Sedgwick Claims Kit Oklahoma

Sedgwick Claims Kit Oklahoma P.O. Box 14153 Lexington, KY 40512-4153 PHONE 602.906.3620 FAX 859.264.4062 FREE 800.9063.8582

Dear Insured: We would like to welcome you as a policyholder of Dallas National Insurance Company. Sedgwick is your Claims Administrator and we are pleased to be able to provide you with workers compensation claims handling services. Please follow the below instructions for filing a new claim and note the claim kit attachment. Sedgwick Claim Kit Attachments Workers Compensation Notice and Instruction to Employers and Employees (Form 1A-English) Workers Compensation Notice and Instruction to Employers and Employees (Form 1A-Spanish) Employer s First Report of Injury Form (Form 2) Employee First Notice of Accidental Injury and Claim for Compensation ( Form 3) Workers Compensation Employee s Frequently Asked Questions Claim Office Directory Medical Provider Search Tool Job Aid Atlas General First Fill Temporary Pharmacy Card Atlas General Pharmacy Card Report of Injury Nurse Advice Poster To Report a Claim Phone: 855-728-5277 (855-7ATLAS7) Email: 6200atlasgeneralinsurance@sedgwickcms.com Fax: 866-383-3296 Questions Linda Pettitt Client Services Associate Direct: 866-738-9201 Loss Runs lossruns@atlas.us.com Medical Provider Search https://www.viaoneprovidersearch.net/ User Name: client@sedgwickcms.com Login Password: SedgwickCMS_123 (case sensitive) We appreciate your business and believe that communication is critical for successful claims administration. We encourage you to contact us if you have any questions. www.atlas.us.com/claims

Form 1A Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees All employees of this employer who are entitled to benefits of the Workers' Compensation Code are hereby notified that this employer has complied with all rules of the Workers' Compensation Court and that this employer has secured payment of compensation for all employees and their dependents in accordance with the Code. All employees are further notified this employer will furnish first aid, medical, diagnostic, surgical and any other like services required by law as well as payments of compensation to any injured employee as provided in the Workers Compensation Code. Any employee who has suffered a compensable injury covered by the Workers' Compensation Code shall be entitled to vocational rehabilitation services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform the same occupational duties the employee was performing prior to the injury. The Oklahoma Workers' Compensation Court has a counselor (ombudsman) program to provide information to injured workers, employers, and other interested parties. Mediation is available to address certain workers compensation disputes. For information, call 405-522-8760 or In-State Toll Free 800-522-8210. Signature of Employer Insurer & Insurer Phone Number Employee's Responsibilities In Case of Work Related Injury If accidentally injured or affected by cumulative trauma or an occupational disease arising out of and in the course of employment, however slight, the employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. If this employer is a corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the person in charge of business at the location of operations where the injury occurred. Unless notice is given to the employer or medical treatment is rendered within thirty (30) days of injury, any claim for compensation may be forever barred. If accidentally injured or affected by cumulative trauma or an occupational disease, the employee may file a claim for compensation with the Workers' Compensation Court. Forms to file a compensation claim should be furnished by this employer and also are available from the Workers Compensation Court. The forms are posted on the Court s web site, www.owcc.state.ok.us/court_forms.htm. A claim for compensation must be filed with the Court within the time specified by law, or be forever barred. Based on law effective August 26, 2011, a claim for compensation for any accidental injury or death must be filed with the Court within two (2) years from the date of the accidental injury or death; a claim for compensation for occupational disease must be filed within two (2) years of either the last hazardous exposure or from the date the disease first became manifest, which ever last occurred; and a claim for compensation for cumulative trauma must be filed within two (2) years of when the employee was last employed by the employer. Provided, claims may be filed within two (2) years from the date of the last medical treatment authorized by the employer or payment of any compensation or remuneration paid in lieu of compensation. Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall within seven (7) days report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee s employment status, occurring during the period of receipt of such benefits. Employer's Responsibilities The employer must provide employees with immediate first aid, medical, diagnostic, surgical and any other like services that are reasonable and necessary. This applies to care for all injuries and illnesses arising out of and in the course of employment, regardless of their character. If an employee is injured and this results in the loss of time beyond his/her shift, or requires medical attention away from the work site (fatal or otherwise), the employer MUST file a Form 2 with the Workers Compensation Court within ten (10) days of the notice of injury. The employer must provide a copy of the Form 2 to the employer's workers' compensation insurance carrier, if any. No agreement by any employee to pay any portion of premiums paid by the employer to maintain or carry compensation insurance as required by law shall be valid. Any employer who deducts money from the wages or salary of any employee for that purpose who is entitled to workers' compensation shall be guilty of a misdemeanor. If the employer has actual notice of an undisputed injury and the employer's insurance carrier fails to commence weekly temporary total disability benefit payments due within the time provided by law, the insurer shall pay to the employee a penalty of fifteen percent (15%) of the unpaid or delayed weekly benefits. No agreement by any employee to waive workers' compensation rights and benefits shall be valid. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Workers' Compensation Court 1915 North Stiles Avenue Oklahoma City, Oklahoma 73105-4918 Tele. 405-522-8600 (OKC) 918-581-2714 (TU) In-State Toll Free 800-522-8210 Web Site www.owcc.state.ok.us 08/11 This notice must be posted and maintained by the employer in one or more conspicuous places.

Notificación de Compensación para Trabajadores de Oklahoma e Instrucciones para Empleadores y Empleados Formulario 1A Por el presente, se notifica a todos los empleados de este empleador con derecho a los beneficios del Código de Compensación para Trabajadores, que el empleador mencionado ha cumplido con todas las normas del Tribunal de Compensación de los Trabajadores y que ha garantizado el pago de la compensación de todos los empleados y de las personas a su cargo, de acuerdo con el Código. Además, se notifica a todos los empleados que este empleador prestará servicios de primeros auxilios, de diagnóstico, médicos, quirúrgicos y cualquier otro servicio similar exigido por ley así como también los pagos de compensación a cualquier empleado que sufra lesiones según lo establecido en el Código de Compensación para Trabajadores. Cualquier empleado que haya sufrido una lesión compensable cubierta por el Código de Compensación para Trabajadores tendrá derecho a los servicios de rehabilitación vocacional, incluidas la reeducación y la colocación laboral si, como resultado de la lesión, el empleado no puede llevar a cabo las mismas obligaciones laborales que desempeñaba antes de producirse la lesión. El Tribunal de Compensación de los Trabajadores de Oklahoma tiene un programa de asesores (defensor del pueblo) para brindar información a los trabajadores lesionados, empleadores y a otras partes interesadas. La mediación está disponible para tratar ciertas controversias que surjan de la compensación para trabajadores. Firma del Empleador Compañía Aseguradora y Número Telefónico de la Compañía Para obtener información, llame al 405-522-8760 o llame de forma gratuita dentro del estado al 800-522-8210. Responsabilidades del Empleado en Caso de Lesión Laboral En caso de que el empleado sufra lesiones accidentalmente o que resulte afectado por trauma acumulativo o una enfermedad ocupacional ocasionada por el empleo o durante el empleo, por muy leve que sea, el empleado debe notificar de inmediato al empleador. Si el empleador es una sociedad de personas, se debe notificar a cualquier socio. Si el empleador es una sociedad anónima, se debe notificar a algún representante o funcionario de la sociedad sobre quién se emprenderán las acciones legales. Además, se debe notificar a la persona responsable de la empresa en el lugar de las operaciones comerciales en donde se produjo la lesión. Salvo que se notifique al empleador o se realice el tratamiento médico dentro de los treinta (30) días de producida la lesión, cualquier reclamo por compensación prescribirá para siempre. En caso de que el empleado sufra lesiones accidentalmente o que resulte afectado por trauma acumulativo o una enfermedad ocupacional, puede presentar una demanda por compensación ante el Tribunal de Compensación de los Trabajadores. Los formularios para presentar una demanda por compensación deben ser proporcionados por este empleador y además estarán disponibles en el Tribunal de Compensación de los Trabajadores. Los formularios se publican en el sitio Web del Tribunal, www.owcc.state.ok.us/court_forms.htm. El reclamo por compensación debe presentarse ante el Tribunal dentro del plazo especificado por ley o prescribirá para siempre. Según la ley vigente del 26 de agosto de 2011, un reclamo por compensación en caso de cualquier lesión accidental o muerte se debe presentar ante el Tribunal dentro de los dos (2) años a partir de la fecha en que se produjo la lesión o muerte; un reclamo por compensación en caso de enfermedad laboral se debe presentar dentro de los dos (2) años desde la última exposición peligrosa o a partir de la fecha en que se manifestó por primera vez la enfermedad, cualquiera sea la que sucedió por última vez, y un reclamo por compensación en caso de trauma acumulativo se debe presentar dentro de los dos (2) años a partir de la fecha en que el empleado fue contratado por última vez por el empleador, siempre y cuando, los reclamos puedan presentarse dentro de los dos (2) años a partir de la fecha del último tratamiento médico autorizado por el empleador o del pago de cualquier retribución o remuneración pagada en lugar de indemnización. Cualquier persona que recibe de un empleador o de la compañía aseguradora del empleador beneficios temporarios por incapacidad informará por escrito dentro de los siete (7) días al empleador o a dicha compañía sobre cualquier cambio en un hecho relevante, en la cantidad de ingresos que está recibiendo el empleado o en el status laboral del empleado, cambio que se haya producido durante el período de recibo de dichos beneficios. Responsabilidades del Empleador El empleador debe prestar a los empleados servicios inmediatos de primeros auxilios, de diagnóstico, médicos, quirúrgicos y cualquier otro servicio similar que sea razonable y necesario. Esto se aplica al cuidado de todas las lesiones y enfermedades ocasionadas por el empleo y durante el empleo, independientemente de su naturaleza. Si un empleado sufre una lesión (mortal o distinta) y esto tiene como resultado la pérdida de tiempo fuera del horario de su turno o requiere atención médica lejos del sitio de trabajo, el empleador DEBE presentar un Formulario 2 ante el Tribunal de Compensación de los Trabajadores dentro de los diez (10) días de la notificación de la lesión. El empleador debe proporcionar una copia del Formulario 2 a la compañía aseguradora de compensación de los trabajadores del empleador, si hubiere. No tendrá validez ningún convenio, realizado por cualquier empleado, para pagar una parte de las primas abonadas por el empleador con el fin de mantener o llevar el seguro de accidentes como lo exige la ley. Cualquier empleador que, para ese fin, descuente dinero de los sueldos o salarios de los empleados con derecho a compensación de los trabajadores será culpable de delito menor. Si el empleador ha recibido notificación fehaciente de una lesión innegable y su compañía aseguradora no comienza con los pagos debidos en concepto de beneficio semanal por incapacidad temporal total dentro del plazo establecido por ley, la compañía aseguradora pagará al empleado una multa del quince por ciento (15%) de los beneficios semanales impagos o retrasados. No tendrá validez ningún convenio, realizado por el empleado, para renunciar a los derechos y beneficios de compensación de los trabajadores. Cualquier persona que cometa fraude de compensación de trabajadores será culpable de delito grave con condena. Tribunal de Compensación de los Trabajadores 1915 North Stiles Avenue Oklahoma City, Oklahoma 73105-4918 Teléfono: 405-522-8600 (OKC) 918-581-2714 (TU) Llamada gratuita dentro del estado, 800-522-8210 Sitio web www.owcc.state.ok.us 08/11 Esta notificación debe ser publicada y conservada por el empleador en uno o más lugares visibles.

FORM 2 Send original to Workers Compensation Court and 1 copy to Insurance Carrier Please type or print. Enter all dates in MM/DD/YY format. Full Name of Employee - LAST, FIRST, MIDDLE WORKERS COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 EMPLOYER S FIRST NOTICE OF INJURY Employee Email Address THIS SPACE FOR COURT USE ONLY Complete Address City State Zip Telephone Number Social Security Number Date of Birth Sex Length of Employment Years Months Average Weekly Wage Occupation (job description) Was employment agreement made in Oklahoma? YES NO NOTE: Mediation is available to address certain workers compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. Date of accident or last exposure Time of accident or exposure o clock AM PM Date Employer Notified Time workday began o clock AM PM Last date employee worked Has employee returned to work? YES NO If yes, on what date Did the employee die? YES NO If yes, on what date OSHA Log Case # Place of Accident or Occurrence City: County: State: Injury Resulted from: Single Incident Cumulative Trauma Occupational Disease Nature of Injury or Illness Does employee participate in a certified workplace medical plan: YES NO If yes, name of CWMP: Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee. Identify part(s) of body involved in injury or illness Full Name and address of Treating Physician (please be complete) Employer s Insurance Carrier or Own Risk Group Policy/Self-Insured Number Name Phone Policy Period from to Address City State Zip Employer s Name and Complete Address Name Federal ID# Phone # Address City State Zip Type of business (Example: manufacturing, food service, construction) NAICS Number Type of Ownership: Private State Government County Government Local Government Upon filing this Notice of Injury, permission is given to the Administrator of the Workers' Compensation Court, the Insurance Commissioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating to the notice. Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall within seven (7) days report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee s employment status, occurring during the period of receipt of such benefits. Any person who commits workers compensation fraud, upon conviction, shall be guilty of a felony. The undersigned hereby declares under penalty of perjury that they have examined this notice and all statements contained herein are true, correct and complete, to the best of their knowledge. The undersigned certifies this Form 2 was sent to the Workers Compensation Court and a copy thereof to the employer s insurer on the date noted below: Signed By Telephone Number Date Signature of Preparer Name and Title of Preparer (Please Print) Area Code and Number A Form 2 must be filed with the Workers Compensation Court and sent to the Employer s workers compensation insurance carrier within 10 days of notice that an employee has suffered an accidental injury which results in lost time beyond the shift, or requires medical attention away from the work site, fatal or otherwise. Form 2s filed with the Workers Compensation Court are confidential and not subject to public disclosure except as authorized by law. FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY OR THAT THE EMPLOYEE HAS PROVIDED PROPER NOTICE OF INJURY. Rev. 08/11

FORM 3 Send original and 4 copies to: Workers Compensation Court Name of Claimant (Injured Employee) Name of Employer Court Use Only WORKERS COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 Please check appropriate box I. Original Filing II. Amends Previously Filed Form 3. Must clearly state whether amendment is in addition to, or substitute for, prior information.) THIS SPACE FOR COURT USE ONLY EMPLOYEE S FIRST NOTICE OF ACCIDENTAL INJURY AND CLAIM FOR COMPENSATION NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. WCC FILE NO. (Please type or print) EMPLOYEE NAME (Last, First, Middle): Social Security #: Phone: ( ) Mailing Address (include City, State & Zip): Date of Birth: Age: Sex: Occupation: Was your employment agreement in Oklahoma? YES NO Avg. Weekly Wage: Length of Employment years months Date of Accident, or as applicable, Date of Termination From Employment if a Cumulative Trauma Injury: Describe parts of the body injured or affected Injury resulted from: Time Injury Occurred Single Incident Cumulative Trauma AM PM Place of Injury: City/County/State What is the nature of the Injury or Illness: Describe with details how the injury occurred. Include object or substance which directly injured you: Have you filed a claim for Social Security Disability Insurance Benefits? YES NO Are you eligible for Medicare Benefits or will you become eligible for Medicare Benefits within 30 months of the filing of this Notice of Accidental Injury and Claim for Compensation? YES NO Are you a previously impaired person due to a prior workers compensation injury or obvious and apparent pre-existing disability? If YES, you may be entitled to benefits for combined disabilities against the Multiple Injury Trust Fund. A claim against the Multiple Injury Trust Fund may be commenced by filing a Form 3F with the Workers Compensation Court. Treating Physician (full name): Address: City: State: Zip: Employer: Employer s FEI # (Federal ID Number): Telephone: Complete Mailing Address: City: State: Zip: Complete Street Address (if different from above): City: State: Zip: Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall within seven (7) days report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee s employment status, occurring during the period of receipt of such benefits. Any person who commits workers compensation fraud, upon conviction, shall be guilty of a felony. Name of claimant s attorney if represented: Type or Print Name of Attorney: Mailing Address: OBA# City State Zip Telephone #: ( ) Upon filing this Notice of Accidental Injury And Claim For Compensation, permission is given to the Administrator of the Workers' Compensation Court, the Insurance Commissioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating to the notice. The permission granted to the above persons authorizes them access to medical records pursuant to 76 O.S., 19, including waiver of any privilege granted by law concerning communications made to a physician or health care provider or knowledge obtained by such physician or health care provider by personal examination. This form is not intended for use as a medical authorization. Nothing shall be construed to waive, limit or impair any evidentiary privilege recognized by law. I declare under penalty of perjury that I have examined this notice and claim for compensation and all statements contained herein are true, correct and complete to the best of my knowledge and belief. Signed this day of, Signature of Attorney for Claimant Signature of Claimant (must be signed by claimant) 08/26/11

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 interpretation of the Workers Compensation Code and should not be construed as offering or providing legal advice. Workers Compensation Court Counselor Program 1915 N. Stiles Avenue, Oklahoma City, OK 73105 210 Kerr State Office Bldg., 440 S. Houston, Tulsa, OK 74127 (405) 522-8760 OKC (918) 581-2714 TU (800) 522-8210 In-State Toll Free Rev 08/12

What Is Workers= Compensation? Workers compensation is an insurance program that provides compensation for disability, and medical and rehabilitation benefits, for employees injured on the job. In the case of accidental death of an employee, it includes benefits to the employee s dependents. Under workers compensation, both workers and employers are protected. Each covered worker has a right to benefits for a compensable injury. In return, employers are protected from liability lawsuits outside the workers compensation system. NOTES How Long Do I Have To Work To Be Covered By Workers= Compensation? There is no waiting period. You are covered by workers= compensation as soon as you begin your employment. Who is Covered By The Workers= Compensation Code? Generally, every employee hired in Oklahoma or who is injured in Oklahoma is covered by the workers compensation laws of the state. Independent contractors are not employees and are therefore not covered. Other exceptions to coverage include persons covered for job-related injuries under the federal law; certain agricultural workers; licensed real estate brokers paid on a commission basis; certain persons providing services administered by the Oklahoma Department of Human Services; any person employed by an employer with 5 or fewer employees, all of whom are related by blood or marriage to the employer; any person employed by a tax-exempt youth sports league; sole proprietors, members of a partnership, certain persons who are a party to a franchise agreement, certain members of a limited liability company and certain stockholders of a corporation; any person that provides voluntary service who receives no wages for the services other than meals, drug or alcohol rehabilitation therapy, transportation, lodging or reimbursement for incidental expenses; owner-operators of a truck-tractor; and drive-away owner operators. All of these groups of people are exempt from the workers compensation laws of the state by law. 2 13

NOTES What If My Employer Does Not Have Workers= Compensation Coverage? If your employer failed to secure the payment of workers compensation as provided by law, you, or your legal representative if death results from the injury, may maintain an action either in the Workers Compensation Court or in the district court, but not both, for damages due to the injury. If the action is maintained in the district court, the limits on benefits under the workers compensation law do not apply. When Should I Report An Accident That Occurred On The Job? Any job-related injury should be reported to your supervisor as soon as possible. Failure to timely report an injury may result in the loss of benefits. An employee must report a single event injury to the employer within 30 days or medical treatment must be obtained within the 30-day period. In cases of occupational disease or injuries caused by repeated trauma, an employee must give notice to the employer within 90 days of the employee s separation from employment. What Do I Do About Medical Treatment? After you are injured, your employer shall promptly provide medical, surgical or other treatment that is reasonable and necessary due to the injury. Your employer has the right to select the treating physician. However, an employee is allowed to secure necessary medical services from a physician of the employee s choice, at the employer s expense, where the employer fails or neglects to provide treatment within 7 days after actual notice of the injury, or where an emergency exists. The physician selected by the employer shall become the treating physician. If the employee is covered by a certified workplace medical plan, the employer shall select a treating physician for the injured employee from the plan s network of physicians. Can I Change Doctors? Yes, but the procedure for changing a treating physician is different depending upon whether or not the employee is covered by a certified workplace medical plan (CWMP). CWMPs are organizations that provide managed care in workers compensation. 14 3

If the employee is not covered by a CWMP, the employee may apply to the Court for one change of physician for any affected body part. No change of treating physician is allowed for a body part unless medical care for that body part was provided for 180 days before the application. No more than two (2) changes of physician are allowed in a claim. NOTES If the employee is covered by a CWMP, the employee may apply for a one-time change of physician to another appropriate physician within the network of the CWMP using the dispute resolution process set out in the CWMP. Once the dispute resolution process has been exhausted, the employee may petition the Court for a change of physician within the plan. If there is not a physician available within the plan that is qualified to treat the employee s injuries, a physician outside of the plan may be selected if the physician agrees to comply with all the rules, terms and conditions of the certified workplace medical plan. What If I Need Emergency Medical Treatment? Must I Use The Certified Workplace Medical Plan? No. An injured worker that is covered by a certified workplace medical plan may secure necessary emergency medical services, at the employer s expense, from medical providers who are not part of the plan. Do I Have To Pay For Any Of The Medical Costs? No. Your employer or its insurance company must pay for all authorized and medically necessary care for a compensable injury. How Long Before Weekly Temporary Total Disability (TTD) Benefits Begin? If you are off work due to your injuries for more than 7 calendar days after your injury, you may be entitled to weekly TTD benefits. No TTD benefits are authorized for the first 7 days after the injury unless the Court determines you were temporarily totally disabled for more than 21 days. In that event, TTD benefits are payable from the first day. TTD benefits may be commenced without a Court order. 4 13

Where Can I Obtain Additional Information About Workers= Compensation? You may contact the Workers Compenation Court s Counselor Program, visit the Court s web site at www.owcc.state.ok.us, or search the Oklahoma statutes on workers compensation online at www.owcc.state.ok.us/administrator_and_court_rules.htm. What Are My Responsibilities? As an injured worker, you have the obligation to assist in your recovery. To help make this happen, you should: Keep in touch with your employer; Keep appointments made with your doctor, the insurer, and job counselor. Missing a doctor s appointment without good cause may result in you being ordered to pay a no show fee; Follow your doctors= instructions and treatment plan. Your entitlement to TTD benefits may be terminated by the employer if, without a valid excuse, you do not comply with your medical treatment, miss medical appointments or abandon care; Cooperate with persons who are helping you get back to work; and Contact your employer immediately when your doctor releases you for work. This pamphlet has been prepared by the Workers Compensation Court Counselor Program to provide information to employees with questions about their rights and responsibilities under the Oklahoma workers compensation laws. If you have further questions, or need additional information, you may contact the Counselor Program at the address and telephone numbers listed below. Workers= Compensation Court Counselor Program 1915 North Stiles Avenue, Oklahoma City, OK 73105 210 Kerr State Office Bldg., 440 S. Houston, Tulsa, OK 74127 Oklahoma City Area: (405) 522-8760 Tulsa Area: (918) 581-2714 Statewide Toll Free: (800) 522-8210 Electronic Mail: Counselors@owcc.state.ok.us How Is The Amount Of My TTD Weekly Income Benefits Determined? When you are injured on the job and you are unable to work for more than 7 calendar days, you are eligible for weekly benefits amounting to 70% of your average weekly wage, up to the maximum set by law. The maximum is equal to the state s average weekly wage. The maximum allowable weekly TTD benefits based on injury date are as follows: Date of Injury Max. TTD Rate Nov. 01, 2012 to Oct. 31, 2013...... $771.00 Nov. 01, 2011 to Oct. 31, 2012...... $735.00 Nov. 01, 2010 to Oct. 31, 2011... $716.00 Nov. 01, 2009 to Oct. 31, 2010... $717.00 Nov. 01, 2008 to Oct. 31, 2009... $683.00 Nov. 01, 2005 to Oct. 31, 2008... $577.00 Nov. 01, 2002 to Oct. 31, 2005... $528.00 Nov. 01, 1999 to Oct. 31, 2002... $473.00 Nov. 01, 1996 to Oct. 31, 1999... $426.00 To obtain rates for earlier injury dates than those listed, please contact the Counselor Program. How Long Am I Eligible For TTD Weekly Income Benefits? Generally, the duration of temporary total disability benefits depends on the date and nature of the injury and when your healing period ends. You may receive TTD benefits for as long as you are unable to work, subject to certain limitations. The maximum duration of TTD benefits is 156 weeks, unless there is a consequential injury, in which case the Court may award an additional 52 weeks. TTD benefits for soft tissue injuries (e.g. sprains, strains, contusions, tendonitis, muscle tears and cumulative trauma) are subject to special rules set by law. In some instances, TTD for a soft tissue injury may be limited to 8 weeks. 12 5

Must I Notify My Employer If I Accept Other Employment While Receiving Temporary Total Disability? Yes. Any person receiving temporary disability benefits from an employer or the employer=s insurance company must report within 7 days, in writing, to the employer or insurance carrier any change in material fact, the amount of income being received, or any change in employment status while receiving temporary total disability benefits. What If My Injury Keeps Me From Getting A Job I Can Perform? You may be entitled to educational assistance and training to learn another skill. You also may be eligible for job-placement assistance in obtaining other employment. What Benefits Am I Eligible To Receive If I Have A Permanent Disability? Permanent Partial Impairment (PPI). PPI benefits are paid for disability resulting from a job-related injury or occupational disease which is permanent but does not result in total disability. If you are determined to be permanently partially impaired, it is expected that you will be able to return to some type of work. PPI benefits are based on the type and extent of disability. Disability for certain injuries is compensated based on a schedule found in the law. A sample of benefits under this schedule is located on the Court s web site at www.owcc.state.ok.us, under Benefit Charts for the applicable injury date. If your injury is not specifically listed in the schedule, your compensation will be based on the percentage of disability to your body as a whole. Scheduled injuries include, but are not limited to, injuries to the hands, feet, arms and legs. Whole body injuries include injuries to the back, neck, head, shoulders and hips. Determination of the percentage of impairment for injuries, except scheduled injuries, is based on the criteria of the American Medical Association s Guides to the Evaluation of Permanent Impairment. PPI benefits are figured at 70% of your average weekly wages, not to exceed $323 per week for injuries occurring on or after August 27, 2010 through August 26, 2015. For injuries occurring on or after August 27, 2010, the PPI benefit shall not be less than $150 per week. What If Workers= Compensation Fraud Is Suspected? Cases of suspected workers= compensation fraud should be referred to the Attorney General Workers= Compensation Fraud Unit for the purposes of investigation, civil action, criminal action or referral to the District Attorney. The Attorney General Workers Compensation Fraud Unit can be contacted at: 313 N.E. 21 Street Oklahoma City, OK 73105 (405) 522-3403 (877) 800-8764 (toll free) Can I Call The Workers= Compensation Court For Information? Yes. The Workers= Compensation Court has established a Counselor Program. The program also is known as the Ombudsman Program. A Counselor provides information and improves communications among injured workers, employers, insurance carriers and health care providers. Contact information for the Counselor/Ombudsman Program is located on the back page of this pamphlet. Who Can Contact The Workers= Compensation Counselor/Ombudsman Program For Information? The injured worker, the heirs of a deceased worker, the employer, the insurance carrier, the health care provider and other interested persons. What Kind Of Information Can The Counselor Provide, and Can The Counselor Provide Legal Advice Or Services? The Workers= Compensation Counselor Program: Cannot provide legal advice or services; Provides general information and an explanation of rights and responsibilities; Helps an employee determine if the employer is insured and whether coverage is through a private carrier, CompSource Oklahoma, or through self-insurance; and Explains how to report an injury and how to file a claim. 6 11

Where Are Trials Held? Trials are held either in Oklahoma City or Tulsa, or as otherwise provided by law. Am I Required To Have An Attorney? No. Workers have the right to represent themselves in a trial before the Workers= Compensation Court. If a trial is necessary because of a dispute, your employer=s insurance carrier must be represented by a lawyer. You have the right, but are not required, to be represented by a lawyer. What If I Want To Hire A Lawyer, But I Do Not Know One? If you are an Oklahoma resident, you may call your county lawyer referral service. Some County Bar Associations will refer you to an attorney. Under no circumstance may any Court employee recommend an attorney to you. How Much Will An Attorney Charge? A maximum of 10% of any award for contested temporary disability, and 20% of any award for permanent disability or for a contested death case is permitted as an attorney fee. All attorney fees are subject to court approval. In addition to the attorney fee, you will be responsible for expenses in preparing your case for settlement or trial. What If I Am Fired For Filing A Workers= Compensation Claim? You may have a cause of action if your employer fires you because you have in good faith filed a claim, retained a lawyer to represent you, or have testified or plan to testify in a court proceeding. These actions are filed in district court. How Can I Report An Employer That Does Not Have Workers= Compensation Insurance Or Who Requires Employees to Pay For Workers= Compensation Insurance Premiums? You may contact the Oklahoma Department of Labor at (405) 521-6100 or toll free statewide at (888) 269-5353, and give them the employer=s name and address. Permanent Total Disability (PTD). PTD benefits are paid for a job-related injury or occupational disease that results in permanent and total disability. PTD benefits are paid during the continuance of the disability until the employee reaches the age of maximum Social Security retirement benefits or for a period of 15 years, whichever is longer. PTD benefits are figured at 70% of your average weekly wages, up to the maximum set by law. The maximum is equal to the average weekly wage in Oklahoma. For injuries occurring from November 1, 2011 through October 31, 2012, the maximum rate for permanent total disability is $735 per week. If I Die As The Result Of A Job-Related Accident, What Benefits Can My Dependents Receive? A surviving spouse is entitled to a lump sum benefit payment, as is each dependent child. In addition, the spouse and other dependents may receive weekly benefits based upon the wages earned by the employee at the time of death, and may receive funeral costs. Benefits stop when a spouse remarries, at which time a lump sum equal to two years compensation is paid. A child=s benefits stop at age 18, but can continue until age 23 if the child is a full-time student enrolled in an accredited educational institution or is home-schooled. A child who is mentally or physically unable to be self-supporting also may be entitled to benefits after age 18. Can I Receive Social Security Disability And Workers= Compensation Benefits At The Same Time? Yes. However, Social Security benefits may take credit for the amount of workers= compensation benefits you are receiving. This may result in a reduced Social Security benefit. Am I Entitled To Receive Temporary Total Disability (TTD) And Unemployment Benefits At The Same Time? No employee may receive TTD benefits covering the same period of time as unemployment compensation benefits or for which employer provided short-term disability benefits are received. 10 7

How Do I File A Workers= Compensation Claim With The Court? If you wish to file a claim as a result of a job-related injury, a Form 3 should be filed with the Workers= Compensation Court. A Form 3B should be filed if you have an occupational disease (such as asbestosis or silicosis ). A Form 3A should be filed for a death claim if an employee dies as the result of a job-related injury. You may request the necessary forms to file a claim from your employer or the Workers= Compensation Court. The forms also are posted on the Court s web site at www.owcc.state.ok.us/court_forms.htm. Is There A Time Limit On Filing A Claim With The Court? Yes. Anyone wishing to file a claim for workers= compensation benefits with the Court must do so within two (2) years from the date of the injury or death, or within two (2) years from the date of payment of any compensation or wages in lieu of compensation, or within two (2) years of authorized medical care. For repeated trauma injuries, the two-year period runs from the date on which the employee was last employed. In case of asbestosis, or asbestosis related disease, silicosis or exposure to nuclear radiation, the two (2) years runs from the date the condition results in a symptom which can be medically diagnosed or from the date of last exposure. How Do I Obtain Benefits? You should contact your employer or the employer s insurance carrier as soon as possible after an accidental injury to see if benefits will be provided voluntarily. An employer or insurance carrier may require a letter from your physician stating the type of treatment being provided and whether you are able to work. You should ask your employer to report the injury by filing a Form 2 (Employer=s First Notice Injury) with the Court and to provide their insurance company with a copy. What Happens After I File A Claim? If you wish the Court to resolve an issue between you and your employer or their insurance carrier, you may ask the Court to set your case before a judge. You or your legal representative must file a Form 9 (Motion To Set For Trial) to request a trial. A Form 9 is available from the Court. The form also is posted on the Court s web site at www.owcc.state.ok.us/court_forms.htm. May A District Attorney Or The Workers= Compensation Court Examine My Records Pertaining To My Job-Related Injury? Yes. Upon filing a notice of injury or claim for benefits with the Court, all employers and employees shall give written permission for the Administrator of the Workers= Compensation Court, the Attorney General, and the District Attorney to examine all records relating to the notice of injury or claim. Although the claim form is not a medical authorization, medical records also may be obtained as permitted by Oklahoma law. What Is A Trial? A trial before the Workers= Compensation Court is much like any other non-jury trial in an Oklahoma court. Your case will be heard by a judge who will decide what, if any, benefits are due under Oklahoma law. The judge=s decision will be based upon the law and the facts involved in your case, including medical evidence introduced and testimony presented to the judge at the trial. Is A Trial Always Necessary? No. A trial is necessary only when there is a dispute between you and the employer or its insurance carrier that cannot be resolved. Claims can be settled without a trial before a judge of the Court. Court approval of all final settlements is required. Other Than A Trial, What Are my Options for Settling a Dispute? A party to a dispute can request mediation to settle a dispute regardless of whether a claim has been filed with the Court. The Court on its own or in response to a request, may order mediation. Any workers compensation claim can be mediated except Multiple Injury Trust Fund claims and disputes on medical care arising within a certified workplace medical plan. All final settlements of a case resolved by mediation must be approved by the Court. If mediation is desired, or if you have questions about mediation or need forms to request mediation, you may contact the Counselor Program. Contact information for the Counselor Program is located on the back page of this pamphlet. 8 9

Atlas General Insurance - Sedgwick Claims Management Services, Inc. Workers' Compensation Claims Handling Offices for Dallas National Insurance Oklahoma Claims Handled in Dallas, Texas States Serviced Office Information Indemnity Examiner Program Management Oklahoma Sedgwick CMS Traci Block Client Service Director PO Box 14497 traci.block@sedgwickcms.com Jean Carey Lexington, KY 40512-4497 214-922-0682 510 962 0044 cell Supervisor Jean.Carey@sedgwickcms.com Lisa O'Hara Fax Number Medical Only Examiner lisa.o'hara@sedgwickcms.com 214-922-0625 Serenthia Shannon Client Services Associate 214-922-0629 To Report a Claim serenthia.shannon@sedgwickcms.com Linda Pettitt (855) 7ATLAS7 (855-728-5277) 214-922-0642 Direct: 866-738-9201 Operations Manager linda.pettitt@sedgwickcms.com Tim Nockels State Jurisdictions Handled tim.nokels@sedgwickcms.com in Dallas 214-922-0616 Louisiana, Oklahoma, and Texas

VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS Provider Search Tool Access: Access Link Login Password Client https://www.viaoneprovidersearch.net/ client@sedgwickcms.com SedgwickCMS_123 Provider Search: Search for Providers several ways: 1. Enter Zip Code, City, State or Distance 2. Enter a specific Address to narrow search results 3. Enter a Phone Number to search for a specific provider s phone number 4. Enter a License number or Tax Identification Number (TIN) 5. Enter partial or full spelling of Group or Provider Name 6. Check the First Treaters box only to receive first treating providers in the search results 7. Check the Hospitals / Facilities box only to receive hospitals / facilities in the search results 8. Check the First Treaters box and Hospitals / Facilities box to receive both types of providers in the search results 9. Check all three boxes to search all provider types and specialties Page 1 of 3

VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS 10. Check the Other box and narrow the search results to specific specialties Network Dropdown Box: When searching in CA, TX or NY, the system will ask you to choose a network; then search. CA Network Options: Sedgwick National No MPN Sedgwick Standard MPN Sedgwick Extended MPN **Note provider directories for the MPN s listed below should be printed from: Sedgwick Standard MPN: http://www.talispoint.com/firsthealth/?ae=997465598&caid=sedmpn Sedgwick Extended MPN: http://www.talispoint.com/firsthealth/?ae=997465602&caid=sekmpn TX Network Options: Sedgwick National No HCN Coventry TX HCN SWMPN Southwest HCN NY Network Options: Sedgwick National Sedgwick DOC Sedgwick ROC The networks listed above differ depending on individual participation. The user must select the correct network before searching. Page 2 of 3

VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS Search Results: When the search results populate, you can view them by Specialty, Group or Provider. The number to the right of the specialty is a count of the number of providers / groups. To expand the specialties, click on the + symbol to the left of the specialty name To collapse the listing, click on the - symbol To filter the search results, use the filter button on the far right hand side of the screen. Click on the drop-down box next to the appropriate title Status: P = Provider is on a provider listing panel V= Provider has been validated within 6 months VP= Valid provider on a provider listing panel Page 3 of 3

First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Print this page 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. Prescription Card CARRIER/TPA Sedgwick INJURED WORKER NAME SOCIAL SECURITY NUMBER Please provide directly to Pharmacist EMPLOYER/OTHER ENTITY Atlas General Insurance DATE OF INJURY 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 866.599.5426. Attention Pharmacists: Call 800.964.2531 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 800.964.2531 NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at 800.964.2531. 2. Provide the information listed above. 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 one of the following pharmacy chains: Walgreens Rite Aid Walmart CVS Duane Reade Kroger Publix Safeway Use our pharmacy locator online: www.pmsionline.com/pharmacy-center. Call us: 866.599.5426 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS.

Tmesys Retail Pharmacy Network* More than 60,000 pharmacies, including large chains and many neighborhood independent pharmacies, meaning that your prescription can be filled at most pharmacies nationwide. Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker s Pharmacy Bartell Drugs Bashas United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy Bi-Lo Bi-Mart Bioscrip Pharmacy BJ s Pharmacy Brookshire s Pharmacy Bruno s Pharmacy Buehler s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn s/cash Wise Concord Drugs Costco Pharmacy Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc s Drug Dominick s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred s Pharmacy Fruth Pharmacy Fry s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith s Knight Drugs Kohl s Pharmacy Kohll s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drug Louis and Clark Lowes Marketplace Marc s Pharmacy Marsh Drugs Martin s Pharmacy May s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Pharmacy Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack n Save Pharmacy Safeway Pharmacy Sam s Pharmacy Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy & Discount Shaw s Pharmacy Shaws/Osco Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG s Pharmacy Waldbaum s Pharmacy Walgreens Wal-Mart Pharmacy Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *List subject to change. This is a partial listing only. 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS

Tarjeta temporal para surtir por primera vez sus recetas en farmacias Facilita la tarea de surtir las recetas correspondientes a la compensación por accidentes o enfermedades laborales. Empleador: Imprima esta página inmediatamente después de recibir un aviso de lesión, complete la información que se encuentra a continuación y entréguesela a su empleado. Empleado lesionado: 1. Si necesita que se le surta una receta por una lesión o enfermedad relacionada con el trabajo, diríjase a una farmacia de la red Tmesys. 2. Entréguele esta página al farmacéutico. 3. El farmacéutico le surtirá la receta sin costo alguno. Prescription Card COMPAÑÑÍA DE SEGUROS/ADMINISTRADOR EXTERNO (TPA) Sedgwick NOMBRE DEL EMPLEADO LESIONADO EMPLEADOR/OTRA ENTIDAD Atlas General Insurance At. farmacéuticos: Llamen al 800.964.2531 a fin de establecer la elegibilidad para el beneficio de surtir por primera vez su receta y obtener el número de ID para la adjudicación en línea de los beneficios aprobados para el trabajador lesionado. Tmesys es la administradora de beneficios de farmacia (PBM) asignada a este paciente. NÚMERO DE SEGURO SOCIAL Entregar directamente al farmacéutico FECHA EN QUE OCURRIÓ LA LESIÓN Aviso al titular de la tarjeta: Para recibir los medicamentos correspondiente a la lesión laboral sufrida, debe presentarle esta tarjeta al farmacéutico. Solo es válida durante 30 días a partir de la fecha de la lesión. Para obtener información sobre el programa o para encontrar farmacias cercanas a usted, llame al 866.599.5426 NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. # (Si desea llevar la tarjeta en la billetera, corte a lo largo de la línea exterior y dóblela por la mitad) Farmacéutico: 1. Llame al servicio de asistencia de farmacias de Tmesys al 800.964.2531. 2. Suministre la información que figura arriba. 3. El servicio de asistencia le dará un número de ID correspondiente a la adjudicación. Cómo encontrar una farmacia de la red Para encontrar una farmacia de la red, use uno de estos sencillos métodos: Visite alguna de las siguientes cadenas de farmacias: Walgreens Walmart Duane Reade Publix Rite Aid CVS Kroger Safeway Use nuestro localizador de farmacias en línea: www.pmsionline.com/pharmacy-center. Llámenos: 866.599.5426 2013 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS

Red de farmacias minoristas de Tmesys* Más de 65,000 farmacias, entre ellas grandes cadenas, así como farmacias independientes, lo cual permite que le puedan surtir sus recetas en la mayoría de farmacias del país. Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker s Pharmacy Bartell Drugs Bashas United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy Bi-Lo Bi-Mart Bioscrip Pharmacy BJ s Pharmacy Brookshire s Pharmacy Bruno s Pharmacy Buehler s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn s/cash Wise Concord Drugs Costco Pharmacy Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc s Drug Dominick s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred s Pharmacy Fruth Pharmacy Fry s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith s Knight Drugs Kohl s Pharmacy Kohll s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drug Louis and Clark Lowes Marketplace Marc s Pharmacy Marsh Drugs Martin s Pharmacy May s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Pharmacy Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack n Save Pharmacy Safeway Pharmacy Sam s Pharmacy Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy Shaw s Pharmacy Shaws/Osco Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG s Pharmacy Waldbaum s Pharmacy Walgreens Wal-Mart Pharmacy Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *Lista sujeta a cambios. Ésta es sólo una lista

.375.625 2.0625 Print Area for P.O. Return Box 152539 Address Tampa, FL 33684-2539 Logo 1 Box Size 1.25 x.5625 PERSONAL 1.875 & CONFIDENTIAL Important Insurance Claim Document Enclosed Customer Address Box Size 2.6875 x 1.0625.625 Prescription Delivery By Mail Logo 2 Box Size 1.25 x.5625 Questions? 1.866.599.5426 Necesitas ayuda en español? Llame al 1.866.599.5426 In addition Pharmacy to Locations providing - currently access setup to for your 5 locations medications at a local pharmacy, Tmesys Box Size 5.6875 x.6875 can also deliver your medications to your home through our PMSI Mail Order Font size: Arial 7pt program at no cost. Using this convenient program means you will not have to drop off or pick up your prescription or wait in line while it is being fi lled. For more information 1 or to sign up, call 1.800.304.1764 or go to www.pmsionline.com/pharmacy-center, click on Mail Order Overview. Matrix measures 8.375 x 5.625.375 Card Logo Box Size 1.25 x.5625 Prescription Card DOI «DOI» ID# «subid» Keytag Info Name «Patientname» Box Size 1.125 x.4375 Carrier «Carrier» Prescription Card DOI «DOI» ID# «subid» Keytag Info Name «Patientname» Box Size 1.125 x.4375 Carrier «Carrier» 2.25 2.25 Prescription Card NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct.# Issuer (80840) 9151014609.5 1.4375 1.55 Card Info Box Size 2.25 x.625 «DOI» «subid» «Patientname» «Carrier» Injury Date ID# Name Carrier/TPA.3125

Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call 1.800.964.2531. NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct.# Issuer (80840) 9151014609 Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call 1.800.964.2531. NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct.# Issuer (80840) 9151014609 Attention Cardholder: For questions regarding coverage or to fi nd a pharmacy call Tmesys at: 1.866.599.5426 or visit www.tmesys.com. Attention Pharmacist: Tmesys is the designated workers compensation PBM for this patient. Call Tmesys with questions regarding transmission or rejection at: 1.800.964.2531. 2.921 Note: Your use of this card is limited to those prescriptions medically related to an injury that is considered to be covered under the applicable state workers compensation law. IMPORTANT: ONCE CARDS HAVE BEEN REMOVED PLEASE RETAIN THIS PORTION FOR YOUR RECORDS Taking Care of Using the Pharmacy Card Name Location 2 - Box Size 2.8125 x.1875 We want to make it easy for you to obtain the medication you need to recover from your work-related injury. Just follow these steps: 1. Activate the card by calling the toll-free number. 2. Separate the attached cards and place one in your wallet and one on your key ring. 3. Give a card to the pharmacist next time you have a new prescription or refill. 4. Your prescription will be filled at no cost. Finding a Pharmacy You can use any pharmacy that is part of the Tmesys network to fi ll your prescription and with over 60,000 locations, the card is accepted at most pharmacies nationwide. Finding a network pharmacy is simple! Use one of the options below: Visit one of the following pharmacy chains: Walgreens Walmart Duane Reade Publix Rite Aid Target Kroger Safeway Go to one of these nearby pharmacies: «Pharmacy1» Pharmacy Locations - currently setup for 5 locations «Pharmacy2» Box Size.4375 x 5.15 «Pharmacy3» Font Size = 7pt Look up a pharmacy on the website: www.tmesys.com, click on Pharmacy Locator and choose a search option. 1.2306 Call us toll free at 1.866.599.5426. <<PATIENTNAME>>.375 Name Location 1 - Box Size 3.09375 x.1875.75 Matrix measures 8.375 x 5.625 2011 PMSI, Inc. All Rights Reserved. SCMSMOD