Fresh Farmer Jack Food City Food Lion Fred's Gemmel Giant Giant Eagle Giant Foods Hannaford Harris Teeter H E B Hi School Pharmacy Hy Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs Kroger LeaderNet (PSAO) Longs Drug Store Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare Network Pharmaceuticals Northeast Pharmacy Services Osco P & C Food Markets Pamida Park Nicollet Pathmark Pavilions Price Chopper Publix Quality Markets Raley's Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam s Club Sav On Save Mart Schnucks Scolari's Sedano Shaw's Shop 'N Save Shopko ShopRite Snyder Stop & Shop Sun Mart Super Fresh Super Rx Target Texas Oncology Srvs The Pharm Thrifty White Times Tom Thumb Tops Ukrop's United Drugs United Supermarkets Vons Waldbaums Wal Mart Wegmans Weis Winn Dixie NOTE: This form is not valid in the state of Ohio. For all other states, liability of a workers compensation claim is not assumed based on the dispensing of medication(s) to a patient Express Scripts, Inc. All Rights Reserved TEMPCARD

25 AMHERST MANCHESTER NEW HAMPSHIRE AMHERST 85 RTE 101-A AMHERST, NH (603) DERRY 48 E BROADWAY DERRY, NH (603) MANCHESTER RD DERRY, NH (603) QOL MEDS 10 TSIENNETO RD DERRY, NH (603) CRYSTAL AVE DERRY, NH (603) ROCKINGHAM ST DERRY, NH (603) SHAWS 55 CRYSTAL AVE DERRY, NH (603) MANCHESTER RD DERRY, NH (603) EPPING 26 CALEF HWY EPPING, NH (603) CALES HWY EPPING, NH (603) GOFFSTOWN HOWE'S 39 MAIN ST GOFFSTOWN, NH (603) MAST RD GOFFSTOWN, NH (603) SHAWS 533 MAST RD GOFFSTOWN, NH (603) HOLLIS HOLLIS 6 ASH ST HOLLIS, NH (603) HUDSON 77 DERRY RD HUDSON, NH (603) LOWELL RD HUDSON, NH (603) LOWELL RD HUDSON, NH (603) SAM'S CLUB 7 BLVD HUDSON, NH (603) LOWELL RD HUDSON, NH (603) LONDONDERRY 117 MAMMOUTH RD LONDONDERRY, NH (603) HAMPTON DR LONDONDERRY, NH (603) NEIGHBORCARE - PEMBROKE 13 COMMERCE AVE LONDONDERRY, NH (603) NASHUA RD LONDONDERRY, NH (603) SHAWS RT 102 OLD ORCHARD VIEW DR LONDONDERRY, NH (603) MERRIMACK 456 DANIEL WEBSTER HWY MERRIMACK, NH (603) DANIEL WEBSTER HWY MERRIMACK, NH (603) SHAWS 7 CONTINENTAL BLVD MERRIMACK, NH (603) SHAWS 570 DANIEL WEBSTER HWY MERRIMACK, NH (603) MILFORD 15 MT VERNON ST MILFORD, NH (603) NASHUA ST MILFORD, NH (603) ELM ST MILFORD, NH (603) NASHUA COSTCO 311 DANIEL WEBSTER HWY NASHUA, NH (603) DANIEL WEBSTER HWY NASHUA, NH (603) MAIN ST # 242 NASHUA, NH (603) MAIN ST NASHUA, NH (603) S NEW HAMPSHIRE MEDICAL CTR 8 PROSPECT ST NASHUA, NH (603) SHAWS 300 MAIN ST NASHUA, NH (603) ST JOSEPH HEALTHCARE RET PHCY 172 KINSELY ST NASHUA, NH (603) TARGET 310 DANIEL WEBSTER HWY NASHUA, NH (603) WINGATE'S 129 MAIN ST NASHUA, NH (603) NASHUA MEDICINE WORLD 262 MAIN DUNSTABLE RD. NASHUA, NH (603) NASHUA 633 AMHERST ST NASHUA, NH (603) COLISEUM AVE NASHUA, NH (603) KMART 375 AMHERST ST BLDG 1 NASHUA, NH (603) AMHERST ST NASHUA, NH (603) TARGET 600 AMHERST ST NASHUA, NH (603) NASHUA RICE'S 59 MAIN ST NASHUA, NH (603) PELHAM 48 ATWOOD RD PELHAM, NH (603) RAYMOND 2 FREETOWN RD RAYMOND, NH (603) FREETOWN RD RAYMOND, NH (603) SALEM 510 S BROADWAY # 512 SALEM, NH (603) S BROADWAY SALEM, NH (603) MAIN ST SALEM, NH (603) TARGET S BROADWAY SALEM, NH (603) N BROADWAY SALEM, NH (603) WINDHAM 1 WALL ST WINDHAM, NH (603) SHAWS 43 INDIAN ROCK RD WINDHAM, NH (603) MANCHESTER 788 S WILLOW ST MANCHESTER, NH (603) KEN'S 36 ELM ST MANCHESTER, NH (603) ELM ST MANCHESTER, NH (603) November 2011

26 MANCHESTER WARNER MANCHESTER 432 S MAIN ST MANCHESTER, NH (603) MAST RD MANCHESTER, NH (603) MCGREGOR ST MANCHESTER, NH (603) MANCHESTER 201 JOHN DEVINE DR MANCHESTER, NH (603) MANCHESTER METRO TREATMENT CTR 5 A DRIVING PARK RD MANCHESTER, NH (603) WILLOW ST MANCHESTER, NH (603) SHAWS 375 S WILLOW ST MANCHESTER, NH (603) KELLER ST MANCHESTER, NH (603) MANCHESTER 271 MAMMOUTH RD MANCHESTER, NH (603) BICENTENNIAL DR MANCHESTER, NH (603) HANOVER ST MANCHESTER, NH (603) HOOKSETT RD MANCHESTER, NH (603) HOOKSETT 10 WHITEHALL RD HOOKSETT, NH (603) HOOKSETT RD HOOKSETT, NH (603) TARGET 100 QUALITY DR HOOKSETT, NH (603) COMMERCE DR HOOKSETT, NH (603) MANCHESTER 270 MAMMOTH RD MANCHESTER, NH (603) BEDFORD BEDFORD 209 ROUTE 101 BEDFORD, NH (603) CRITICAL CARE SYSTEMS 10 COMMERCE PARK NORTH BEDFORD, NH (603) S RIVER RD BEDFORD, NH (603) JENKINS RD BEDFORD, NH (603) COLBY CT BEDFORD, NH (603) SOUTH RIVER RD BEDFORD, NH (603) TARGET 220 S RIVER RD BEDFORD, NH (603) COLBY CT BEDFORD, NH (603) BELMONT 96 DANIEL WEBSTER HWY UNIT 17 BELMONT, NH (603) BRISTOL 360 SUMMER ST BRISTOL, NH (603) CONTOOCOOK COLONIAL VILLAGE 54 PARK AVENUE PLZ CONTOOCOOK, NH (603) EPSOM CARE 1912 DOVER RD EPSOM, NH (603) FRANKLIN 861 CENTRAL ST FRANKLIN, NH (603) CENTRAL ST FRANKLIN, NH (603) CENTRAL ST FRANKLIN, NH (603) HENNIKER HENNIKER 4 BRIDGE ST HENNIKER, NH (603) HILLSBORO OSCO 276 W MAIN ST HILLSBORO, NH (603) W MAIN ST HILLSBORO, NH (603) LACONIA 220 UNION AVE LACONIA, NH (603) UNION AVE LACONIA, NH (603) SHAWS 1400 LAKE SHORE DR LACONIA, NH (603) LAKE SHORE RD LACONIA, NH (603) GILFORD 1371 LAKE SHORE DR GILFORD, NH (603) LINCOLN 50 MAIN ST LINCOLN, NH (603) MEREDITH 38 NH ROUTE 25 STE 4 MEREDITH, NH (603) NEW LONDON COLONIAL 247 NEWPORT RD NEW LONDON, NH (603) NORTHWOOD 174 FIRST NH TPKE NORTHWOOD, NH (603) PITTSFIELD 41 CARROLL ST PITTSFIELD, NH (603) PLYMOUTH RTE 25 HATCH SHOPPING PLAZA PLYMOUTH, NH (603) OLIVER 19 AVERY ST STE 7 PLYMOUTH, NH (603) S MAIN ST PLYMOUTH, NH (603) TENNEY MTN HWY PLYMOUTH, NH (603) ALLENSTOWN EXPRESS 68 SCHOOL ST ALLENSTOWN, NH (603) ALLENSTOWN RD ALLENSTOWN, NH (603) TILTON SHAWS 75 LACONIA RD TILTON, NH (603) E MAIN TILTON, NH (603) WARNER WARNER 11 E MAIN ST WARNER, NH (603) November 2011

27 CONCORD WEST LEBANON CONCORD CONCORD METRO TREATMENT CENTER 8 LOUDON RD CONCORD, NH (603) HALL ST CONCORD, NH (603) N MAIN ST CONCORD, NH (603) FORT EDDY RD CONCORD, NH (603) MODERN 5 CLINTON ST CONCORD, NH (603) NORTHEAST SERVICES 125 N MAIN ST CONCORD, NH (603) PHARMERICA 38 LOCKE RD UNIT 3 CONCORD, NH (603) FORT EDDY RD CONCORD, NH (603) SOUTH ST CONCORD, NH (603) NORTH ST CONCORD, NH (603) SAM'S CLUB 304 SHEEP DAVIS RD CONCORD, NH (603) SHAWS 246 LOUDON RD CONCORD, NH (603) TARGET 80 D'AMANTE DR CONCORD, NH (603) THE PRESCRIPTION CENTER 246 PLEASANT ST STE 100 CONCORD, NH (603) THE PRESCRIPTION CENTER 18 FOUNDRY ST CONCORD, NH (603) THE PRESCRIPTION CENTER 125 N MAIN ST CONCORD, NH (603) LOUDON RD CONCORD, NH (603) CONCORD PENACOOK 305 VILLAGE ST CONCORD, NH (603) PENACOOK FISHERVILLE 219 FISHERVILLE RD PENACOOK, NH (603) KEENE 268 W ST KEENE, NH (603) WEST ST KEENE, NH (603) PRICE CHOPPER 16 ASHBROOK RD KEENE, NH (603) WINCHESTER ST KEENE, NH (603) TARGET 46 ASH BROOK RD KEENE, NH (603) HINSDALE 724 BRATTLEBORO RD HINSDALE, NH (603) JAFFREY 14 PETERBOROUGH ST JAFFREY, NH (603) PETERBOROUGH 125 DUBLIN RD PETERBOROUGH, NH (603) WILTON RD PETERBOROUGH, NH (603) RINDGE 752 US ROUTE 202 RINDGE, NH (603) RT 202 RINDGE, NH (603) WEST SWANZEY KEENE METRO TREATMENT CENTER 1076 OLD SWANZEY RD WEST SWANZEY, NH (603) WINCHESTER 10 W MAIN ST WINCHESTER, NH (603) LITTLETON AMMONOOSUC COMMMUNITY HEALTH 25 MOUNT EUSTIS RD LITTLETON, NH (603) MEADOW ST STE 136 LITTLETON, NH (603) SHAWS 625 MEADOW ST LITTLETON, NH (603) MEADOW ST LITTLETON, NH (603) BERLIN 200 PLEASANT ST BERLIN, NH (603) COLEBROOK 91 MAIN ST COLEBROOK, NH (603) GORHAM 561 MAIN ST GORHAM, NH (603) LANCASTER 177 MAIN ST LANCASTER, NH (603) CLAREMONT BANNON 109 PLEASANT ST CLAREMONT, NH (603) WALL ST CLAREMONT, NH (000) PLEASANT ST CLAREMONT, NH (603) BOWEN ST CLAREMONT, NH (603) ENFIELD FAMILY BROOKSIDE PLZ RTE 4 ENFIELD, NH (603) HANOVER 79 S MAIN ST HANOVER, NH (603) DICK'S HOUSE 5 ROPE FERRY RD HANOVER, NH (603) EASTMAN'S STORE 22 S MAIN ST HANOVER, NH (603) LEBANON DARTMOUTH HITCHCOCK 1 MEDICAL CENTER DR LEBANON, NH (603) LEBANON PRICE CHOPPER 370 MIRACLE MILE RD LEBANON, NH (603) NEWPORT 51 S MAIN ST NEWPORT, NH (603) SUGAR RIVER 46 JOHN STARK HWY NEWPORT, NH (603) Z 239 SUNAPEE ST NEWPORT, NH (603) WEST LEBANON 250 PLAINFIELD RD WEST LEBANON, NH (603) MARKET ST WEST LEBANON, NH (603) November 2011

28 WEST LEBANON EFFINGHAM KMART ROUTE 12 A WEST LEBANON, NH (603) PRICE CHOPPER 285 PLAINFIELD RD WEST LEBANON, NH (877) BENNING ST WEST LEBANON, NH (603) PLAINFIELD RD WEST LEBANON, NH (603) WOODSVILLE 4976 DARTMOUTH COLLEGE HWY WOODSVILLE, NH (603) DARTMOUTH COLLEGE HWY WOODSVILLE, NH (603) NEWINGTON 2200 WOODBURY AVE NEWINGTON, NH (603) PORTSMOUTH 674 ISLINGTON ST PORTSMOUTH, NH (603) MARTIN'S POINT PORTSMOUTH PHCY 161 CORPORATE DR PORTSMOUTH, NH (603) ISLINGTON ST UNIT 1 PORTSMOUTH, NH (603) LAFAYETTE RD STE 3 PORTSMOUTH, NH (603) WOODBURY AVE PORTSMOUTH, NH (603) LAFAYETTE RD PORTSMOUTH, NH (603) ALTON 80 WOLFBORO HWY ALTON, NH (603) CENTER CONWAY SHAWS 1150 EASTMAN RD CENTER CONWAY, NH (603) DOVER CARE 118 CENTRAL AVE DOVER, NH (603) CENTRAL AVE DOVER, NH (603) GRAPEVINE DR DOVER, NH (603) CENTRAL AVE DOVER, NH (603) CENTRAL AVE DOVER, NH (603) DURHAM 5 MILL RD DURHAM, NH (603) EAST HAMPSTEAD 305 SANDOWN RD EAST HAMPSTEAD, NH (603) EXETER 69 PORTSMOUTH AVE EXETER, NH (603) FARMINGTON 829 NH ROUTE 11 FARMINGTON, NH (603) GREENLAND TARGET 1450 GREENLAND RD STE 1 GREENLAND, NH (603) HAMPTON 321 A LAFAYETTE RD HAMPTON, NH (603) LAFAYETTE RD HAMPTON, NH (603) LAFAYETTE RD HAMPTON, NH (603) KINGSTON 53 CHURCH ST KINGSTON, NH (603) NEWMARKET 73 EXETER ST NEWMARKET, NH (603) NORTH CONWAY 1351 WHITE MOUNTAIN HWY NORTH CONWAY, NH (603) ROUTE 16 MTN VALLEY MALL NORTH CONWAY, NH (603) WHITE MOUNTAIN HWY NORTH CONWAY, NH (603) MOUNTAIN VALLEY BLVD NORTH CONWAY, NH (603) LEE 58 CALEF HWY LEE, NH (603) NORTH HAMPTON 72 LAFAYETTE RD NORTH HAMPTON, NH (603) OSSIPEE RTE 16 AMES PLAZA OSSIPEE, NH (603) ROUTE 16 OSSIPEE, NH (603) PLAISTOW 4 PLAISTOW RD PLAISTOW, NH (603) PLAISTOW RD PLAISTOW, NH (603) PLAISTOW RD. PLAISTOW, NH (603) ROCHESTER CARE OF ROCHESTER 161 S MAIN ST ROCHESTER, NH (603) LILAC MALL # 2 ROCHESTER, NH (603) N MAIN ST ROCHESTER, NH (603) WAKEFIELD ST ROCHESTER, NH (603) FARMINGTON RD ROCHESTER, NH (603) ROCHESTER 104 MILTON RD ROCHESTER, NH (603) SEABROOK 628 LAFAYETTE RD SEABROOK, NH (603) SAM'S CLUB 11 BATCHELDER RD SEABROOK, NH (603) LAFAYETTE RD SEABROOK, NH (603) SOMERSWORTH 338 HIGH ST SOMERSWORTH, NH (603) HIGH ST SOMERSWORTH, NH (603) TARGET 11 ANDREWS RD SOMERSWORTH, NH (603) HIGH ST SOMERSWORTH, NH (603) EFFINGHAM LAKEVIEW 244 HIGHWATCH RD EFFINGHAM, NH (603) November 2011

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