RE: Workers’ Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies’ Workers’ Compensation Insurance Program. Although we hope that your company never has to experience 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 New York statemandated 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 Melville, New York. Once reported, a claims representative will contact you to get additional information about the injured employee and to answer any questions that you might have regarding the New York workers’ compensation process. The following State forms have been included in your claims kit packet: 1. New York Form C-2- Employer’s Report of Work Related Injury/Illness – Employers must maintain records of injuries for 18 years. Employers must file this form within 10 days to the NY Workers Compensation Board and carrier if lost time is balance of shift plus one day, or if claimant requires medical treatment beyond first aid, or if person needs more than two treatments by a person rendering first aid. Article 7 Section 110 of the New York WKC Code. Refusal or neglect to maintain records or file a C-2 form is a misdemeanor and punishable up to $1,000. The board also has discretion to assess a penalty of $2,500 following an administrative hearing. 2. New York Form C-11 Employer’s Report of Injured Workers Change in Status or Return to Work- Employer is to report the claimant’s initial lost time and any subsequent lost time with the Board and Carrier. This form must be filed whenever the employment status changes. . 3. New York Form C-240- Employer Statement of Wage Earnings – This form must be filled out and returned to the carrier at the time of injury. Once requested by the Board carrier has 10 days to file the C-240 form. Failure to file this form could result in the Board establishing the Average Weekly Wage of the injured worker based on testimony. 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
Workers compensation claims can be reported in several different ways, you can: •
Complete and submit the New York Form C-2- Employer’s Report of Work Related Injury/Illness – and submit the form via one of the following:
•
E-mail the completed form to
[email protected]. 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
C-2
EMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESS State of New York - Workers' Compensation Board
If one of your employees has a work-related injury or illness, you must complete and file this form within 10 days of the injury/illness or be subject to a penalty. For additional information on filing this form please refer to Workers' Compensation Law Section 110 at the end of this form. Type or print neatly. WCB Case Number (if you know it):
Date of Injury/illness: ________/________/________
Carrier Case Number (if you know it):
Date of this Report: ________/________/_________
A. EMPLOYER INFORMATION 1. Employer:
2. Employer FEIN:
3. Mailing Address: 4. Location Address (if different): 5. Phone Number: (______)______________________ 6. Nature of Business or Industry Code: 7. OSHA Case Number (if known):
8. NY UI Employer Reg Number:
B. INSURANCE CARRIER / SELF-INSURED EMPLOYER If individually self-insured, enter your Board W Number and skip to Section C. 1.Board W Number: W
2. Carrier/Group Name: Policy Period: From: ______/______/______ To: ______/______/______
3. Policy Number:
5. Phone Number: (______)_____________
4. If Carrier Unknown, Insurance Agent Name:
C. EMPLOYEE'S PERSONAL INFORMATION 1. Name:
2. Date of Birth: ______/______/______ First
MI
Last
3. Mailing Address: 5. Contact Phone Number:(______)_______________ 6. Gender:
4. Social Security Number:
Male
Female
D. EMPLOYEE'S INJURY OR ILLNESS AM
1. Time of day employee began work on date of injury: 3. Has the employee given you notice of injury/illness?
Yes
PM 2. Time of injury:
AM
PM
No
If yes, notice was given to: _________________________________
in writing Date notice provided: ______/______/______
orally
If available, attach a copy of the employee's written notice and medical notes, and the employer's incident report. 4. Have you given the employee a Claimant Information Packet?
Yes
No
If yes, give date: ______/______/______
5. Where did the injury/illness happen (e.g., 1 Main St., Pottersville, at the front door):
6. Was this location where the employee normally worked?
Yes
No If no, why was the employee there?
7. Employee's supervisor: ____________________________________ 8. Did supervisor see injury happen? 9. Did anyone else see the injury happen?
Yes
No
Unknown
Yes
No
Unknown
If yes, give name(s): ___________________________________
10. What was the employee doing when he/she was injured or became ill? (e.g., unloading a truck, stocking a shelf, typing annual report)
C-2.0 (1-11) Page 1 of 3
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
www.wcb.state.ny.us
EMPLOYEE'S NAME:
DATE OF INJURY/ILLNESS:______/______/______ First
MI
Last
D. EMPLOYEE'S INJURY OR ILLNESS continued 11. How did the injury/illness occur? (e.g., the employee tripped over a pipe and fell on the floor)
12. Explain fully the nature of the employee's injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):_____________
13. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?
Yes
14. Was the injury the result of the use or operation of a licensed motor vehicle? If yes,
employee's vehicle
No If yes, what was it? Yes
No
other vehicle License plate number (if known):
employer's vehicle
If employer's vehicle was involved, give name and address of your motor vehicle insurance carrier:
15. Did the injury/illness result in the employee's death? Name and address of the nearest relative:
Yes
If yes, what was the date of death? ______/______/______
No
E. MEDICAL TREATMENT 1. What was the date of the employee's first treatment? ______/______/______
None received
2. Where did the employee receive first medical treatment for this injury/illness?
On site
Clinic/Hospital/Urgent Care
Hospital Stay over 24 hours
Unknown
Doctor's office
Emergency Room
Unknown
Who treated the employee and where? 3. Is the employee still being treated for this injury/illness?
Yes
No
Unknown
If yes, name and address of treating doctor(s):
4. To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you? Yes
No If yes, name the doctor(s) who treated the previous injuries/illnesses (if known):
F. RETURN TO WORK 1. Did the employee stop work because of his/her injury/illness? 2. Has the employee returned to work?
Yes
If yes, on what date? ______/______/______
Yes
No
If yes, on what date? ______/______/______
No regular duty
limited duty
3. If the employee has returned to limited duty, what are his/her average gross earnings per week? C-2.0 (1-11) Page 2 of 3
www.wcb.state.ny.us
EMPLOYEE'S NAME:
First
MI
DATE OF INJURY/ILLNESS:______/______/______
Last
G. EMPLOYEE'S WORK INFORMATION on the date of the injury or illness 1. Date the employee was hired: ______/______/______ 2. What was the employee's job title? 3. What types of activities did the employee normally perform at work? (Attach job description if available.)____________________________
H. EMPLOYEE'S PAYROLL INFORMATION on the date of the injury or illness 1. Employee's gross pay in an average week was: $ 2. Did the employee receive lodging or tips in addition to pay?
3. Employee's job was (check one):
Full Time
4. Which days of the week did the employee usually work?
Yes
Part Time Mon.
5. Was the employee paid for a full day on the day of the injury/illness?
No
If yes, describe:
Seasonal Tues.
Wed.
Yes
No
Volunteer Thurs.
Other:__________________ Sat.
Fri.
6. Did you continue to pay the employee after the injury/illness (e.g., sick leave, vacation, disability, regular salary)?
Yes
Sun.
No
I. ADDITIONAL INFORMATION
An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. The above information is true to the best of my knowledge and belief. If prepared by the employer: Signature of Person Preparing Form:
Date: ______/______/______
Print Name:
Title:
Phone Number: (______)______________
If prepared by a Third Party on Behalf of the Employer: Signature of Person Preparing Form: Print Name:
Date: ______/______/______ Title:
Phone Number: (______)______________
Company Name and Address: Name & Phone Number of Person Who Provided Information Necessary to Prepare This Form: Reports should be filed by sending directly to the appropriate WCB district office (DO) at the address below with a copy sent to the insurance carrier: Albany DO - 100 Broadway-Menands, Albany NY 12241 866-750-5157 (for accidents in the following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington) Binghamton DO - State Office Building, 44 Hawley Street, Binghamton NY13901 866-802-3604 (for accidents in the following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins) Buffalo DO - 295 Main Street, Suite 400, Buffalo NY 14203 866-211-0645 (for accidents in the following counties: Cattaraugus, Chautauqua, Erie, Niagara) Rochester DO - 130 Main Street West, Rochester NY 14614 866-211-0644 (for accidents in the following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates) Syracuse DO - 935 James Street, Syracuse NY 13203 866-802-3730 (for accidents in the following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego,St. Lawrence) Downstate Centralized Mailing - PO Box 5205, Binghamton NY, 13902-5205 for all DO's in NYC 800-877-1373; in Hempstead 866-805-3630; in Hauppauge 866-681-5354; in Peekskill 866-746-0552 (for accidents in the following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester)
C-2.0 (1-11) Page 3 of 3
Statewide Fax Line: 877-533-0337
www.wcb.state.ny.us
WORKERS' COMPENSATION LAW Section 13 Treatment and care of injured employees (a) "The employer shall promptly provide for an injured employee such medical, surgical, optometric or other attendance or treatment, nurse and hospital service, medicine, optometric services, crutches, eye-glasses, false teeth, artificial eyes, orthotics, functional assistive and adaptive devices and apparatus for such period as the nature of injury or the process of recovery may require.****" Section 13 Injury to employee's prosthesis (a) "Damage to or loss of a prosthetic device shall be deemed an injury except that no disability benefits shall be payable with respect to such injury under section fifteen of this article.****" Section 25 Effect of failure to file reports 3. (e) "If the employer or its insurance carrier fails to file a notice or report requested or required by the board or chair or otherwise required within the specified time period or within ten days if no time period is specified, the board may impose a penalty in the amount of fifty dollars.****" Section 51 Posting of notice regarding compensation "Every employer who has complied with section fifty of this chapter shall post and maintain in a conspicuous place or places in and about his place or places of business typewritten or printed notices in form prescribed by the chairman, stating the fact that he has complied with all the rules and regulations of the chairman and the board and that he has secured the payment of compensation to his employees and their dependents in accordance with the provisions of this chapter, but failure to post such notice as herein provided shall not in any way affect the exclusiveness of the remedy provided for by section eleven of this chapter. ****" Section 52 Effect of failure to secure compensation 1. (a) "Failure to secure the payment of compensation shall constitute a misdemeanor, punishable by a fine of not less than five hundred nor more than two thousand five hundred dollars or imprisonment for not more than one year, or both. (b) Where any person has previously been convicted of a failure to secure the payment of compensation within the preceding five years, upon conviction for a second violation such person shall be fined not less than one thousand nor more than five thousand dollars in addition to any other penalties including fines otherwise provided by law, and upon conviction for a third or subsequent violation such person may be fined up to seven thousand five hundred dollars in addition to any other penalties including fines otherwise provided by law. (c) Where the employer is a corporation, the president, secretary and treasurer thereof shall be liable for failure to secure the payment of compensation under this section.****" Section 110 Record and report of injuries by employers 1. An employer, or a third party designated by the employer, shall record any injury or illness incurred by one of its employees in the course of employment using the form prescribed by the chair for reporting injuries under subdivision two of this section. Such form, a copy of which shall be provided to the injured employee upon request, shall be maintained by the employer, or a third party designated by the employer, for at least eighteen years, and shall be subject to review by the chair at any time. Such form need not be filed with the chair unless the status of such injury or illness changes resulting in a loss of time from regular duties or in medical treatment which would require reporting in accordance with subdivision two of this section. 2. An employer, or a third party designated by the employer, shall file with the chair of the workers' compensation board and with the carrier if the employer is insured, upon a form prescribed by the chair, a report of any accident resulting in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid. Such report shall state the name and nature of the business of the employer, the location of its establishment or place of work, the name, address and occupation of the injured employee, the time, nature and cause of the injury and such other information as may be required by the chair. Such report shall be filed within ten days after the occurrence of the accident. An employer shall furnish a report of an occupational disease incurred by an employee in the course of his or her employment, to the chair of the workers' compensation board, and to the carrier if the employer is insured, upon the same form. The carrier, within fourteen days of receipt of the report or accompanying the initial check forwarded to the employee, whichever is earlier, or a self-insured employer, within fourteen days of transmitting the report to the chair or accompanying the initial check forwarded to the employee, whichever is earlier, shall provide the injured employee or, in the case of death, his or her dependents with a written statement of their rights under this chapter, in a form prescribed by the chair. An employer shall file a report of any other accident resulting in personal injury incurred by its employee in the course of employment, upon the same form, whenever directed by the chair. 3. Any injury or illness which is not required to be reported in accordance with subdivision two of this section, shall not be used as a basis for determining experience modification rates, provided the employer pays in the first instance or reimburses the employer's insurer for the treatment rendered to the employee. 4. An employer who refuses or neglects to make a report or to keep records as required by this section shall be guilty of a misdemeanor, punishable by a fine of not more than one thousand dollars. The board or chair may impose a penalty of not more than two thousand five hundred dollars upon an employer who refuses or neglects to make such report. 5. The chair shall be authorized to promulgate regulations necessary to carry out the provisions of this section.
C-2.0 (1-11)
www.wcb.state.ny.us
Instructions for Completing Form C-2, “Employer's Report of Work-Related Injury/Illness” Please complete this form and send it directly to your local Workers' Compensation Board district office (DO). The addresses are listed at the bottom of page 3. Also send a copy of the form to your insurance carrier. If you need additional help in completing this form, you may contact the Workers' Compensation Board at 1-877-632-4996 or visit http://www. wcb.state.ny.us/. If you do not have or know your Workers' Compensation Board Case Number, please leave this field blank. It is not required to process the form. Fill out the Date of Injury/Illness, to the best of your knowledge, and the Date of this Report at the top of page 1. Remember to enter in the name of the injured employee and the date of injury/illness on the top of page 2 and page 3.
Section A - Employer Information: Item 1: Indicate the name of the company or the owner's name and DBA name. Item 2: Enter the employer's Federal Employer Identification Number (FEIN). This is your Federal Tax ID number. If you do not have a FEIN, enter your Social Security Number. Item 3: Enter the employer's main address where you receive mail (such as a central office). Include P.O. Boxes. Item 4: Enter the physical address of the employer (if different). Item 5: Enter the primary contact phone number for the employer, including area code. Item 6: Indicate the North American Industry Classification System (NAICS) or Standard Industrial Classification (SIC) Code for your business. If you do not know your NAICS or SIC Code, please indicate the type or nature of business as accurately as possible (e.g., Restaurant, Construction, Retail). Item 7: Enter the OSHA Case Number, if known. Item 8: Enter the first 7 digits of your New York Unemployment Insurance (NY UI) Registration Number (UIER). This is the number used to report to the Department of Labor.
Section B - Insurance Carrier / Self-Insured Employer: Item 1: Indicate the Carrier Code Number (W Number) issued by the Workers' Compensation Board. If you do not know the W number, contact your insurance carrier. If you are self-insured, only enter your Carrier Code Number (W Number) and skip to Section C. Item 2: Enter the name of the employer's Workers' Compensation Insurance Carrier or Group Name. If you do not know your insurance carrier, please indicate the employer's Insurance Agent Name for item 4 and the Agent's contact phone number for item 5. Item 3: Enter your Workers' Compensation Insurance Policy Number and indicate the policy effective period for coverage at the time of the injury or illness. Item 4: Insurance Agent Name if the carrier is unknown. Item 5: Insurance Agent phone number, including the area code.
Section C - Employee's Personal Information: Item 1: Indicate the injured employee's full legal name. Item 2: Enter the employee's date of birth. Item 3: Enter the employee's mailing address, including street number, P.O. Box (if applicable), Town or City, State, and Zip Code. Item 4: Indicate the employee's Social Security Number (SSN). Item 5: Enter a contact phone number for the employee, either a home phone number or a cell phone number, including the area code. Item 6: Indicate his/her gender.
Section D - Employee's Injury or Illness: If this is an illness or occupational disease and an exact date of illness cannot be determined, then skip items 1 and 2. Item 1: Indicate the time of day when the employee began work on the day the injury occurred. Item 2: Enter the time when the injury occurred. Item 3: Check whether the employee has given notice of his/her injury or illness to the employer. If so, enter the date notice was given and if it was orally or in writing. If written notice was given, please attach a copy of the employee's notice as well as any medical notes you may have received. Also attach the [supervisor's] incident report, if available. Item 4: Check whether you gave the employee a Claimant Information Packet and if so, when. Item 5: Indicate the location where the injury/illness occurred, including the address of the building and the physical location in the building where the injury/illness happened. Item 6: Check if this was the employee's normal work location. If it was not, explain why the employee was at this location. Item 7: Enter the name of the employee's direct supervisor. Item 8: Indicate whether the supervisor was a witness to the injury/illness. Item 9: Check if anyone else witnessed the injury/illness and if so, list their name(s). C-2.0 (1-11)
Section D - Employee's Injury or Illness (cont.): Item 10: Describe in detail what the employee was doing at the time of the injury/illness (e.g., unloading boxes from a truck by hand). This explains the events leading up to the injury. Item 11: Describe in detail how the injury/illness occurred (e.g., the employee was lifting a heavy box off a truck). This should include all people and events involved in the injury/illness. Item 12: Indicate fully the nature and extent of the employee's injury/illness, including all body parts injured. Be as specific as possible (e.g., lumbar gluteal muscle strain resulting from sudden straining). Item 13: Indicate if some object was involved in the accident OTHER THAN a licensed motor vehicle. Other objects may include a tool (e.g., hammer), a chemical (e.g., acid), machinery (e.g., forklift or drill press), etc. Item 14: Indicate if a licensed motor vehicle was involved in the accident. If so, check if the motor vehicle involved was the employee's, the employer's, or that of a third party and include the license plate number (if known). If the employer's vehicle was involved, fill out the automobile liability insurance carrier for the vehicle and their address. Item 15: Check if the injury/illness resulted in the death of the employee and if so, indicate the date of death and the nearest relative of the deceased (if known).
Section E - Medical Treatment: Item 1: If the employee did not receive medical treatment for this injury/illness, check None Received and skip to item 4. Otherwise, enter the date the employee first started treatment for this injury/illness, or check Unknown if you do not know, and complete the rest of this section. Item 2: Check the location where initial medical treatment was administered for this injury/illness and whom was responsible for treatment/care of the employee (e.g., Physician, Nurse, EMT, etc.). Include the name of the person and the facility. Item 3: If the employee is still receiving ongoing treatment for the same injury/illness, check Yes and indicate the name and address of the physician providing treatment; otherwise check No or Unknown. Item 4: If the employee had a similar work-related injury to the same body part or a similar work-related illness while working for the same employer, check Yes and if known, indicate the name and address of the physician whom provided care; otherwise check No.
Section F - Return To Work: Item 1: If the employee has stopped working as a result of the work-related injury/illness, check Yes and indicate on what date he/she stopped working. Item 2: If the employee has since returned to work, check Yes. Also indicate on what date the employee started working again, as well as if the employee has returned to his/her Normal Duties or if the employee is on Limited or Restricted Duty. (If the employee has not returned to his/her full pre-injury or illness work duties, then the employee is on Limited Duty). Item 3: If the employee has returned to work on Limited Duty, enter in his/her average gross earnings per week.
Section G - Employee's Work Information: Item 1: Indicate the date the employee was hired by the employer. Item 2: Enter the employee's current job title. Item 3: Describe the employee's typical work activities or enter the employee's job description. If you need more space, you may attach an official job description or additional pages to completely and accurately describe the employee's work activities.
Section H - Employee's Payroll Information: Item 1: Enter the employee's average gross weekly pay before the injury/illness. Item 2: Check if the employee received any tips or lodging in addition to his/her regular pay and if so, describe them. Item 3: Check the type of job the employee had. Item 4: Check which days of the week the employee usually worked. If the employee did not work a standard work week, please explain in Section I or attach an additional page or work schedule in order to fully explain. Item 5: Check if the employee was paid for a full day's work on the day of the injury/illness. Item 6: Indicate if the employee continued to receive pay after the illness/injury, such as sick leave or disability pay.
Section I - Additional Information: Enter any additional information that may be relevant to the employee's work-related injury/illness in this section. You can also use this area to further explain other items in this form, such as G-3 or H-4. Sign Form C-2 on the last page. If the form was filled out by a third-party on behalf of the employer, that person should sign on the second signature line. C-2.0 (1-11)
Dear Policyholder: In an effort to provide your employees with quality care, Tower Group Companies would like to notify you that we have implemented the New York Recommendation of Care (NY ROC) Program for workplace injuries. If an employee sustains an injury while at work, the employee must notify you immediately. You should follow your current procedure in reporting the incident. Please advise the employee that there is a posting of providers that we recommend he/she go to for medical treatment. You may also visit www.talispoint.com/cvty/twrgrp.com to locate network providers in your area. Please be aware that the use of these providers is purely voluntary and a full list of authorized health care providers is available from the New York Workers’ Compensation Board. An injured employee may select or change their provider at any time without risking their medical or indemnity benefits. Also, at the time of injury ask the injured employee to sign the C-3.1 form acknowledging his/her understanding that use of the recommended providers is voluntary. Please provide the injured employee a copy of the signed form and retain the original signed copy for the employee’s file to be maintained at the worksite. Should the employee elect not to sign the C-3.1, place a copy of the unsigned consent form in their employee personnel file and document that the C-3.1 form was offered. Completion of the form shall not hinder an injured employee in securing timely, appropriate treatment for a work related injury. This is a voluntary program. Do not hesitate to telephone the Tower Group Claim Department with any questions you might have about obtaining medical care at (866) 856-5522. Sincerely, Melville Claims Team Tower Group Companies
NY Recommendation of Care Program Employer Responsibilities Employee communications or postings MUST clearly indicate, in the form of a disclaimer, that: Use of the specified network or providers is strictly voluntary; The injured worker may obtain a list of authorized health care providers from the Workers’ Compensation Board or online at www.talispoint.com/cvty/twrgrp; and The injured worker may choose or change their provider at will without jeopardizing medical or indemnity benefits. Employee communications or posted information could include: Providing a network directory to the employee for review/choice of treating provider, at the employer site; Posting network’s toll-free number; Posting of a panel of recommended providers; Distributing or posting a letter of introduction to the employee explaining the employer’s/carrier’s participation in the recommendation of care program. Administer Employee Consent Form: C-3.1 Form Ensure C-3.1 form is delivered to the injured worker at the time of injury or immediately following the injury. If by mail must be sent certified with return receipt requested. Document receipt of the C-3.1 form. If injured worker fails to return C-3.1 form, follow-up must be made. Clearly document all attempts to obtain the signed C-3.1 form (letters, phone call, etc.). The State of New York stipulates the signed original be maintained in injured worker’s personnel file. Completion of the C-3.1 must not hinder any injured employee in securing timely, appropriate treatment for a work-related injury/illness.
State of New York WORKERS' COMPENSATION BOARD
Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider Injured Employee's Name
Injured Employee's Social Security No.
Date of Accident
Employer's Name and Address
To the Injured Employee: For the treatment of your work-related injury or illness, you may choose any physician, podiatrist, chiropractor, or psychologist (upon referral from an authorized physician) who is Workers' Compensation Board authorized and who is accepting workers' compensation patients. While you may choose to utilize a network or provider which is recommended by your employer or its workers' compensation insurance carrier or to permit your employer to select a provider on your behalf, you may, at any time, change your health care provider without jeopardizing your workers' compensation claim for benefits. _________________________ __________ _____________________________ _________ Signature of Injured Employee Date Signature of Witness Date
Please note: It is not necessary for you to sign this consent form if your employer is (i) participating in a certified preferred provider organization (PPO) under Article 10-A of the Workers' Compensation Law, or (ii) participating in the alternative dispute resolution (ADR) pilot program under section 25(2-c) of the Workers' Compensation Law. In accordance with these statutory programs, except in emergency situations, you must obtain at least initial treatment for any workers' compensation injury or illness from the certified network(s) or providers designated by your employer.
To the Employer: The employer shall provide the above-named injured employee with a copy of this signed form and shall maintain the original form in the employer's records where it may be inspected by the Workers' Compensation Board at any time. This form shall not be submitted to the Workers' Compensation Board nor shall it be executed prior to the occurrence of this employee's work-related injury or illness. The Workers' Compensation Board employs and serves people with disabilities without discrimination.
C-3.1 (1-04)
www.wcb.state.ny.us
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE IN EMPLOYMENT STATUS RESULTING FROM INJURY This report is to be filed directly with the Chair, Workers' Compensation Board at the address shown on reverse side as soon as the employment status of an injured employee, as reported on Form C-2 or EC-2, or on a previous Form C-11 or EC-11, is changed. Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and increase or reduction of wages. A copy should also be sent to your insurance carrier. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. Case Number
3. Carrier Code
5. Claimant's Soc. Sec. No.
4. Date of Injury
2. Carrier Case Number
Name
Address to which notice should be sent (Give Number and Street, City, State, and Zip Code)
6. Injured Person
Apt.No.
7. Employer
8. Carrier
9. Date of most recent Employer's Report filed: (check "x" & give date filed)
C-2/EC-2_____________
10. Date of first full day employee lost from work: ___________________________
C-11/EC-11_____________
11. Nature of Injury:_________________________
__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 12. Date employee returned to work: __________________________________ 13. (a) Change of employment status resulting from above injury: Employment Status
Hours per Day
Days per Week
Earnings
Occupation
Prior To Injury Changed To
(b) Date of this change in employment status:____________________ (c) Remarks:____________________________________ ______________________________________________________________________________________________________ 14. Loss of time resulting from above injury since first return to work: From (Mo., Day, Year)
Reason
TO (Mo., Day, Year)
15. Is injured person still under physician's care?______ If yes, give name of physician:______________________________________ 16. Has injured person died?_______ If yes, give date of death:_____________________________ Name and address of nearest known relative:_____________________________________________________________________ Date of this Report_________________ Tel. No.______________________Firm Name___________________________________ Prepared By:_________________________________________ Official Title____________________________________________
C-11 (1-11)
C-11
C-11
C-11
C-11
STATE OF NEW YORK
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
WORKERS' COMPENSATION BOARD EMPLOYER'S STATEMENT OF WAGE EARNINGS (Preceding the Date of Accident) 1.
2.
W.C.B. CASE NO.
CARRIER'S CASE NO.
3.
4.
DATE OF ACCIDENT
EMPLOYEE'S SOC. SEC. NO.
ADDRESS
NAME
APT.
5. INJURED EMPLOYEE
6.
CARRIER
7.
EMPLOYER
8. Employee was employed at a ..........................................wage for a .......................day week. (hourly, daily, weekly or monthly)
(5, 6 or 7)
9. Was injured employee in military service during the 52 week period immediately preceding the date of accident?.............................. If "Yes", give date of discharge.......................................................................................................................................................... INSTRUCTIONS: 1. Give gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. 2. If injured employee has not worked at the same work for a year or a substantial part thereof (234 days for a 5 day week, 270 days for a 6 day week) give the weekly gross earning of another employee of the same class who has worked for a year or a substantial part thereof immediately preceding the date of accident.
10. The following is a schedule of gross wage earnings for the 52 weeks immediately preceding the date of accident of: (Check "X" one) The injured employee named in item 5 above. .............................................................................................................................................................................................. (Name of employee of the same class)
Week No.
Week Ending Date
Days Worked
Gross amount paid including overtime
Week No.
(Address)
Week Ending Date
Days Worked
Gross amount paid including overtime
Week No.
1
19
37
2
20
38
3
21
39
4
22
40
5
23
41
6
24
42
7
25
43
8
26
44
9
27
45
10
28
46
11
29
47
12
30
48
13
31
49
14
32
50
15
33
51
16
34
52
17
35
18
36
Week Ending Date
Days Worked
Gross amount paid including overtime
TOTAL
11. Was this employee given free rent, lodging, board, tips, bonus or other allowance in addition to the above earnings?........................... If "Yes", state weekly value thereof $............................. Describe:........................................................................................................ 12. Was there any wage adjustment made affecting the 52 week period scheduled above? If "Yes", explain:............................................. .................................................................................................................................................................................................................... I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT: Date................................................................................
Prepared by.............................................................................................
Tel. No. & Ext. ................................................................
Official Title..............................................................................................
C-240 (1-11)
INSTRUCTIONS TO THE EMPLOYERS Reports should be sent directly to the district offices at these addresses:
ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, W arren, W ashington.
BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins.
BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara.
ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, W ayne, W yoming, Yates.
SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence.
DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland,Suffolk, W estchester.
Statewide Fax Line: 877-533-0337
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-240 (1-11) Reverse
INSTRUCTIONS TO THE EMPLOYERS Reports should be sent directly to the district offices at these addresses:
ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester.
Statewide Fax Line: 877-533-0337
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-11 (1-11) Reverse
www.wcb.state.ny.us
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:
¿Necesitas ayuda en español? Llame al 1.866.599.5426
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
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:
Questions? Call 1.866.599.5426
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.
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.
Prescription Card CARRIER / TPA
¿Necesitas ayuda en español? Llame al 1.866.599.5426
EMPLOYER
Tmesys is the designated PBM for this patient. INJURED WORKER NAME
SOCIAL SECURITY NUMBER
Tmesys Pharmacy Help Desk 800.964.2531
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.
RxBin RxPCN
NDC Envoy 004261 or 002538 CAL or Envoy Acct. #
(To create a card for your wallet, cut along outer line and fold in half.)
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.
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
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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.
¿Preguntas? Llame al 1.866.599.5426
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.
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.
Prescription Card PORTADORA
Need help in English? Call 1.866.599.5426
EMPLEADOR
Tmesys is the designated PBM for this patient. NOMBRE DEL TRABAJADOR LESIONADO
NUMERO DE SEGURO SOCIAL
Tmesys Pharmacy Help Desk 800.964.2531
FECHA DE LA LESIÓN
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.
RxBin RxPCN
NDC Envoy 004261 or 002538 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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Administered By:
