SCHOOL POOL FOR EXCESS LIABILITY LIMITS

Transcription

1 SCHOOL POOL FOR EXCESS LIABILITY LIMITS JOINT INSURANCE FUND ACCASBOJIF, BCIPJIF, & GCSSDJIF CLAIM COORDINATOR MANUAL S P E L ACCASBO L BCIP GCSSD SEJIF I F REVISED OCTOBER 2013

2 Section 14 SAMPLE COMPLETED CLAIM FORM- WORKERS COMPENSATION

3 CLAIM EXAMPLE Workers Compensation Accident Member District Name: ABC District Date of Accident: January 26, 2013 Description of Accident: Consequence: A football coach was teaching his players how to perform a bull rush by demonstrating the technique. Unfortunately, the student lineman was real big and the coach s knee gave way before the student did. The coach tore the medial meniscus in his damaged right knee requiring an extensive surgery and putting the coach out of commission for eight weeks.

4 QUALCARE, INC. WORKERS' COMPENSATION CLAIM TRANSMITTAL FORM TO: QualCare, Inc. 100 Decadon Drive Egg Harbor Township, NJ PHONE: FAX NUMBER: (Only for Workers' Compensation ) NUMBER OF PAGES SENT (#) FROM: (Name of Claim Coordinator) (Name of District) This is a: New Claim Additional Information on Existing Claim (Claim Number, if known) Date of Loss: Claimant Name: Always complete this form whenever transmitting Workers' Compensation Claims to QualCare

5 School District Employee s Authorization for Medical Attention, is authorized to leave the premises of the Board of Education to seek medical attention for an injury or illness reported to the first undersigned at a.m. p.m., on / /. The Board of Education is not in a position to determine whether or not the injury is compensable within the meaning of the New Jersey Worker s Compensation Law. However, it is the intent of the Board of Education to provide its employees and authorized treating physicians with an answer to the question of compensability as soon as possible. Therefore, the employee receiving this form is required to have the treating medical provider complete this form at the time of his/her initial treatment. First Undersigned: Date: (Claim Coordinator, Principal, Nurse or Supervisor) Second Undersigned: Date: (Injured Employee) Initial Complaint: Instructions to Medical Provider Please complete and sign this form, then fax it and the Workers Compensation Treatment And Status Report to our Claim Administrator and to the Board of Education at the addresses and facsimile numbers shown below. Your prompt attention to this request will help speed up all processes resulting in a more efficient delivery of services to our employee and faster processing of claim activity. Signed: Date: (Medical Provider) Fax Completed Form To: Qual-Lynx ACCASBOJIF/BCIPJIF/GCSSDJIF Claims 100 Decadon Drive Egg Harbor Twp., NJ Phone: Fax: (General) (Worker s Comp) School District Name and Address Copy To District Claim Coordinator Copy To Medical Provider F:\DATA\Risk\WINWORD\School Pool for Excess Liability Limits\Claim Coord Manual Rev 07 12\Section 9-Forms\Employee Authorization for Medical Attention.doc

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8 CLAIM TRANSMITTAL FORM TO: Qual-Lynx 100 Decadon Drive Egg Harbor Twp., NJ PHONE: FAX NUMBER: (Only for Workers Compensation) FAX NUMBER: (All other claim reports and information transmitted) NUMBER OF PAGES SENT (#) FROM: (Name of Claim Coordinator) (Name of District) PHONE: (Telephone number) FAX: (FAX number) DATE: FORM OF TRANSMISSION Fax (check which applies) Telephone This is a: New Claim Additional Information on Existing Claim (Claim Number, if known) Date of Loss: (Date of Incident) Claimant Name: (Name of claimant or district) Claim Type: Property/Theft/Employee Dishonesty Liability or Automobile Physical Damage Workers Compensation (employee injured on the job) Department: (please check the appropriate box) Administration Facilities/Maintenance/Custodial Food Service Instructional Staff Transportation Always complete this form whenever transmitting claim information to Qual-Lynx

9 Check All Claim Forms Which Are Attached Incident Reporting Form Property Loss\Claim Form Worker s Compensation Claim Forms Liability Loss Claim Form Other relevant information, please explain: Tort Notice Information - See Below. Tort Notice Section (Third Party Liability Claims) Initial letter and form sent to claimant (third party) with copies to the Fund s Claim Administrator and Attorney. Completed form received, date stamped, copied and sent to the Fund s Claim Administrator and Attorney. f:/d/r/w/gcssdjif/forming/98-99/clmcoord/clmtrns.doc 2

10 CLAIM TRANSMITTAL FORM TO: Qual-Lynx 100 Decadon Drive Egg Harbor Twp., NJ PHONE: FAX NUMBER: (Only for Workers Compensation) FAX NUMBER: (All other claim reports and information transmitted) NUMBER OF PAGES SENT (#) FROM: (Name of Claim Coordinator) (Name of District) PHONE: (Telephone number) FAX: (FAX number) DATE: FORM OF TRANSMISSION Fax (check which applies) Telephone This is a: New Claim Additional Information on Existing Claim (Claim Number, if known) Date of Loss: (Date of Incident) Claimant Name: (Name of claimant or district) Claim Type: Property/Theft/Employee Dishonesty Liability or Automobile Physical Damage Workers Compensation (employee injured on the job) Department: (please check the appropriate box) Administration Facilities/Maintenance/Custodial Food Service Instructional Staff Transportation Always complete this form whenever transmitting claim information to Qual-Lynx

11 Check All Claim Forms Which Are Attached Incident Reporting Form Property Loss\Claim Form Worker s Compensation Claim Forms Liability Loss Claim Form Other relevant information, please explain: Tort Notice Information - See Below. Tort Notice Section (Third Party Liability Claims) Initial letter and form sent to claimant (third party) with copies to the Fund s Claim Administrator and Attorney. Completed form received, date stamped, copied and sent to the Fund s Claim Administrator and Attorney. f:/d/r/w/gcssdjif/forming/98-99/clmcoord/clmtrns.doc 2