WORKERS COMPENSATION Claims Kit
Dear Customer, Thank you for choosing ProSight Specialty Insurance as your Workers Compensation Insurance carrier. We pride ourselves on providing excellent service and will do our very best to meet your Workers Compensation Claims needs. ProSight Specialty Insurance writes our Workers Compensation policies through our New York Marine and General Insurance Company underwriting company, which is the name you will see listed on your policy. ProSight has partnered with a leading Workers Compensation claims service provider, Gallagher Bassett Services, to assist us in the administration of claims. Gallagher Bassett will be your primary point of contact for claims. To determine which office will be handling your claims, please refer to the map included with this packet. Please make sure to include your Policy Number on all correspondence. For your convenience, the following documents can be found inside your claims kit: Instructions on how to report a claim Claim Handling Map List of Claim office locations, mailing addresses, and claim contacts How to locate a Physician Pharmacy cards Links to your state s Workers Compensation forms and Web Pages Please do not hesitate to contact us should you have any questions or concerns. Workers Compensation Claims Department ProSight Specialty Insurance 412 Mt. Kemble Avenue Morristown, NJ 07960 claimsinquiry@prosightspecialty.com Phone: 800-774-2755 Fax: 855-657-3534
Need to Report a Claim? By e-mail: claims@prosightspecialty.com By phone: (800)-774-2755 Press 1 to report a claim (Available anytime- days, nights & weekends) By fax: (800)-326-2864 Press 2 to inquire about a claim (Available 8:00am to 5:00pm EST) By Mail: ProSight Specialty Insurance Claims Department 412 Mt. Kemble Avenue Suite 300C Morristown, NJ 07960 Additional Instructions: Online: -. EXPERIENCED PROFESSIONALS. INSIGHTFUL SOLUTIONS.SM
Workers Compensation Claim Handling Washington Montana North Dakota New Hampshire Vermont Maine Oregon Nevada California Idaho Utah Arizona Wyoming Colorado New Mexico Minnesota South Dakota Wisconsin Nebraska Iowa Illinois Kansas Missouri Oklahoma Arkansas Michigan Ohio Indiana Kentucky Tennessee New York Pennsylvania West Virginia Virginia North Carolina South Carolina New Jersey Delaware Maryland Massachusetts Rhode Island Connecticut Mississippi Alabama Georgia Alaska Texas Louisiana Hawaii Florida ProSight Specialty Insurance Gallagher Bassett Services LWP Claims Solutions Monopolistic
Claims Handling Offices ProSight Specialty Insurance Mailing Workers Compensation Claims Department ProSight Specialty Insurance 412 Mt. Kemble Avenue Morristown, NJ 07960 claimsinquiry@prosightspecialty.com Phone: 800-774-2755 Fax: 855-657-3534 Alabama Arkansas California Colorado Connecticut Delaware DC Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maryland Massachusetts Michigan Minnesota Missippi Missouri Nebraska New Hampshire New Jersey New York North Carolina Pennsylvania Rhode Island South Carolina South Dakota Tennessee Utah Vermont Virginia West Virginia Wisconsin WC Claims Manager: Melissa Kovacsy mkovacsy@prosightspecialty.com Lost Time Adjuster: Patrick Gano pgano@prosightspecialty.com Medical Only Adjuster: Melinda Bullock mbullock@prosightspecialty.com
Mailing Claims Handling Offices Alaska Wilton Adjustment Service, Inc. 425 625 E. 34th Avenue, Suite 400 Anchorage, AK 99503 Phone: 907-276-3311 Fax: 907-276-7877 Alaska Branch Manager: Joanne Pride, x 3412 joanne-pride@wiltonalaska.com Adjuster: McKenna Wentworth, x 3452 mckenna-wentworth@wiltonalaska.com Medical Only: Shea Loescher, x 3317 shea-loescher@wiltonalaska.com
Claims Handling Offices Arizona Mailing Gallagher Bassett Services- 007 (Phoenix) PO Box 10849 Scottsdale, Arizona 85271 Arizona Phone: 480-586-9500 Fax: 480-443-8416 Toll Free: 800-231-3759 Branch Manager: Bruce Martin Bruce_martin@gbtpa.com
Claims Handling Offices Hawaii Mailing Gallagher Bassett Services -162 900 Fort Street, Suite 420 Honolulu, HI 96813-4511 Phone: 808-532-7362 Fax: 808-545-5967 Toll Free: 877-492-9645 Hawaii Nadine Kurihara-Nakasu, Branch Manager Nadine_Kurihara-Nakasu@gbtpa.com
Claims Handling Offices Idaho Mailing Gallagher Bassett Services 193 720 East Park Blvd., Suite 125 Boise, ID 83712 Phone: 208/345-8090 Fax: 208/345-3996 Toll Free: 866/217-1192 Idaho Regina Pearson, Branch Manager Regina_Pearson@gbtpa.com
Claims Handling Offices Montana Mailing Gallagher Bassett 080 (Missoula) 2501 Catlin Street, Suite 200 Missoula, MT 59801 Phone: 855-335-7892 Fax: 406-721-2735 Montana Regina Pearson 208-515-3835 regina_pearson@gbtpa.com
Claims Handling Offices Nevada Mailing Gallagher Bassett Services 156 P.O. Box 70030 Las Vegas, NV 89170 Phone: 702-789-4500 Toll Free: 866-889-4755 Fax: 866-823-4130 Nevada Charles Rostad, Branch Manager Charles_Rostad@gbtpa.com (UPS, Federal Express, etc) 2110 E. Flamingo Road, Suite 314 Las Vegas, NV 89119
Claims Handling Offices New Mexico Mailing Gallagher Bassett Services - 046 2424 Louisiana NE, Suite 220 Albuquerque, NM 87110 Phone: 505-837-2180 Fax: 505-837-2187 Toll Free: 866-859-2180 New Mexico Regina Pearson, Branch Manager Regina_Pearson@gbtpa.com
Claims Handling Offices Oklahoma Mailing Gallagher Bassett Services - 132 6303 Waterford Blvd., Suite 120 Oklahoma City, OK 73118 Phone: 405/843-7244 Fax: 405/843-8658 Toll Free: 800/943-7244 Oklahoma Stacy Goble, Branch Manager Stacy_Goble@gbtpa.com
Claims Handling Offices Oregon Mailing Gallagher Bassett Services 155 (Portland) 4550 Kruse Way, Suite 155 Lake Oswego, OR 97035 Phone: 503-675-6575 Fax: 503-675-6574 Toll Free: 877-800-3059 Oregon Eric Sorem, Branch Manager Eric_Sorem@gbtpa.com
Claims Handling Offices Texas Mailing Gallagher Bassett Services - 025 (Dallas) 6404 International Parkway, Suite 2300 Plano, Texas 75093 Phone: 972-931-6277 Fax: 972-931-6256 Toll Free: 800-382-0166 Texas Terry Tarter, Branch Manager Terry_Tarter@gbtpa.com
Navigating the Coventry Medical Provider Directory Website Use this search tool to locate Medical Providers ONLY If your claims are administered by Gallagher Bassett Go to www.firsthealth.com/welcome Enter Login ID: GBMCS A new page will appear, click on the link Channeling Tools The next page will give you four options to choose from: Address Search: This option is a radius search from a centralized address. Name Search: Allows the user to look up a certain provider in the database by name or phone. Region Search: This option allows the user to search in a specific region such as city, county, zip code, etc. Quick Search: A search using a limited number of specialties for providers who provide initial treatment to a maximum radius of 35 miles around an address. Creates output to a custom Worksite Poster or Directory. Worksite Posters: This option allows the user to make a Worksite Poster with the closest network providers while following all jurisdictional regulations and guidelines. ADDRESS SEARCH Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties and/or distance. Once you click on find providers your results will be displayed. NAME SEARCH Use the Name Search tab if you already know a Provider s name, group affiliation or phone REGION SEARCH Use this feature if you are searching for a provider in a specific area. QUICK SEARCH Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine, Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific address. WORKSITE POSTER (WSP) This page is used to create Worksite Posters or batches of Posters. For your convenience, you can upload your Locations and create your posters!
Temporary Prescription Services ID For Claims Administered by Gallagher Bassett Attached you will find a prescription form (also called a temporary pharmacy card) that must be given to each and every employee when there is an on the job injury. Employees simply call the First Script number to locate a local pharmacy where they can get their Workers Compensation prescription(s) filled. It is a good idea to distribute these forms to your Supervisors, Team Leaders, and your Human Resources department so they are familiar with the form. Chances are they will receive the notices of injury and will likely be responsible for handing the form to the injured employee.
PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES ProSight Specialty Injured Worker No Cost STEP 1 STEP 2 No Delay Feel Better Faster 1-866-445-7344 Pharmacy Instructions Medco 1-866-445-7344 Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. Pharmacy: (Above information to be completed by injured worker or supervisor) MEDCO FSNCVTY 610014 005174
Programa de Beneficio Farmacéutico Para Accidentes Laborales ProSight Specialty Empleado Lastimado Ningún Costo Paso #1 Paso #2 Sin Tardanza/ Sin Demora Siéntase Mejor Mas Rápido 1-866-445-7344 Pharmacy Instructions Medco 1-866-445-7344 Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. Pharmacy: (Above information to be completed by injured worker or supervisor) MEDCO FSNCVTY 610014 005174 ProSight Specialty
Dear Policyholder: For your convenience, we have included the following website addresses to your state s Workers Compensation web page. From the links below, you can access any forms that you might need when submitting a Workers Compensation claim. Alabama http://dir.alabama.gov Alaska http://www.labor.alaska.gov/wc/ Arizona http://www.ica.state.az.us/ Arkansas http://www.awcc.state.ar.us/ California http://www.dir.ca.gov/dwc/ Colorado http://www.colorado.gov/ Connecticut http://wcc.state.ct.us/ Delaware http://www.delawareworks.com/ DC http://www.does.dc.gov/does/ Florida http://www.myfloridacfo.com/wc Georgia http://sbwc.georgia.gov/portal/ Hawaii http://hawaii.gov/labor/rs/ Idaho http://www.iic.idaho.gov/ Illinois http://www.iwcc.il.gov/ Indiana http://www.in.gov/wcb/ Iowa http://www.iowaworkforce.org Kansas http://www.dol.ks.gov/wc/about.html Kentucky http://www.labor.ky.gov/ Louisiana http://www.laworks.net/ Maine http://www.maine.gov/wcb/ Maryland http://www.wcc.state.md.us/ Massachusetts http://www.state.ma.us/wcac/ Michigan http://www.michigan.gov/wca Minnesota http://www.doli.state.mn.us/ Mississippi http://www.mwcc.state.ms.us/ Missouri http://labor.mo.gov/ Montana http://erd.dli.mt.gov/ Nebraska http://www.wcc.ne.gov Nevada http://dirweb.state.nv.us/wcs/wcs.htm New Hampshire http://www.labor.state.nh.us/ New Jersey http://lwd.state.nj.us/labor/wc/wc_index.html New Mexico http://www.workerscomp.state.nm.us/ New York www.wcb.state.ny.us North Carolina http://www.ic.nc.gov/forms.html North Dakota http://www.workforcesafety.com/ Ohio http://www.ohiobwc.com/ Oklahoma http://www.owcc.state.ok.us/ Oregon http://www.cbs.state.or.us/wcd/ Pennsylvania http://www.portal.state.pa.us Rhode Island http://www.dlt.ri.gov/wc/ South Carolina http://www.wcc.sc.gov/pages/default.aspx South Dakota http://dlr.sd.gov/workerscomp/ Tennessee http://www.tn.gov/labor-wfd/ Texas http://www.tdi.state.tx.us/forms/ Utah http://www.laborcommission.utah.gov/ Vermont http://www.labor.vermont.gov/ Virginia http://www.vwc.state.va.us/portal/ Washington http://www.lni.wa.gov/ West Virginia http://www.wvinsurance.gov/ Wisconsin http://dwd.wisconsin.gov/wc/ Wyoming http://doe.wyo.gov/aboutus/