The following State forms have been included in your claims kit packet:

Size: px
Start display at page:

Download "The following State forms have been included in your claims kit packet:"

Transcription

1 RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee, we want you to have all the information you might need in the event one occurs. Enclosed is our Workers Compensation Injury Reporting Kit that contains the Massachusetts state-mandated forms and a step-by-step process to follow in case an employee sustains an injury. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the How to File an Injury form included in this packet. The Tower Group claim office which will be handling your claim is located in Melville, NY. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the Massachusetts workers compensation process. The following State forms have been included in your claims kit packet: 1. Massachusetts Form 101-Employer s First Report of Injury or Fatality This form must be submitted to the Massachusetts Department of Industrial Accidents, the carrier and the employee. It must be sent to the Department of Industrial Accidents within seven (7) calendar days (not including Sunday and legal holidays) from the fifth full or partial day the employee has been disabled. The submission of this form does not constitute an admission of liability. Fines may be imposed for three (3) of more violations within one (1) year. 2. Directing Medical Care (not a state form)- The employer has the right to designate a health care provider for the first visit. After the first visit, the employee has the right to choose their own health care provider. 3. Massachusetts Form 127- Average Weekly Wage Computation Schedule- Please submit this form to Tower Group Companies at the time of injury. 4. Medical Authorization- Please have the injured employee fill out and sign this form and send to Tower Group Companies at the time of an injury. We thank you for your business and look forward to being of service to you. Very truly yours, Tower Group Companies CL TGC (08/10)

2 HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Workers compensation claims can be reported in several different ways, you can: Complete and submit the Massachusetts Form 101-Employer s First Report of Injury or Fatality and submit the form via one of the following: the completed form to wcreportaloss@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at Call the Tower Group Companies Claims office at By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call The after hours telephone number for reporting claims provides the opportunity to report a claim 24 hours a day 7 days a week. Loss details will be gathered to determine if an emergency exists and if an immediate field contact is indicated. IN02 08/08

3 E M P L O Y E E FORM 101 The Commonwealth of Massachusetts Department of Industrial Accidents Department Washington Street 7th Floor, Boston, Massachusetts Info. Line ext. 470 in Mass. Outside Mass ext EMPLOYER S FIRST REPORT OF INJURY OR FATALITY DIA USE ONLY THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES. INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned. 1. Employee s Name (Last, First, MI): 2. Home Telephone Number: 5. Home Address (No., Street, City, State & Zip Code): 8. Date of Hire (mm/dd/yyyy): 3. Social Security Number*: 4. Sex: M F 6. Marital Status: 7. No. of Dependents: M S 9. Date of Birth (mm/dd/yyyy): 10. Average Weekly Wage: 11. Employer s Name: 12. Federal Tax I.D. Number: $ Estimated Actual E M P L O Y E R I N J U R Y I N F O R M A T I O N 13. Employer s Address (No., Street, City, State & Zip Code): 14. Employer s Telephone Number: 16. Workers Compensation Insurance Carrier and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR): 17. W.C. Policy Number: 18. Self-Insured? Yes No If Yes, Self-Insurer Number: 20. DATE OF INJURY (mm/dd/yyyy): 21. Was Employee Injured on Employer s Premises? Yes No 23. FIRST day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 25. If Employee has Died, Date of Death (mm/dd/yyyy): 27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved: 28. Person to Whom Injury was Reported (list position): 31. Injury Code(s) a. to body part b. to body part c. to body part Body Part Code(s) a. b. c. 15. Industry Code (See Reverse Side): 19. Business Type : Service Wholesale Mfg. Retail Other 22. Location of Injury if not on Employer s Premises: 24. FIFTH day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 26. Source of Injury (Chemicals, Machinery, etc.): 29. Date Reported (mm/dd/yyyy): 30. Date Reported as work related (mm/dd/yyyy): 32. Witness(es) to Injury - Give Full Name(s), if none state as such: 33. Has Employee Returned to Work? Yes No 34. Date Employee Returned to Work(mm/dd/yyyy): 35. Employee s Regular Occupation: 36. Has Employee Returned to Regular Occupation: Yes No 37. EMPLOYER S Name (SEE INSTRUCTIONS ON REVERSE SIDE): 38. Title: 39. EMPLOYER S Signature (SEE INSTRUCTIONS ON REVERSE SIDE): 40. Date Prepared (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report. Form Revised 8/ Reproduce as needed. THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE S CLAIM FOR BENEFITS UNDER WORKERS COMPENSATION.

4 EMPLOYER S FIRST REPORT OF INJURY OR FATALITY FILING INSTRUCTIONS 1. WHEN TO FILE: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages. This form is not an admission of liability, but must be filed even though the Employer may believe that the Employee is not injured, or that the Employee is not entitled to benefits under M.G.L. Chapter WHERE TO FILE: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be provided to the Employee and to the Employer s Workers Compensation insurer. 3. PENALTIES: Failure to report injuries on this form may result in a fine of $ in accordance with M.G.L. Chapter 152, Section EMPLOYER S NAME & SIGNATURE IN BOXES 37 & 39: This form must be filed by the employer or an authorized agent/representative of the employer. Agriculture, Forestry and Fishing 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry 09 Fishing, Hunting and Trapping Mining 10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas 14 Nonmetallic Minerals, Except Fuels Construction 15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing 20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products 23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing 100 Amputation or Erucloation 110 Asphyxia or Strangulation Etc. 120 Burns (Heat) 130 Burns (Chemical) 140 Concussion 160 Contusion, Crushing, Bruise 170 Cut, Laceration, Puncture 190 Dislocation 200 Electric Shock, Electrocution 210 Fracture 250 Hernia, Rupture 300 Scratches, Abrasions 310 Sprains, Strains 400 Multiple Injuries 900 No Injury 950 Damage to Prosthetic Devices 995 No Other Injury, NEC** 999 Non-classifiable Infective or Parasitic Disease 150 Infective or Parasitic Disease, UNS* 151 Amebiasis 152 Anthrax 153 Brucellosis 154 Conjunctivitis and Opthalmia 156 Tetanus Head 100 Head, UNS* 110 Brain 120 Ear(s), UNS* 121 Ear(s), External 124 Ear(s), Internal 130 Eye(s), UNS* 140 Face, UNS* 141 Jaw, Chin 144 Mouth and Throat (vocal chords, larynx) 146 Nose 148 Face, Multiple Parts 149 Face, NEC** 150 Scalp *UNS - UNSPECIFIED 28 Chemicals and Allied Products 29 Petroleum and Coal Products 30 Rubber and Misc. Plastic Products 31 Leather and Leather Products 32 Stone, Clay and Glass Products 33 Primary Metal Industries 34 Fabricated Metal Products 35 Industrial Machinery and Equipment 36 Electronic and Other Electrical Equipment 37 Transportation Equipment 38 Instruments and Related Products 39 Miscellaneous Manufacturing Industries Transportation and Public Utilities 40 Railroad Transportation 41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Transportation Services 48 Communications 49 Electric, Gas and Sanitary Services Wholesale Trade 50 Wholesale Trade - Durable Goods 51 Wholesale Trade - Non-durable Goods Retail Trade 52 Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail Finance, Insurance and Real Estate 60 Depository Institutions 61 Non-depository Institutions 62 Security and Commodity Brokers 63 Insurance Carriers 64 Insurance Agents, Brokers and Service 65 Real Estate 67 Holding and Other Investment Officers Services 70 Hotels and Other Lodging Places 72 Personal Services 73 Business Services 75 Auto Repair Services and Parking 76 Miscellaneous Repair Services NATURE OF INJURY OR ILLNESS CODES 157 Tuberculosis 159 Other Infective or Parasitic Diseases Dermatitis 180 Dermatitis, UNS* 183 Primary Infections of the Skin 184 Other Skin Conditions 185 Dermatitis, Allergenic or Contact 189 Skin Condition, NEC** Poisoning Systemic 270 Poisoning, Systemic, UNS* 271 Due to Toxic Materials other than Lead 272 Diseases of the Blood and Blood Forming Organs 273 Upper Respiratory Conditions 274 Influenza, Pneumonia, Etc. 276 Other Diseases of the Gastro-Intestinal Tract 278 Effects of Lead 279 Other Toxic Effects of One System Only Respiratory Systems, Conditions of 570 Respiratory Systems, Conditions of 571 Upper Respiratory 572 Asthma, Influenza, Pneumonia Pneumoconiosis 280 Pneumoconiosis 160 Skull 198 Head Multiple 200 Neck & Cervical Vertebrae UPPER EXTREMITIES 300 Upper Extremities, NEC** 310 Arm(s), UNS* 311 Upper Arm 313 Elbow(s) 315 Forearm(s) 318 Arm(s), Multiple 319 Arm(s), NEC** 320 Wrist(s) 330 Hand(s), Not Wrists or Fingers 340 Finger(s) INDUSTRY CODES 281 Aluminosis 282 Anthracosis 283 Asbestosis 284 Byssinosis 285 Siderosis 286 Silicosis 287 Other Pneumoconioses 289 Pneumoconiosis and Tuberculosis Nervous System, Conditions of 560 Nervous System, Conditions of - NEC** 561 Diseases of the Central Nervous System 562 Diseases of the Nerves and Peripheral Ganglia Neoplasm Tumor 550 Neoplasm Tumor, UNS* 551 Malignant 552 Benign Radiation Effects 290 Radiation Effects, UNS* 291 Non-Ionizing Radiation 292 Microwaves 293 Ionizing Radiation - X-Ray 294 Ionizing Radiation - Isotopes 295 Welder s Flash BODY PART AFFECTED CODES 398 Upper Extremities, Multiple 400 Trunk, UNS* 410 Abdomen, Internal Organs, Inguinal Hernia 420 Back 430 Chest, Ribs, Breastbone, Internal Organs 440 Hip(s)..,Pelvis, Organs and Buttocks 450 Shoulder(s) 498 Trunk, Multiple LOWER EXTREMITIES 500 Lower Extremities 510 Leg(s), UNS* 78 Motion Pictures 79 Amusements and Recreation Services 80 Health Services 81 Legal Services 82 Educational Services 83 Social Services 84 Museums, Botanical, Zoological Gardens 86 Membership Organizations 87 Engineering and Management Services 88 Private Households 89 Services, NEC Public Administration 91 Executive, Legislative and Garden 92 Justice, Public Order, and Safety 93 Finance, Taxation, and Monetary Benefits 94 Administration of Human Services 95 Environmental Quality and Housing 96 Administration of Economic Program 97 National Security and International Affairs Non-classifiable Establishments 99 Non-classifiable Establishments Other 265 Carpal Tunnel Syndrome 510 Cardiovascular and Other Conditions of the Circulatory System 520 Complications Peculiar to Medical Care 500 Effects of Changes in Atmospheric Pressure 240 Effects of Environmental Heat 220 Effects of Exposure to Low Temperature 530 Eye, other Diseases of the Eye 230 Hearing Loss or Impairment 991 Heart Condition,Excludes Heart Attack 320 Hemorrhoids 330 Hepatitis, Serum and Infective 275 Hepatitis, Toxic 260 Inflammation of Joints, Etc. 540 Mental Disorders 900 No Illness 999 Non-classifiable 990 Occupational Disease, NEC** 580 Symptoms and Ill-defined Conditions 513 Knee(s) 515 Lower Leg(s) 518 Leg(s), Multiple 519 Leg(s), NEC** 520 Ankle(s) 530 Foot or Feet, Not Ankle 540 Toe(s) 598 Lower Extremities, Multiple 700 MULTIPLE PARTS Applies when more than one major body part as been effected such as an arm and a leg 999 NON-CLASSIFIABLE - Insufficient information to identify part of body effected. Includes damage to prosthetic devises. **NEC - NOT ELSEWHERE CLASSIFIED

5 FORM 127 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100, Boston, Massachusetts Info. Line ext. 470 in Mass. Outside Mass ext AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE DIA USE ONLY Print or Type 1. Employer s Name and Address: 2. Insurer s Case File #: 3. DIA Board # (if known): 4. Employee s Name and Address: 5. # of dependent children: 6. # of other dependents: 7. Date of Injury (mm/dd/yyyy): 8. Date of Disability (mm/dd/yyyy): 9. Date of Employment (mm/dd/yyyy): 10. Has employee been certified by U.S. Veterans Administration for any type of disability? Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule, substitute wages of a fellow employee in the same class of employment who has worked for one year or more. 11. Week No. Year: Week Ending Month Day Gross Amount Before Taxes Week No. Year: Week Ending Month Day Gross Amount Before Taxes Week No. Year: Week Ending Month Day Gross Amount Before Taxes Total: 12. Was room furnished to the employee? Yes No 13. If tips or other benefits were earned, describe and state value per week: THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT 14. Name of Fellow Employee (if applicable): 15. Employer/Preparer Signature: 16. Date Signed (mm/dd/yyyy): Make any comments on the reverse side of this form or on a separate sheet. Form Created 8/2005 Reproduce as needed.

6 Comments:

7 WORKERS COMPENSATION INJURY MEDICAL AUTHORIZATION Authorization for Medical Records And Communication Release By this form or copy thereof, I, hereby authorize any licensed physician, chiropractor, medical practitioner, hospital, clinic or other related medical or medically related facility, insurance company or other organization, institution, or person, that has any records or knowledge of my mental, physical health, history, condition or well being, to supply such information to my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys. I specifically authorize any treating physician or medical care provider to communicate orally or in writing with my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys as to my care and treatment and as to any other issues including but not limited to diagnosis, prognosis, causal connection of care and treatment to my work injury or duties and ability to work. In conjunction with this, I authorize any treating physician or medical provider to review any additional medical records provided to them. I understand that by signing this authorization for medical records and communication release that my applicable medical provider will be releasing information subject to the HIPPA restrictions. I specifically waive any rights or protections that I may have under the HIPPA regulation and request that the medical providers release the requested information. A photo copy of this authorization shall be valid as the original. This release shall remain valid for the length of my claim. Name (Please Print) Address (Street, City/Town, Zip Code) Signature Date Signed TWR05 08/08

8 WORKERS COMPENSATION MANAGED CARE PROGRAMS Tower Group Companies strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers needs in managing their workers compensation claims. Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker. A summary of each program is outlined below. Medical Bill Review Services The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs. Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and Aetna networks; as well as other top regional PPO s. The combination of these network providers offers coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work. In some states, such as California and Texas state regulations allow specialty networks which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments. One of the first steps in providing quality medical care to your injured employee is to understand how to access network providers, and generate workplace provider panel cards or provider listings. There are two convenient ways to locate a network provider or develop provider network listings: 1. Telephonically: Simply call Coventry at x Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via Internet Access: For the standard national workers compensation network go to and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network.

9 If you participate in a Specialty Network, such as a MPN or HCN, select the applicable network from the drop-down box. For California, chose the First Health Select CA MPN; Texas participants in the Coventry HCN. For large panel card production or if you require additional information regarding web access please contact Tower Group Medical Management division at Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims. Tower s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee s lost time and medical costs. Your Tower Group designated adjuster will be responsible for managing all aspects of the injured employee s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these programs.

10 Re: Important Information about your Workers Compensation Prescriptions This letter is provided to inform you that your employer s workers compensation, Tower Group Companies, has selected PMSI as its workers compensation pharmacy partner.with PMSI, you can choose to pick-up your medications for your work-related injury at a nearby pharmacy through a program known as Tmesys, or have them delivered to your home through the mail. Within the next few weeks, you will receive a new workers compensation pharmacy card in the mail. You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your next refill or new prescription for your work-related injury. If you do not receive your new pharmacy card within two weeks, please call Tmesys at and we will be happy to assist you or send another card. If you are interested in finding out about how to receive your prescriptions through the mail, please call To help you transition to the new pharmacy program, we have provided answers to some frequently asked questions: Q: How do I know if my pharmacy participates with the new program? A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the Pharmacy Center on our website, Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at to find a network pharmacy near you. Q: How does this affect my workers compensation claim? A: Using PMSI s program for your workers compensation medications will enable you to continue to receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy, as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you can have your prescriptions delivered to your home through our convenient mail order program. Q: Who do I call with questions about the program? A: PMSI has representatives available to help you with any questions that you may have about the pharmacy program. Please call our help desk at to speak to a representative. If you have any questions about your workers compensation claim, we will help you reach your claims adjuster for assistance. We look forward to serving you and meeting your workers compensation medication needs. Sincerely, PMSI Necesitas ayuda en español? Llame al

11 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. Questions? Call Necesitas ayuda en español? Llame al Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk Notice to Cardholder: This card should be presented to your pharmacy to receive medication for your work-related injury. It is only valid within 30 days of your date of injury. For information regarding the program or to find nearby pharmacies call NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information from the card. 3. The Help Desk will provide an ID number for adjudication. (To create a card for your wallet, cut along outer line and fold in half.) Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: Visit your local Walgreens or Rite Aid Pharmacy Call us: Use our pharmacy locator online: PMSI, Inc. All rights reserved. C

12 First Fill Temporary Pharmacy Card En Primer Relleno Tarjeta Temporal de Farmacia Hacerlo fácil de llenar sus recetas de la compensación del trabajador. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Empleado Lesionado: 1. Si usted necesita una receta para un accidente de trabajo o enfermedad ocupacional, ir a una farmacia de la red Tmesys. 2. Dar esta página al farmacéutico. 3. El farmacéutico surtir su receta sin costo alguno. Preguntas? Llame al Need help in English? Call Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # (Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.) Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information listed above. 3. The Help Desk will provide an ID number for adjudication. Encontrar una farmacia de la red Utilice uno de estos métodos fáciles para encontrar una farmacia de la red: Visite a su local de Walgreens y Rite Aid Pharmacy. Nos llame al: Utilice nuestro localizador de farmacias en linea: PMSI, Inc. Todos los derechos reservados. C

13 Administered By:

The following State forms have been included in your claims kit packet:

The following State forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never has to experience an injury to an

More information

The following State forms have been included in your claims kit packet:

The following State forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never has to experience an injury to an

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following State forms have been included in your claims kit packet:

The following State forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never has to experience an injury to an

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

RE: Workers Compensation Claims Kit. Dear Policyholder:

RE: Workers Compensation Claims Kit. Dear Policyholder: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following State forms have been included in your claims kit packet:

The following State forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never has to experience an injury to an

More information

The following State forms have been included in your claims kit packet:

The following State forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

Associated Insurance Services, LLC Workers Compensation Claims Folder

Associated Insurance Services, LLC Workers Compensation Claims Folder Associated Insurance Services, LLC Workers Compensation Claims Folder 54 Third Avenue * P.O. Box 4070 * Burlington, MA 01803 Telephone: 781-221-1600 / 800-876-2765 Fax: 781-270-5599 Associated Insurance

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

NEW YORK DBL BENEFITS FROM THE HARTFORD.

NEW YORK DBL BENEFITS FROM THE HARTFORD. GROUP BENEFITS Rate guide: Effective February 1, 2012 NEW YORK DBL BENEFITS FROM THE HARTFORD. More disability benefit choices for NY employers with 10 to 99 employees. THE HARTFORD EXPANDS NY DISABILITY

More information

NOTICE OF INJURY/ILLNESS REPORT

NOTICE OF INJURY/ILLNESS REPORT Office of the President University of Massachusetts NOTICE OF INJURY/ILLNESS REPORT This form is intended for internal use for all Human Resources Division/Workers Compensation Unit user agencies and must

More information

Total Employees 9,863 17,107 Total Establishments 448 1,751

Total Employees 9,863 17,107 Total Establishments 448 1,751 Business Comparison Geography: ZIP - 98498, ZIP - The total number of businesses in the demographic reports may be higher due to the roll-up of additional small business entities not otherwise contained

More information

The following state forms have been included in your claims kit packet:

The following state forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

0.5 Miles: N ANN ARBOR ST & E MICHIGAN AVE SALINE, MI 48176. Total Employees 1,492 3,240 4,955 Total Establishments 184 403 595

0.5 Miles: N ANN ARBOR ST & E MICHIGAN AVE SALINE, MI 48176. Total Employees 1,492 3,240 4,955 Total Establishments 184 403 595 Business Comparison Geography: 0.5 Miles: N ANN ARBOR ST &, 1 Mile: N ANN ARBOR ST & E MICHIGAN AVE SALINE, MI, 2 Miles: N ANN ARBOR ST & The total number of businesses in the demographic reports may be

More information

Notice of Injury (NOI) package. University of Massachusetts Dartmouth 285 Old Westport Rd North Dartmouth MA 02747

Notice of Injury (NOI) package. University of Massachusetts Dartmouth 285 Old Westport Rd North Dartmouth MA 02747 Notice of Injury (NOI) package University of Massachusetts Dartmouth 285 Old Westport Rd North Dartmouth MA 02747 Please return the completed NOI package to: Office of Human Resources Attn: Danielle Drabble

More information

We look forward to serving you!

We look forward to serving you! Dear Construction Customer: Enclosed you will find your DP&L Electric Construction Packet. This packet provides you with the information needed to obtain your new electric service or electric service change

More information

Voluntary Short-Term Disability Insurance

Voluntary Short-Term Disability Insurance Voluntary Short-Term Disability Insurance available from Employee s Choice Group Sizes 5-19 An independent licensee of the Blue Cross and Blue Shield Association. Affordable salary protection in case of

More information

Massachusetts Groups. Claims Kit

Massachusetts Groups. Claims Kit Massachusetts Groups Claims Kit Massachusetts Retail Merchants Workers Compensation Group, Inc. Massachusetts Care Self-Insurance Group, Inc. Massachusetts Healthcare Self-Insurance Group, Inc. Massachusetts

More information

21 - MINING. 42 0.87% 221 Utilities 42 0.87% 6,152 0.68 23 - CONSTRUCTION

21 - MINING. 42 0.87% 221 Utilities 42 0.87% 6,152 0.68 23 - CONSTRUCTION Total of State, Local Government and Private Sector 11 - AGRICULTURE, FORESTRY, FISHING & HUNTING 21 - MINING 4,824 71 1.47% 111 Crop Production 24 0.50% 2,754 0.87 112 Animal Production 35 0.73% 5,402

More information

Workplace Nonfatal. Injuries and Illnesses. Illinois, 2001

Workplace Nonfatal. Injuries and Illnesses. Illinois, 2001 Workplace Nonfatal Injuries and Illnesses Illinois, 2001 A Publication of the Illinois Department of Public Health Division of Epidemiologic Studies Springfield, IL 62761 July 2003 This project was supported

More information

The following State forms have been included in your claims kit packet:

The following State forms have been included in your claims kit packet: RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,

More information

Workplace Nonfatal. Injuries and Illnesses. Illinois, 1998

Workplace Nonfatal. Injuries and Illnesses. Illinois, 1998 Workplace Nonfatal Injuries and Illnesses Illinois, 1998 A Publication of the Illinois Department of Public Health Division of Epidemiologic Studies Springfield, IL 62761 July 2000 This project was supported

More information

DRAFT. All NAICS. 3-Digit NAICS BP C 3 P 76 X 0 BP C 0 P 0 X 2 OC C 29 P 44 X 35 OC C 0 P 0 X 2 MH C 96 MH C 8 P 37 X 62 P 1107 X 587

DRAFT. All NAICS. 3-Digit NAICS BP C 3 P 76 X 0 BP C 0 P 0 X 2 OC C 29 P 44 X 35 OC C 0 P 0 X 2 MH C 96 MH C 8 P 37 X 62 P 1107 X 587 All NAICS 3-Digit NAICS BP C 3 P 76 X 0 OC C 29 P 44 X 35 MH C 96 P 1107 X 587 BP C 0 P 0 X 2 OC C 0 P 0 X 2 MH C 8 P 37 X 62 ML C 66 P 958 X 772 ML C 4 P 34 X 69 A. Resource Uses. 11 Agriculture, Forestry,

More information

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees. RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation

More information

Survey Data Analysis with China and US Geo-Explorers. Shuming Bao China Data Center University of Michigan

Survey Data Analysis with China and US Geo-Explorers. Shuming Bao China Data Center University of Michigan Survey Data Analysis with China and US Geo-Explorers Shuming Bao China Data Center University of Michigan Topics 1. Exploring local amenity data (environmental data) with China Geo-Explorer 2. Integrating

More information

Nature of Accident Nature of Injury Body Part Code Table

Nature of Accident Nature of Injury Body Part Code Table Nature of Accident Burn or Scald; Heat or Cold Exposure Contact With Chemicals 01 Hot Objects or Substances (Contact with Hot Objects) 02 Temperature Extremes 03 Fire or Flame 04 Steam or Hot Fluids 05

More information

Business Major Industries Summary

Business Major Industries Summary Business Major Industries Summary Geography: Youngstown The number of businesses in the Business/Households data includes more small business entities, therefore the count of businesses under that tab

More information

North Bay Industry Sector Rankings (By County) October 2015 Jim Cassio

North Bay Industry Sector Rankings (By County) October 2015 Jim Cassio North Bay Rankings (By County) October 2015 Jim Cassio North Bay Rankings (By County) Source: EMSI (Economic Modeling Specialists, Intl.) Contents Lake County... 3 Jobs... 3 Job Growth (Projected)...

More information

VERMONT UNEMPLOYMENT INSURANCE WAGES, BENEFITS, CONTRIBUTIONS AND EMPLOYMENT BY INDUSTRY CALENDAR YEAR 2014

VERMONT UNEMPLOYMENT INSURANCE WAGES, BENEFITS, CONTRIBUTIONS AND EMPLOYMENT BY INDUSTRY CALENDAR YEAR 2014 WAGES, BENEFITS, CONTRIBUTIONS AND EMPLOYMENT BY INDUSTRY Vermont Department of Labor VERMONT UNEMPLOYMENT INSURANCE PROGRAM WAGES, BENEFITS, CONTRIBUTIONS AND EMPLOYMENT BY INDUSTRY Visit us at our web

More information

Business-Facts: 3 Digit NAICS Summary 2014

Business-Facts: 3 Digit NAICS Summary 2014 Business-Facts: 3 Digit Summary 4 County (see appendix for geographies), Agriculture, Forestry, Fishing and Hunting 64 4.6 Crop Production 8.8 Animal Production and Aquaculture. 3 Forestry and Logging

More information

Request for Designated Doctor Examination Type (or print in black ink) each item on this form

Request for Designated Doctor Examination Type (or print in black ink) each item on this form Texas Department of Insurance Division of Workers Compensation 7551 Metro Center Drive, Suite 100 MS-603 Austin, TX 78744-1645 (512) 804-4380 phone (512) 804-4121 fax Complete, if known: DWC Claim # Carrier

More information

NAICS CHANGES IN CES PUBLISHING DETAIL CHANGES FROM SIC TO NAICS By: Joseph F. Winter, CES Supervisor

NAICS CHANGES IN CES PUBLISHING DETAIL CHANGES FROM SIC TO NAICS By: Joseph F. Winter, CES Supervisor NAICS CHANGES IN CES PUBLISHING DETAIL CHANGES FROM SIC TO NAICS By: Joseph F. Winter, CES Supervisor The change in the CES publishing structure from the SIC industry groupings to the NAICS is in effect

More information

Business-Facts: 3 Digit NAICS Summary 2015

Business-Facts: 3 Digit NAICS Summary 2015 Business-Facts: Digit Summary 5 5 Demographics Radius : 9 CHAPEL ST, NEW HAVEN, CT 65-8,. -.5 Miles, Agriculture, Forestry, Fishing and Hunting Crop Production Animal Production and Aquaculture Forestry

More information

Reporting Instructions for LIBC-344 Employer s Report of Occupational Injury or Disease IMPORTANT INFORMATION:

Reporting Instructions for LIBC-344 Employer s Report of Occupational Injury or Disease IMPORTANT INFORMATION: Reporting Instructions for LIBC-344 Employer s Report of Occupational Injury or Disease All work related injuries/incidents should be reported to your supervisor and the Office of Human Resources immediately.

More information

**Student Employee** Workplace Injury Reporting Instructions

**Student Employee** Workplace Injury Reporting Instructions **Student Employee** Workplace Injury Reporting Instructions **Student Employee** Employer s Report of Occupational Injury or Disease (Injury Report) The two-page Injury Report form must be completed and

More information

Workers Compensation

Workers Compensation Workers Compensation All work-related injuries or illnesses must be reported. If the injury is an emergency, arrange for appropriate medical treatment. The employee has the right to select his or her own

More information

Application for a Medical Impairment Rating (MIR)

Application for a Medical Impairment Rating (MIR) STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 Phone (615) 253-1613 Fax

More information

Log and Summary of Occupational Injuries and illnesses

Log and Summary of Occupational Injuries and illnesses Log and Summary of Occupational Injuries and illnesses NOTE: This form is required by Public Law 91-596 and must be kept RECORDABLE CASES: You are required to record information about every in the establishment

More information

Creative Commons. Disclaimer. 978-1-74361-779-3 (pdf) 978-1-74361-795-3 (docx)

Creative Commons. Disclaimer. 978-1-74361-779-3 (pdf) 978-1-74361-795-3 (docx) 2011 12 Australian Workers Compensation Statistics In this report: >> Summary of statistics for non-fatal workers compensation claims by key employment and demographic characteristics >> Profiles of claims

More information

The proportion of all nonfatal

The proportion of all nonfatal Restricted work due to workplace injuries: a historical perspective In anticipation of upcoming data on worker characteristics and on case circumstances surrounding workplace injuries that result in job

More information

RECORDING AND REPORTING OCCUPATIONAL INJURIES ILLNESSES PART 1904

RECORDING AND REPORTING OCCUPATIONAL INJURIES ILLNESSES PART 1904 RECORDING AND REPORTING OCCUPATIONAL INJURIES ILLNESSES PART 1904 The Occupational Safety and Health Act of 1970 requires most private sector employers to prepare and maintain records of work related injuries

More information

1997 NAICS Agriculture, Forestry, Fishing and Hunting Mining Utilities

1997 NAICS Agriculture, Forestry, Fishing and Hunting Mining Utilities 11 1997 NAICS Adult Entertainment Business Agriculture, Forestry, Fishing and Hunting 111 Crop Production 1114 Greenhouse, Nursery & Floriculture Production L M H MHR CSC NC LNC OPD DD PUD Mixed A-1 L1

More information

SHORT TERM DISABILITY. benefits for employees that benefit employers

SHORT TERM DISABILITY. benefits for employees that benefit employers SHORT TERM DISABILITY benefits for employees that benefit employers Short Term Disability VOLUNTARY Doesn t it make sense to protect your paycheck? Statistics show that the majority of American families

More information

How To File A Worker S Compensation Claim In Azoria

How To File A Worker S Compensation Claim In Azoria Workers Compensation Instructions for Filing a Claim Please complete following steps within 24 48 hours of the incident: Report the incident to your supervisor immediately or, if a medical emergency, dial

More information

GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION NAICS CODES GENERAL INFORMATION

GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION NAICS CODES GENERAL INFORMATION GIF CODES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION NAICS CODES GENERAL INFORMATION The United States has a new industry

More information

Accepted disabling workers' compensation claims for Health Workers where the Event of Injury is Assaults and Violent Acts

Accepted disabling workers' compensation claims for Health Workers where the Event of Injury is Assaults and Violent Acts Assaults and Violent Acts Health Workers Health Workers 63 68 73 91 83 21 399 Page 1 Health Workers x Industry 623210 Residential Mental Retardation Facilities 2 2 622110 General Medical and Surgical Hospitals

More information

Voluntary Long-Term Disability Insurance

Voluntary Long-Term Disability Insurance Voluntary Long-Term Disability Insurance available from Employee s Choice An independent licensee of the Blue Cross and Blue Shield Association. Group Sizes 10+ Full-time employees 24-hour protection Affordable

More information

DEL MAR PHYSICAL THERAPY Patient Information

DEL MAR PHYSICAL THERAPY Patient Information PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************

More information

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees. RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation

More information

Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using:

Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using: Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using: Online system link located at http://ohr.psu.edu/workers-compensation/ or Call Center

More information

AIG Primary Medical Provider Network Implementation Notice. Aviso de Implementación de la Red Primaria de Proveedores Médicos de AIG

AIG Primary Medical Provider Network Implementation Notice. Aviso de Implementación de la Red Primaria de Proveedores Médicos de AIG AIG Primary Medical Provider Network Implementation Notice Unless you pre-designate a physician or medical group, a new work injury arising on or after 10/8/10_ will be treated by providers in the AIG

More information

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees. RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation

More information

FILING WORKERS COMPENSATION CLAIMS IN IDAHO

FILING WORKERS COMPENSATION CLAIMS IN IDAHO Claims contact information First Report of Injury forms ReportClaim@IdahoSIF.org General e-mail ClaimsIM@IdahoSIF.org FILING WORKERS COMPENSATION CLAIMS IN IDAHO Provider inquiries 208-332-2169 or 800-334-2370

More information

Injury / Incident Investigation

Injury / Incident Investigation Injury / Incident Investigation CAA HSU INFO 5.3 Rev 02: 08/09 Contents Flowcharts Forms Injury/Incident Investigation Injury/Incident Form Investigation Form Serious Harm Notification Form Definitions

More information

Employment Change Due to Carbon Pricing, 2035 Policy Scenario Vs Baseline Industry Name North American Industrial Classification System # (NAICS)

Employment Change Due to Carbon Pricing, 2035 Policy Scenario Vs Baseline Industry Name North American Industrial Classification System # (NAICS) Employment Change Due to Carbon Pricing, 2035 Policy Scenario Vs Baseline Industry Name North American Industrial Classification System # (NAICS) 2035 (Net Jobs) Construction - 23 4774 1.21% Scientific

More information

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey

More information

REMI Industries for v9 Models

REMI Industries for v9 Models 1 Forestry, fishing, related activities, and other 113-115 1 Forestry and logging; Fishing, hunting, and trapping 113, 114 1 Forestry; Fishing, hunting, and trapping 1131, 1132, 114 2 Logging 1133 2 Agriculture

More information

Australian Workers Compensation Statistics, 2012 13

Australian Workers Compensation Statistics, 2012 13 Australian Workers Compensation Statistics, 2012 13 In this report: Summary of statistics for non-fatal workers compensation claims by key employment and demographic characteristics Trends in serious claims

More information

Who Is Covered by the WC Law?

Who Is Covered by the WC Law? Who Is Covered by the WC Law? More than 98% of Wisconsin workers are covered from the day they start employment. You are covered if your employer usually has three or more fulltime or part-time employees.

More information

INCIDENT RATES DEFINITIONS:

INCIDENT RATES DEFINITIONS: INCIDENT RATES Incident rates are an indication of how many incidents have occurred, or how severe they were. They are measurements only of past performance or lagging indicators. Incident rates are also

More information

of INJURY REPORT and APPLICATION for Benefit Occupational Health and Safety Authority PART 1. TO BE FILLED IN BY THE PERSON MAKING THE CLAIM / REPORT

of INJURY REPORT and APPLICATION for Benefit Occupational Health and Safety Authority PART 1. TO BE FILLED IN BY THE PERSON MAKING THE CLAIM / REPORT 38, Ordnance Street, Valletta VLT2000 Tel: 2590 3000 Fax: 2590 3001 e-mail: social.security@gov.mt website: www.socialsecurity.gov.mt SPIC (Social Policy Information Centre) Tel: 159 Occupational Health

More information

Team Leaders - Claims Services Department. 2014 Adjusters Seminar: I.M. Hurt v. Know Your Knot Tree Service

Team Leaders - Claims Services Department. 2014 Adjusters Seminar: I.M. Hurt v. Know Your Knot Tree Service Team Leaders - Claims Services Department Benefits Under the Act Wage Loss Benefits Temporary Total, Temporary Partial, Permanent Total and Fatal Permanent Partial Disability Benefits Loss of Use, Amputation,

More information

ACCIDENT/INCIDENT INVESTIGATION RIDDOR

ACCIDENT/INCIDENT INVESTIGATION RIDDOR 1.0 INTRODUCTION ACCIDENT/INCIDENT INVESTIGATION RIDDOR In the event of an employee, contractor, visitor or member of the public suffering an injury from a work related incident, certain procedures must

More information

ILLINOIS WORKERS COMPENSATION COMMISSION HANDBOOK OCCUPATIONAL DISEASES AND FOR INJURIES AND ILLNESSES BEFORE 2/1/06

ILLINOIS WORKERS COMPENSATION COMMISSION HANDBOOK OCCUPATIONAL DISEASES AND FOR INJURIES AND ILLNESSES BEFORE 2/1/06 ILLINOIS WORKERS COMPENSATION COMMISSION HANDBOOK ON WORKERS COMPENSATION AND OCCUPATIONAL DISEASES FOR INJURIES AND ILLNESSES BEFORE 2/1/06 ILLINOIS WORKERS COMPENSATION COMMISSION Note: On January 1,

More information

WORKERS COMPENSATION FORMS CENTRAL STORES COMMODITY CODES

WORKERS COMPENSATION FORMS CENTRAL STORES COMMODITY CODES WORKERS COMPENSATION FORMS CENTRAL STORES COMMODITY CODES Employer s Report of Occupational Injury/ Illness (5020) 7673 Authorization to Release Records (WC10) 7697 Workers Compensation Benefit Election

More information

Guide. to Recovery Under The Illinois Workers Compensation Act. The Injured Employee s

Guide. to Recovery Under The Illinois Workers Compensation Act. The Injured Employee s The Injured Employee s Guide to Recovery Under The Illinois Workers Compensation Act Prepared By: Romanucci & Blandin, LLC 33 North LaSalle Street, 20th Floor Chicago, Illinois 60602 Toll Free: 888.458.1145

More information

INDUSTRY CODES. MINING 040 Metal mining 041 Coal mining 042 Oil and gas extraction 050 Nonmetallic mining and quarrying, except fuels

INDUSTRY CODES. MINING 040 Metal mining 041 Coal mining 042 Oil and gas extraction 050 Nonmetallic mining and quarrying, except fuels AGRICULTURE, FORESTRY, AND FISHERIES 010 Agricultural production, crops 011 Agricultural production, livestock 012 Veterinary services 020 Landscape and horticultural services 030 Agricultural services,

More information

Inteligencia-Economica-exportaciones-por-naics

Inteligencia-Economica-exportaciones-por-naics PrimaryNaics Main_Export_Dest 42 - Wholesale Trades 60 546 - Management, Scientific, and Technical Consulting Services 3-33 - 32 549 - Other Professional, Scientific, and Technical Services 4224 - Grocery

More information

Guide to. For Connecticut Private Sector Employees

Guide to. For Connecticut Private Sector Employees Guide to Workers Compensation For Connecticut Private Sector Employees NEW ENGLAND HEALTH CARE EMPLOYEES UNION DISTRICT 1199, SEIU 77 Huyshope Avenue, Hartford, CT 06106 860-549-1199 September 2009 Workers

More information

Workers Compensation Packet and Instructions Effective March 6, 2014 PINK PACKET

Workers Compensation Packet and Instructions Effective March 6, 2014 PINK PACKET Main Office: Phone (607)778-2402 Fax: (607)778-2918 Workers Compensation Packet and Instructions Effective March 6, 2014 PINK PACKET 1. Instructions to be read by employee (claimant) and supervisor and

More information

Promoting Careers in Maintenance

Promoting Careers in Maintenance Promoting Careers in Maintenance I m 18 years old and don t especially want to go to college. I m not sure what I want to study or what kind of a program or career to pursue. I ve got good grades. I suppose

More information

2010 Data ILLINOIS Occupational Health Indicators

2010 Data ILLINOIS Occupational Health Indicators 2010 Data ILLINOIS Occupational Health Indicators Employment Demographics Employed Persons 5,970,000 P1. Percentage of civilian workforce unemployed 10.2 P2. Percentage of civilian employment self-employed

More information

Injury Reporting Procedure

Injury Reporting Procedure Injury Reporting Procedure Your business is very important to us, and we're dedicated to providing you with the resources you need to help you be as successful as possible. Toward that end, Paychex Business

More information

Report ALL on-the-job injuries to

Report ALL on-the-job injuries to 1817 N. Stewart Street, Suite 20 Carson City, NV 89706 Phone: 775-283-0040 Toll Free: 888-873-4234 Fax: 775-283-0035 Report ALL on-the-job injuries to Tri-Odyssey Risk Management Department Phone: 775-283-0040

More information

Workers Compensation Program Employee Information Packet

Workers Compensation Program Employee Information Packet Workers Compensation Program Employee Information Packet The information included in this packet will become important to you in the event that you seek medical attention or lose time from work due to

More information

2012 Georgia Occupational Health Indicators: Demographics and Summary Tables

2012 Georgia Occupational Health Indicators: Demographics and Summary Tables Georgia Occupational Health Surveillance Data Series Table 1. Georgia and U.S. General Employment Demographics, 2012 Georgia U.S. Employed Persons, 16 Years and Older 2012 Georgia Occupational Health Indicators:

More information

WORKER S COMPENSATION TREATMENT AUTHORIZATION FORM

WORKER S COMPENSATION TREATMENT AUTHORIZATION FORM FLORIDA TECH EMPLOYEE ACCIDENT/ INJURY REPORT Contact Financial Affairs @ 674-7297 OR 8885 IMMEDIATELY regarding an Employee's Injury. Employee AND Supervisor must complete this report. EMPLOYEE INFORMATION

More information

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.

We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees. RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never experiences a workers

More information

Return to Work Rates & Other Selected Characteristics of Workers Compensation Claimants

Return to Work Rates & Other Selected Characteristics of Workers Compensation Claimants Return to Work Rates & Other Selected Characteristics of Workers Compensation Claimants Data Supplement to Report of the Commissioner on Return to Work Pursuant to Section 35 of the Workers Compensation

More information

RESEARCH UPDATE. California Workers Compensation Reform Monitoring. Part 3: Temporary Disability Outcomes Accident Years 2002 2007 Claims Experience

RESEARCH UPDATE. California Workers Compensation Reform Monitoring. Part 3: Temporary Disability Outcomes Accident Years 2002 2007 Claims Experience January 2009 RESEARCH UPDATE California Workers Compensation Reform Monitoring Part 3: Temporary Disability Outcomes Accident Years 2002 2007 Claims Experience by Alex Swedlow, MHSA and John Ireland, MHSA

More information

Accident Coverage Details

Accident Coverage Details Accident Coverage Details Choose Level 1 or Level 2 Benefits Accident Coverage provides 24-hour coverage or off-the-job coverage. Select the level of coverage that best meets your needs and budget. BENEFITS

More information

EMPLOYEE S WORK INJURY AND ILLNESS REPORT

EMPLOYEE S WORK INJURY AND ILLNESS REPORT State of Wisconsin University Of Wisconsin System UW- UWS/OSLP-1Emp (03/02) EMPLOYEE S WORK INJURY AND ILLNESS REPORT PLEASE TYPE OR PRINT FOR AGENCY USE ONLY Claim Number INSTRUCTIONS: 1. Complete within

More information

Workers' Compensation in Oklahoma Employee s Rights & Responsibilities

Workers' Compensation in Oklahoma Employee s Rights & Responsibilities Workers' Compensation in Oklahoma Employee s Rights & Responsibilities Workers Compensation Court Counselor Program 1915 N. Stiles Avenue, Oklahoma City, OK 73105 210 Kerr State Office Bldg., 440 S. Houston,

More information

Workers' Compensation in Oklahoma Employee s Rights & Responsibilities

Workers' Compensation in Oklahoma Employee s Rights & Responsibilities Workers' Compensation in Oklahoma Employee s Rights & Responsibilities The information provided in this pamphlet is general in nature and for informational purposes only. It is not intended to be a legal

More information

Private sector wage and salary workers 2 Government workers 3 Self-employed workers 4. Number Percent Number Percent Number Percent Number Percent

Private sector wage and salary workers 2 Government workers 3 Self-employed workers 4. Number Percent Number Percent Number Percent Number Percent Total 106 100.0 88 100.0 11 100.0 7 100.0 Goods producing 45 42.5 44 50.0 -- -- 1 14.3 Natural resources and mining 13 12.3 13 14.8 -- -- -- -- Agriculture, forestry, fishing and hunting -- -- -- -- --

More information

The Commonwealth of Massachusetts Department of Industrial Accidents. For injured workers

The Commonwealth of Massachusetts Department of Industrial Accidents. For injured workers The Commonwealth of Massachusetts Department of Industrial Accidents For injured workers WHAT IS WORKERS COMPENSATION? The Massachusetts Workers Compensation system is in place to protect you if you are

More information

MULTI-STATE WORKERS COMPENSATION GUIDANCE MATERIAL

MULTI-STATE WORKERS COMPENSATION GUIDANCE MATERIAL Topic : Item : State : Compensation 1. Notifying of injury and claim lodgement AUSTRALIAN CAPITAL TERRITORY When does an Employer need to report a workplace injury? If an accident has caused the death

More information

STATE FUND LOCATIONS CUSTOMER SERVICE CENTER. BAKERSFIELD Policy (661) 664-4000 Claims (661) 664-4000

STATE FUND LOCATIONS CUSTOMER SERVICE CENTER. BAKERSFIELD Policy (661) 664-4000 Claims (661) 664-4000 California State Employees Assn. STATE FUND LOCATIONS BAKERSFIELD Policy (661) 664-4000 Claims (661) 664-4000 EUREKA Policy (707) 443-9721 Claims (707) 443-9721 FRESNO Policy (559) 433-2600 Claims (559)

More information

Superintendent s Circular

Superintendent s Circular Superintendent s Circular School Year 2011-2012 NUMBER: HRS-PP7 DATE: WORKERS COMPENSATION PROCEDURES OBJECTIVE The Boston Public Schools Workers Compensation Service is located within Boston City Hall,

More information

Summary of Survey Methods

Summary of Survey Methods 2 Summary of Survey Methods 1. Objective of the survey This survey is conducted as part of the basic statistical surveys under the Statistics Act, in accordance with the Regulations on Surveys for the

More information

Work Injury Reporting Hotline 877 682-7778

Work Injury Reporting Hotline 877 682-7778 FACTS ABOUT WORKERS COMPENSATION The content of this pamphlet has been approved by the Administrative Director of the Division of Workers Compensation. The information in this pamphlet is available in

More information

INDUSTRIAL COMMISSION OF ARIZONA

INDUSTRIAL COMMISSION OF ARIZONA INDUSTRIAL COMMISSION OF ARIZONA WORKERS COMPENSATION INFORMATION FOR THE INJURED WORKER Phoenix Office: Industrial Commission of Arizona 800 W. Washington Street Phoenix, Arizona 85007-2922 Claims Phone:

More information

New Regulations For Texas Nonsubscribers Effective January 1, 2013

New Regulations For Texas Nonsubscribers Effective January 1, 2013 New Regulations For Texas Nonsubscribers Effective January 1, 2013 There are NEW RULES regarding certain forms nonsubscribers must file with the Texas Department of Insurance and Notices which must be

More information

Group term life insurance

Group term life insurance Group term life insurance Broker information for groups with 2 to 50 eligible employees Effective July 1, 2011 Life insurance, underwritten by Blue Shield of California Life & Health Insurance Company

More information