SUSQUEHANNA CONFERENCE OF THE UNITED METHODIST CHURCH WORKERS COMPENSATION

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1 SUSQUEHANNA CONFERENCE OF THE UNITED METHODIST CHURCH WORKERS COMPENSATION I. Workers Compensation Coverage II. Who Is Covered III. Who Is T Covered IV. How to Report a Claim I. WORKERS COMPENSATION COVERAGE The Susquehanna Conference of the United Methodist Church has been a Member of the United Methodist Workers Compensation Trust Fund, a Group Self-Insurance Fund, since The Trust selfinsures their Workers Compensation obligation and is regulated by the Department of Labor and Industry and must comply with Pennsylvania Workers Compensation Laws. As a Member of the Trust, the Susquehanna Conference, provides workers compensation benefits to employees as required by the Workers Compensation Law or occupational disease law of Pennsylvania, to include medical treatment and loss of wages, to employees who sustain a work-related injury or workrelated disease, including resulting death, during the course of their employment. The Trust also includes Employers Liability coverage for the legal obligation of the employer (Susquehanna Conference and Susquehanna Conference -United Methodist Churches) to pay damages because of bodily injury by accident or disease, including resulting death, sustained by an employee and only if the injury or death of an employee arises out of and in the course of employment. II. WHO IS COVERED EMPLOYEES of the Susquehanna Conference of the United Methodist Church; EMPLOYEES of United Methodist churches in the Susquehanna Conference, that are directly owned, operated and controlled by the Susquehanna Conference and/or owned, operated and controlled by a United Methodist church in the Susquehanna Conference, including: 1) All paid employees of the Susquehanna Conference 2) All paid pastors of United Methodist churches in the Susquehanna Conference 3) All paid employees of United Methodist churches in the Susquehanna Conference --who are directly owned, operated and controlled by the United Methodist Church

2 4) You must provide a copy of a W-2 statement or pay stub of your employer - the Susquehanna Conference or a United Methodist church in the Susquehanna Conference and 5) Provide a federal employee identification number on the Workers Compensation Claim Report III. WHO IS T COVERED 1) Coverage is T provided to any Methodist or ecumenical program that is not fully owned, operated and controlled by the Susquehanna Conference or owned, operated and controlled by a United Methodist church in the Susquehanna Conference 2) Coverage is T provided to any day care, pre-school, mission, organization, group that is not fully owned, operated and controlled by the Susquehanna Conference or owned, operated and controlled by a United Methodist church in the Susquehanna Conference 3) Coverage is T provided to any organization or group that leases any property or space from the Susquehanna Conference or a United Methodist church in the Susquehanna Conference 4) Coverage is T provided to any Conference volunteer, United Methodist Church volunteer or any volunteer For day cares, pre-schools, groups, organizations, missions, non-profit organizations, joint ventures, volunteers, etc., that have a relationship with the Susquehanna Conference or United Methodist churches in the Susquehanna Conference, DO T ASSUME you are covered by the Susquehanna Conference Workers Compensation program. You must be owned, operated and controlled by the Susquehanna Conference or owned, operated and controlled by a United Methodist church in the Susquehanna Conference for this coverage to apply. If you have ANY questions about workers compensation, please contact the Conference Treasurer immediately. IV. INSTRUCTIONS ON HOW TO REPORT A CLAIM Report any work-related injury immediately. Ensuring prompt and appropriate medical care for injured employees and returning them to work is our central focus. Our efforts will be most effective when you report your claims immediately. Inservco Insurance Services, Inc. is the claim management company hired by the United Methodist Workers Compensation Trust Fund to administer and manage the Susquehanna Conference workers compensation claims. There is a dedicated staff to manage the United Methodist claims. You will be contacted by an Inservco representative after you report your claim to the Conference Treasurer.

3 HOW TO REPORT A CLAIM 1) Complete the Workers Compensation Claim Form Employers First Report of Injury - included in the Conference website and forward it to the Conference Treasurer 2) Scan or Fax a copy of the latest W-2 or pay stub for the injured employee to the Conference Treasurer at with the Employers First Report of Injury 3) Make sure the Employer Federal Identification Number is included on the Claim Form 4) Forward the completed claim form to the Conference Treasurer For assistance - Direct all questions to the Conference Treasurer Reminder: All Conference and Church locations are mandated to post the Department of Labor and Industry Workers Compensation Posting Notice LIBC 500 (5/09) found in the Conference website

4 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON, ROOM 103 HARRISBURG, PA (TOLL FREE) TTY (TOLL FREE) EMPLOYEE FIRST NAME Inservco claim number: EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR DISEASE EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE LAST NAME ADDRESS CODE COUNTY PHONE NUMBER EMPLOYEE: NUMBER OF DEPENDENTS DATE OF BIRTH MALE MARRIED FEMALE SINGLE OCCUPATION OR JOB TITLE NCCI CLASS CODE (IF KWN) EMPLOYMENT STATUS FT = Full-Time SL = Seasonal PT = Part-Time VO = Volunteer ZZ = Other EMPLOYER ADDRESS CODE SIC CODE EMPLOYER FEIN PHONE NUMBER COUNTY NAICS CODE FULL PAY FOR DAY OF INJURY? TIME EMPLOYEE BEGAN WORK. AM PM TIME OF OCCURRENCE. AM PM LAST DAY WORKED DATE DISABILITY BEGAN DATE EMPLOYER TIFIED DATE RETURNED TO WORK DATE OF HIRE MONTH DAY YEAR CONTACT FIRST NAME CONTACT PHONE NUMBER CONTACT LAST NAME TICE: Report should be clearly completed, (preferably typed) and original mailed to the Bureau at the address in the upper left corner and a copy to employee and insurer. LIBC-344 INSHBG REV 1/01 (OVER)

5 LIBC-344 TYPE OF INJURY CODE PART OF BODY AFFECTED CODE CAUSE OF INJURY CODE (ENTER CODES, IF KWN) TYPE OF INJURY OR ILLNESS PARTS OF BODY AFFECTED CAUSE OF INJURY DID INJURY OR ILLNESS OCCUR ON EMPLOYER'S PREMISES? IF OUT OF, SPECIFY OF INJURY WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE SAFEGUARDS OR SAFETY EQUIPMENT USED? ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABRMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE IF FATAL, GIVE DATE OF DEATH INITIAL TREATMENT: MEDICAL TREATMENT PHYSICIAN/HEALTH CARE PROVIDER FIRST NAME: LAST NAME: MIR BY EMPLOYEE CLINIC / HOSPITAL PANEL PHYSICIAN EMPLOYEE PHYSICIAN EMERGENCY CARE - HOSPITALIZED MORE THAN 24 HOURS POLICY PERIOD FROM: HOSPITAL NAME: - POLICY PERIOD TO: POLICY/SELF INSURED NUMBER: WITNESS FIRST NAME WITNESS PHONE NUMBER WITNESS LAST NAME PERSON COMPLETING THIS FORM: NAME: TITLE: INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED) NAME: PHONE: DATE PREPARED BUREAU CODE: FEIN: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165.

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