The following state forms have been included in your claims kit packet:

RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee, we want you to have all the information you might need in the event one occurs. Enclosed is our Workers Compensation Injury Reporting Kit that contains the Colorado State mandated forms, and a step-by-step process to follow in case an employee sustains an injury. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the How to File an Injury form included in this packet. The Tower Group claim office which will be handling your claim is located in Irving, Texas. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the Colorado workers compensation process. The following state forms have been included in your claims kit packet: 1. Colorado Form WC15- Workers Claim for Compensation- The employee has four (4) days to report the injury to the employer. The employer has ten (10) days from the date of occupational disease, permanent partial disability or lost time greater than three (3) working days to report to the Division. 2. Colorado Form WC12 Supplemental Report of Return to Work- Tower Group Companies must have written documentation with return to work status and must receive supporting documentation (i.e. a doctor s return to work note). 3. Wage Statement- Please complete and send a copy of employee s Wage Statement to Tower Group Companies at the time of injury. 4. Medical Authorization- Please have the injured employee fill out and sign this form and send to Tower Group Companies at the time of an injury. We thank you for your business and look forward to being of service to you. Very truly yours, Tower Group Companies CL-08-045 TGC (08/10)

HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Worker s compensation claims can be reported in several different ways, you can: Complete and submit the Colorado Form WC15- Workers Claim for Compensation and submit the form via one of the following: E-mail the completed form to wcreportaloss@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at 888-535-3407. Call the Tower Group Companies Claims office at 888-856-5522. By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call 888-856-5522. The after hours telephone number for reporting claims provides the opportunity to report a claim 24 hours a day 7 days a week. Loss details will be gathered to determine if an emergency exists and if an immediate field contact is indicated. IN02 08/08

See instructions on reverse side before completing form COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS COMPENSATION WORKER S CLAIM FOR COMPENSATION Employee s name (first, middle, last) Social Security # Male Female Employee s home phone # Division Use Only Employee s street address City State Zip code SOI Birth date Marital status Dependents Date of hire Occupation Employment status POB Married Separated Yes Full time Part time / / Single Unknown No / / Other Unknown Employer s name (Company) Employer s phone # NOI Employer s mailing address City State Zip code Coder Average Weekly Wage A. Calculate the average weekly wage. Multiply the average number of hours worked per week, excluding overtime, times the hourly wage see instructions Subtotal (A) $ B. Check box if employee receives Will benefit continue If benefit will not continue, provide the average weekly during disability? value of the benefit Overtime Yes No $ Tips (amount reported to IRS) Yes No $ Commissions Yes No $ Piecework Yes No $ Mileage (if a form of salary) Yes No $ Other (room, board, etc.) Yes No $ Health Insurance (see instructions) Yes No $ Subtotal (B) $ C. Add subtotals A & B = Average weekly wage at time of injury (C) $ Date of injury/disease / / (See instructions) Time employee began work a.m p.m Injury time a.m. p.m Unknown Last date worked / / Which part of body was affected? (specify upper or lower for arms, legs and back injuries) Date employer notified / / Date you returned to work / / Do you claim to have a permanent disability? Yes No Unknown Tell us the nature of the injury/illness (sprain, strain, laceration, contusion, fracture, etc.) 1 What were you doing just before the accident occurred? 2 How did the injury occur? 3 What object or substance directly harmed you? 4 Where did the accident occur? (street address, city, state, and county) Name and phone number of witness To whom was it reported? Initial treatment (check one) Do you claim to have a disfigurement None Emergency room Hospital stay over 24 hrs or scar? Minor on-site Clinic/Hospital Yes No Name and address of treating doctor or other health care professional Name and address of facility where treated If claim is for an occupational disease (i.e., asbestos related, repetitive motion, hearing loss), give names of employers where the exposure occurred and dates of employment (attach additional sheet if needed). Employer Employer / / to / / Dates of employment / / to / / Dates of employment Completed by Date completed / / For Division Use Only FEIN Carrier claim # Policy # Adjuster Code Block # WC15 Rev 04/06 Page 1 of 2

CALCULATION OF AVERAGE WEEKLY WAGE To determine the weekly wage calculate the following: First, calculate your average weekly wage. Multiply the average number of hours worked per week (excluding overtime) times your hourly wage. If you are paid by the month, multiply your monthly salary times 12 (months) and divide by 52 (weeks). If you are paid bi-weekly (every other week), take your bi-weekly salary and divide by 2. If you are paid on a per diem basis, multiply the daily wage times the number of days and fractions of days in the week you would have worked under the contract of hire if the injury had not occurred Next, determine the average weekly amount of any overtime, tips (as reported to the IRS), commissions, piecework (average weekly value can be calculated by taking the total amount earned with the employer in the 12 months immediately preceding the injury and dividing that amount by the number of weeks, and fractions of weeks worked). If mileage is a form of salary, take the average earned per week in the 60 days immediately preceding the injury. Add the average weekly value of any board, rent, housing or lodging, etc., provided by the employer if the employer will not be paying such benefit during the period of disability. If you are covered by group health insurance and your employer does not continue your health insurance coverage during the period of disability, add your cost of converting to a similar or lesser insurance plan and include this cost in the average weekly wage computation. Add the totals from each of the above categories to obtain your average weekly wage and insert in Average weekly wage at time of injury field. DATE OF INJURY/DISEASE Always include a date of injury. In the case of an occupational disease, use the date you were last exposed to the hazard. INJURY DESCRIPTION 1 Be more specific than hurt, pain, or sore. Examples: strained back ; chemical burn, hand ; carpal tunnel syndrome. 2 Describe the activity, as well as the tools, equipment or material you were using. Be specific. Examples: climbing a ladder while carrying roofing materials ; spraying chlorine from hand sprayer ; or daily computer key-entry. 3 Tell us how the injury occurred. Examples: When ladder slipped on wet floor, I fell 20 feet ; I was sprayed with chlorine when gasket broke during replacement ; I developed soreness in my wrist over time. 4 Examples: concrete floor ; chlorine ; radial arm saw, beryllium. FILING AND BENEFIT INFORMATION Upon completion, mail or deliver two (2) copies of the Worker s Claim for Compensation to: The Colorado Division of Workers Compensation, Customer Service Unit, 633 17 th St., Suite 400, Denver, CO 80202-36. In order to obtain information on benefits and dispute resolution options, or to request a copy of the Employee s Guide, please contact our Customer Service Unit at (303) 318.8700 or toll free at (888) 390.7936 for English, or (800) 685.0891 for Spanish. You may also visit our website at www.coworkforce.com/dwc/ GENERAL INFORMATION When your claim form is received by the Division of Workers Compensation, a copy will be sent to your employer s insurance carrier (insurer). The insurer has 20 days from receipt of this information to advise, in writing, whether liability will be admitted or denied, that is, whether it accepts responsibility for payment of related medical and/or lost wage benefits. If the insurer fails to admit liability within the prescribed time limit, you will receive information from the Division on the options that are available to you. Always notify your employer of an injury. Failure to report an injury to the employer in writing within 4 days could result in loss of one day s compensation for each day s failure to notify. Seek medical assistance as soon as possible. The employer has the right to select the physician who attends you. If you fail to remain under the care of a physician designated by the employer or its insurer, you may be responsible for payment of any unauthorized medical expenses. If the employer fails to designate a physician, you have the right to select a treating physician. If you would like to change physicians, you must first request in writing, from the insurer, permission to change physicians and receive authorization to do so. If such permission is neither granted nor refused within twenty days, the insurer shall be deemed to have waived any objection to the change. Failure to attend medical appointments may result in the suspension of benefits by the insurer. For additional information on the provisions of the Colorado workers compensation system, you may contact the Customer Service Unit of the Colorado Division of Workers Compensation at (303) 318.8700, or toll free at (888) 390.7936. NOTICES You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S. YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of your benefits pursuant to section 8-42-113.5, C.R.S. C.R.S. Section 10-1-128(6) (a) states: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. WC15 Rev 04/06 Page 2 of 2

Colorado Workers' Compensation Supplemental Report of Return To Work Workers' Compensation (We) # Date of Injury Employee Name Carrer Claim # Social Security # Employer Purpose: The purpose of this form is to provide information to determine the accurate payment of temporary disabilty benefis. Instructions: 1. This form may be completed by the employee or employer. 2. This form should be completed each time the employee returns to work at full or reduced wages. 3. This form should be forwarded to your workers' compensation carrier. 1. Last day employee worked 2. Date employee returned to work 3. Employee's return-to-work-wages (Check the box that applies) D Full Wages D Reduced Wages (Provide wage information to the claims adjuster every 2 weeks during periods of wage loss) Additional Information Completed by (Check the box that applies) D Employee DEmployer Name Date Address Phone # Fax # Wel2 Rev 07/03

W AGE S TATEMENT Employer: Employee: Please provide the 52 weeks of wages prior to the date of injury of Date employee ceased to work: Number of Hours employee is scheduled to work per week: Is employee paid by hour, day, week or month Date Hired Claim Number At what rate: Does Employee work Overtime Yes No If yes, is Overtime mandatory Yes No State the date and amount of any pay increases during the past 52 weeks Date Amount Date Amount Date Amount Date Amount Dates Incl of each Week Pd Hrs Wkd Regular Pay Overtime Pay Dates Incl of each Week Pd From To Yr From To Yr 1 27 2 28 3 29 4 30 5 31 6 32 7 33 8 34 9 35 10 36 11 37 12 38 13 39 14 40 15 41 16 42 17 43 18 44 19 45 20 46 21 47 22 48 23 49 24 50 25 51 26 52 Hrs Wkd Regular Pay Overtime Pay SUBTOTAL SUBTOTAL GRAND TOTAL This is a correct statement of Employee s earnings as actually taken from Payroll Records Employer s Signature Title Date

WORKERS COMPENSATION INJURY MEDICAL AUTHORIZATION Authorization for Medical Records And Communication Release By this form or copy thereof, I, hereby authorize any licensed physician, chiropractor, medical practitioner, hospital, clinic or other related medical or medically related facility, insurance company or other organization, institution, or person, that has any records or knowledge of my mental, physical health, history, condition or well being, to supply such information to my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys. I specifically authorize any treating physician or medical care provider to communicate orally or in writing with my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys as to my care and treatment and as to any other issues including but not limited to diagnosis, prognosis, causal connection of care and treatment to my work injury or duties and ability to work. In conjunction with this, I authorize any treating physician or medical provider to review any additional medical records provided to them. I understand that by signing this authorization for medical records and communication release that my applicable medical provider will be releasing information subject to the HIPPA restrictions. I specifically waive any rights or protections that I may have under the HIPPA regulation and request that the medical providers release the requested information. A photo copy of this authorization shall be valid as the original. This release shall remain valid for the length of my claim. Name (Please Print) Address (Street, City/Town, Zip Code) Signature Date Signed TWR05 08/08

WORKERS COMPENSATION MANAGED CARE PROGRAMS Tower Group Companies strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers needs in managing their workers compensation claims. Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker. A summary of each program is outlined below. Medical Bill Review Services The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs. Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and Aetna networks; as well as other top regional PPO s. The combination of these network providers offers coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work. In some states, such as California and Texas state regulations allow specialty networks which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments. One of the first steps in providing quality medical care to your injured employee is to understand how to access network providers, and generate workplace provider panel cards or provider listings. There are two convenient ways to locate a network provider or develop provider network listings: 1. Telephonically: Simply call Coventry at 1-800-243-2336 x 4680. Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via e-mail. 2. Internet Access: For the standard national workers compensation network go to www.talispoint.com/cvty/twrgrp and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network.

If you participate in a Specialty Network, such as a MPN or HCN, select the applicable network from the drop-down box. For California, chose the First Health Select CA MPN; Texas participants in the Coventry HCN. For large panel card production or if you require additional information regarding web access please contact Tower Group Medical Management division at 312-277-1600. Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims. Tower s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee s lost time and medical costs. Your Tower Group designated adjuster will be responsible for managing all aspects of the injured employee s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these programs.

Re: Important Information about your Workers Compensation Prescriptions This letter is provided to inform you that your employer s workers compensation, Tower Group Companies, has selected PMSI as its workers compensation pharmacy partner.with PMSI, you can choose to pick-up your medications for your work-related injury at a nearby pharmacy through a program known as Tmesys, or have them delivered to your home through the mail. Within the next few weeks, you will receive a new workers compensation pharmacy card in the mail. You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your next refill or new prescription for your work-related injury. If you do not receive your new pharmacy card within two weeks, please call Tmesys at 1.866.599.5426 and we will be happy to assist you or send another card. If you are interested in finding out about how to receive your prescriptions through the mail, please call 1.800.304.1764. To help you transition to the new pharmacy program, we have provided answers to some frequently asked questions: Q: How do I know if my pharmacy participates with the new program? A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the Pharmacy Center on our website, www.pmsionline.com/pharmacy-center. Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at 1.866.599.5426 to find a network pharmacy near you. Q: How does this affect my workers compensation claim? A: Using PMSI s program for your workers compensation medications will enable you to continue to receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy, as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you can have your prescriptions delivered to your home through our convenient mail order program. Q: Who do I call with questions about the program? A: PMSI has representatives available to help you with any questions that you may have about the pharmacy program. Please call our help desk at 1.866.599.5426 to speak to a representative. If you have any questions about your workers compensation claim, we will help you reach your claims adjuster for assistance. We look forward to serving you and meeting your workers compensation medication needs. Sincerely, PMSI Necesitas ayuda en español? Llame al 1.866.599.5426

First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: 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. Questions? Call 1.866.599.5426 Necesitas ayuda en español? Llame al 1.866.599.5426 Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY 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 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. 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 from the card. 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 your local Walgreens or Rite Aid Pharmacy Call us: 866.599.5426 Use our pharmacy locator online: www.tmesys.com. 2011 PMSI, Inc. All rights reserved. C1257-1011-02..

First Fill Temporary Pharmacy Card En Primer Relleno Tarjeta Temporal de Farmacia Hacerlo fácil de llenar sus recetas de la compensación del trabajador. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Empleado Lesionado: 1. Si usted necesita una receta para un accidente de trabajo o enfermedad ocupacional, ir a una farmacia de la red Tmesys. 2. Dar esta página al farmacéutico. 3. El farmacéutico surtir su receta sin costo alguno. Preguntas? Llame al 1.866.599.5426 Need help in English? Call 1.866.599.5426 Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN 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 Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame 866.599.5426. NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. # (Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.) 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. Encontrar una farmacia de la red Utilice uno de estos métodos fáciles para encontrar una farmacia de la red: Visite a su local de Walgreens y Rite Aid Pharmacy. Nos llame al: 866.599.5426. Utilice nuestro localizador de farmacias en linea: www.tmesys.com. 2011 PMSI, Inc. Todos los derechos reservados. C1257-1011-03..

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