How To Contact Firstcomp.Com

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1 Southern Insurance Company Southern Insurance Company 5525 LBJ Freeway Dallas, 5525Texas LBJ Freeway Dallas, Texas Servicing Office: Servicing FirstComp Office: Insurance Mailing Agency Address FirstComp Central ParkInsurance Plaza South Agency PO Central 222Box South Park th Plaza Street, South Suite Omaha, South NE15th Street, Suite 1200 Omaha, (888) NE (888) YOUR INSURANCE POLICY YOUR INSURANCE POLICY Coverage afforded by this policy is provided by the Company and named in the Declarations. Coverage afforded by this policy is provided by the Company and named in the Declarations. In Witness Whereof, the company has caused this policy to be executed, attested, and countersigned by a duly In authorized Witness Whereof, representative the company of the company. has caused this policy to be executed, attested, and countersigned by a duly authorized representative of the company. Parker W. Rush, President Parker W. Rush, President Michael E. Ditto, Corporate Secretary Michael E. Ditto, Corporate Secretary FC--Republic-SIC (03/2006) FC--Republic-SIC (03/2006)

2 Important Notice About the Protection of Your Privacy We value your business and the trust youʼve placed in us. Thatʼs why we want to assure you that we are serious about keeping your personal information private before, during and after your business relationship with us. This notice explains our privacy protection policy with respect to your personal information that is not publicly available. This includes your financial information regarding an insurance product used for a personal, family, or household purpose as well as your individual health information. We provide this notice annually to you as our policyholder as well as to workersʼ compensation plan participants. We do not provide our annual privacy notice to former customers. If we materially amend our privacy protection policy, we will provide you with an amended notice. If two or more policyowners are named on one policy, we will provide only one notice to the policyowners jointly. You do not need to call or do anything in response to this notice. It is meant to inform you of how we use and protect your personal nonpublic information. Collecting Information We may collect information about you, some of which is not publicly available. This enables us to identify you as our customer or former customer, to process your policy and requests quickly, to pay your claim or to tell you about useful products or services. This information may come from: You, on applications or related forms, such as your name, address, telephone, premium payments, or financial account information. Transactions, with us or our affiliates, such as insurance premiums, claim history, policy numbers, or the products you purchase from us. Others, such as producers, consumer reporting agencies about your credit history or medical providers. Disclosure Information Financial Information - We do not share your personal information or that of former customers with companies outside our family group, except for limited and permitted uses as allowed by law. Health Information - We do not share your health information or that of former customers without your specific written authorization unless a law allows or requires us to do so. We share only the health information that is necessary for compliance. Fair Credit Reporting Act - We do not disclose your financial information with others within our family group except as authorized by law such as transactions with us and our experience with you... Allowed by Law - In certain circumstances, we may share your private information as allowed by law. For example, we may provide information to our service providers such as third-party administrators or consultants for claims adjudication or underwriting activities. We may also provide information to government regulators, law enforcement agencies, fraud prevention, when you request or give your permission. PR CA (06/08) Page 1 of 2

3 Confidentiality Confidentiality and Security and Security We strive We to maintain strive to maintain appropriate appropriate physical, physical, electronic, electronic, and procedural and procedural safeguards safeguards to protect to your protect private your private information. information. We provide We training provide to training our employees to our employees and limit and access limit to access the information. to the information. Our service Our service providers providers must agree must to agree safeguard to safeguard your information your information and may and not use may or not share use or the share information the information any for any purpose other purpose than other to carry than out to carry the business out the business function function our behalf. on our We behalf. maintain We maintain policies about policies the about the proper physical proper security physical of security workplaces of workplaces and records. and records. Your policy Your is written policy is in written one of the in one following of the following companies, companies, each a separate each a separate legal entity: legal entity: Republic Republic Underwriters Underwriters Insurance Insurance Company Company Republic Republic Fire and Casualty Fire and Casualty Insurance Insurance Company Company Republic-Vanguard Republic-Vanguard Insurance Insurance Company Company Republic Republic Lloyds Lloyds Southern Southern Insurance Insurance Company Company Southern Southern County Mutual County Insurance Mutual Insurance Company Company Southern Southern Underwriters Underwriters Insurance Insurance Company Company Southern Southern Vanguard Vanguard Insurance Insurance Company Company Accessing Accessing Your Personal Your Personal Information Information You have You the right have to the access right to and access request and changes request to changes your personal to your information. personal information. For more For information more information on on how you may how exercise you may these exercise rights, these please rights, contact please our contact servicing our servicing agent at: agent at: FirstComp FirstComp Insurance Insurance Agency Agency P.O. Box P.O Box 3009 Omaha, NE Omaha, NE PR CA PR (06/08) CA (06/08) Page 2 of 2 Page 2 of 2

4 Central Park Plaza 222 South 15th Street, Suite 1500N Omaha NE FirstComp is a filed trademark for Aspen Holdings, Inc. and its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group, FirstComp Insurance Agency, FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc. and Pinebrook Insurance Agency.

5 Central Park Plaza 222 South 15th Street, Suite 1500N Omaha NE FirstComp is a filed trademark for Aspen Holdings, Inc. and its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group, FirstComp Insurance Agency, FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc. and Pinebrook Insurance Agency.

6 Central Park Plaza 222 South 15th Street, Suite 1500N Omaha NE FirstComp is a filed trademark for Aspen Holdings, Inc. and its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group, FirstComp Insurance Agency, FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc. and Pinebrook Insurance Agency.

7 Central Park Plaza 222 South 15th Street, Suite 1500N Omaha NE FirstComp is a filed trademark for Aspen Holdings, Inc. and its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group, FirstComp Insurance Agency, FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc. and Pinebrook Insurance Agency.

8 Central Park Park Plaza Plaza South South South 15th 15th Street, Street, Suite Suite 1500N 1200 Omaha, NE NE Telephone Underwriting Fax Claims Fax Henderson, NV Providence, RI Tampa, FL Date Member Name Contact Person Address Dear: In an effort to reduce your workers compensation costs, FirstComp, in partnership with mymatrixx, has implemented a prescription drug card program. mymatrixx enjoys a solid national reputation in the pharmacy management industry and carries well over 55,000 pharmacies in its pharmacy network. This program is designed to provide a comprehensive structure for the focused delivery of pharmacy management services, which will result in an average cost savings of at least 20% on prescription drugs. This program will also provide for convenient prescription drug transactions by injured workers. Below is a brief summary on how the new pharmacy program will operate: First Fill Protocol The First Fill letter allows for prescriptions to be completed during the claim submission process with a prescription fill limit of 5 days. First Fill letters should be given to any injured employee filing a workers compensation claim. Prescription Card Issuance Within 5 business days the injured worker will receive a letter at their home outlining the 9 closest in-network pharmacies. The letter will also contain the worker s personalized prescription drug card. This prescription drug card is only serviceable for their workers compensation claim. Best Regards, FirstComp FirstComp is a is registered a filed trademark for for Aspen Aspen Holdings, Inc. Inc. and and its affiliates its including but but not not limited limited to those to those doing doing business as FirstComp as Insurance Company, FirstComp FirstComp Underwriters Underwriters Group, Inc., Group, FirstComp Inc., FirstComp Group, FirstComp Group Inc., Insurance FirstComp Agency, Group, FirstComp Insurance Services Agency, of Nebraska, Pinebrook Pinebrook Insurance Insurance Group, Inc. Group, and Pinebrook Inc. and Pinebrook Insurance Insurance Agency. Agency.

9 Central Park Plaza 222 South 15th Street, Suite 1500N Omaha NE FirstComp is a filed trademark for Aspen Holdings, Inc. and its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group, FirstComp Insurance Agency, FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc. and Pinebrook Insurance Agency.

10 Central Park Park Plaza Plaza South South South 15th 15th Street, Street, Suite Suite 1500N 1200 Omaha, NE NE Telephone Underwriting Fax Claims Fax Henderson, NV Providence, RI Tampa, FL FirstComp is a is registered a filed trademark for for Aspen Aspen Holdings, Inc. Inc. and and its affiliates its including but but not not limited limited to those to those doing doing business as FirstComp as Insurance Company, FirstComp FirstComp Underwriters Underwriters Group, Inc., Group, FirstComp Inc., FirstComp Group, FirstComp Group Inc., Insurance FirstComp Agency, Group, FirstComp Insurance Services Agency, of Nebraska, Pinebrook Pinebrook Insurance Insurance Group, Inc. Group, and Pinebrook Inc. and Pinebrook Insurance Insurance Agency. Agency.

11 Save TIME and MONEY with online bill payment! FirstComp s* online payment options give you the convenience, security and savings of no hassle premium payments automatically withdrawn from your account. With flexible payment options you can choose to enroll in recurring payments or make a one-time only payment. No premium limits Receive verification of your payment Secure transfer Eliminate installment fees on recurring payment plans! To sign up, visit and click the Online Payment link or call a Customer Service Representative at (888) *FirstComp is a registered trademark of Aspen Holdings, Inc. used under license by its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group Inc., First- Comp Group, FirstComp Insurance Agency, Inc., FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc., Pinebrook Insurance Agency and Risk Exchange Insurance Services, Inc., a subsidiary of Rex, Inc. also doing business as Risk Exchange Insurance Agency Services, Inc. In addition, it is a servicing entity for Endurance Workers Compensation Insurance Company, Delos Insurance Company, Republic Fire and Casualty Insurance Company, Republic Underwriters Insurance Company, Southern Insurance Company, Southern Vanguard Insurance Company and Virginia Surety Company. FC7118(0510)_Online Bill Pay

12 Central Park Plaza 222 South 15th Street, Suite 1500N Omaha NE FirstComp is a filed trademark for Aspen Holdings, Inc. and its affiliates including but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Group, FirstComp Insurance Agency, FirstComp Insurance Services of Nebraska, Pinebrook Insurance Group, Inc. and Pinebrook Insurance Agency.

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17 ADDITIONAL INFORMATION FOR CALIFORNIA POLICIES WITH CONSTRUCTION DUAL WAGE CLASSFICATION Please be advised if your policy contains the following Construction class codes you may qualify for additional classifications based on the dollar per hour you pay specific employees: 5185 AUTOMATIC SPRINKLER INSTALLATION within buildings including storage and yard employees employees whose regular hourly wage does not equal or exceed $26.00 per hour 5186 AUTOMATIC SPRINKLER INSTALLATION within buildings including storage and yard employees employees whose regular hourly wage equals or exceeds $26.00 per hour 5645 CARPENTRY construction or remodeling of detached private residences for occupancy by one or two families including the construction of private garages and the installation of interior trim, builders finish, doors and cabinet work in connection with such structures - employees whose regular hourly wage does not equal or exceed $25.00 per hour 5697 CARPENTRY construction or remodeling of detached private residences for occupancy by one or two families including the construction of private garages and the installation of interior trim, builders finish, doors and cabinet work in connection with such structures employees whose regular hourly wage equals or exceeds $25.00 per hour 5403 CARPENTRY including the installation of interior trim, builders finish, doors and cabinet work in connection there with employees whose regular hourly wage does not equal or exceed $25.00 per hour N.O.C CARPENTRY including the installation of interior trim, builders finish, doors and cabinet work in connection therewith employees whose regular hourly wage equals or exceeds $25.00 per hour N.O.C CONCRETE OR CEMENT WORK pouring or finishing or concrete sidewalks, driveways, patios, curbs or gutters including the making or stripping of forms - employees whose regular hourly wage does not equal or exceed $23.00 per hour 5205 CONCRETE OR CEMENT WORK pouring or finishing of concrete sidewalks, driveways, patios, curbs or gutters including the making or stripping of forms - employees whose regular hourly wage equals or exceeds $ ELECTRICAL WIRING within buildings including installation or repair of fixtures or appliances shop and outside employees whose regular hourly wage does not equal or exceed $27.00 per hour 5140 ELECTRICAL WIRING within buildings including installation or repair of fixtures or appliances shop and outside employees whose regular hour wage equals or exceeds $27.00 per hour 5467 GLAZIERS away from shop employees whose regular hourly wage does not equal or exceed $25.00 per hour 5470 GLAZIERS away from shop employees whose regular hourly wage equal or exceeds $25.00 per hour 5027 MASONRY employees whose regular hourly wage does not equal or exceed $23.00 per hour N.O.C MASONRY employees whose regular hourly wage equals or exceeds $23.00 per hour N.O.C PAINTING, DECORATING OR PAPER HANGING including shop operations employees whose regular hourly wage does not equal or exceed $23.00 per hour N.O.C PAINTING, DECORATING OR PAPER HANGING including shop operations employees whose regular hourly wage equals or exceeds $23.00 per hour N.O.C PLASTERING OR STUCCO WORK employees whose regular hourly wage does not equal or exceed $24.00 per hour 5485 PLASTERING OR STUCCO WORK employees whose regular hourly wage equals or exceeds $24.00 per hour 5183 PLUMBING shop and outside gas, steam, hot water or other pipe fittings installation, including house connections installation employees whose regular hourly wage does not equal or exceed $24.00 per hour N.O.C PLUMBING shop and outside gas, steam, hot water or other pipe fittings installation, including house connections installation employees whose regular hourly wage equals or exceeds $24.00 per hour N.O.C REFRIGERATION EQUIPMENT not household units installation, service and repair shop and outside employees whose regular hourly wage does not equal or exceed $24.00 per hour N.O.C REFRIGERATION EQUIPMENT not household units installation, service and repair shop and outside employees whose regular hourly wage equals or exceeds $24.00 per hour N.O.C 5538 SHEET METAL WORK erection, installation or repair shop and outside including installation of furnaces or air conditioning systems employees whose regular hourly wage does not equal or exceed $24.00 per hour N.O.C SHEET METAL WORK erection, installation or repair shop and outside including installation of furnaces or air conditioning systems employees whose regular hourly wage equals or exceeds $24.00 per hour N.O.C WALLBOARD APPLICATION within buildings installation or application of gypsum wallboard including finishing and preparation prior to painting employees whose regular hourly wage does not equal or exceed $25.00 per hour N.O.C WALLBOARD APPLICATION within buildings installation or application of gypsum wallboard including finishing and preparation prior to painting employees whose regular hourly wage equals or exceeds $25.00 per hour N.O.C (2) WATERPROOFING other than roofing or subaqueous work when performed as a separate operation not a part of or incidental to any other operation including shop operations employees whose regular hourly wage does not equal or exceed $23.00 per hour 5482 (2) WATERPROOFING other than roofing or subaqueous work when performed as a separate operation not a part of or incidental to any other operation including shop operations employees whose regular hourly wage equals or exceeds $23.00 per hour

18 Earnings Verification Employee: Employer: Claim No.: Date of injury: Date of Hire: Job Title: Social Security Number: Wages: per hour per week per month Date rate took effect: # of hours regularly worked per week: # of overtime hours worked per week: Overtime wages: per Tips reported: per week If employee s compensation package included an allowance for any of the following, please indicate each actual or estimated value: Meals: per week Automobiles: per week Rent/Lodging: per week Bonus: per week per month annual Was this employee? Permanent Temporary Seasonal Indicate last day of season job: PLEASE COMPLETE THE FOLLOWING: GROSS WAGES FOR THE 52 WEEKS PRIOR TO INJURY OR ENTIRE PERIOD OF EMPLOYMENT, WHICHEVER IS LESS: WEEKS NO. NO. WEEK AMOUNT WEEKS DAYS HOURS ENDING PAID NO. DAYS NO. HOURS WEEK ENDING AMOUNT PAID I CERTIFY THE ABOVE INFORMAITON IS CORRECT: Signature Title/Position Date

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