RE: Workers Compensation Claims Kit. Dear Policyholder:

15 

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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 South Carolina

state-mandated Forms and 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 Maitland, Florida. 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 South Carolina workers compensation process.

The following state forms are included in your claims kit packet:

1.

South Carolina First Report of Injury or Illness- Form 12A- (rev 04/2006)- This form

must be completed by the employer when an employee reports and injury or accident.

Please complete the form with as much available information as possible.

2.

South Carolina Temporary Compensation Report – Form 15- (rev 10/2004)- The

insurance company must complete and file this form with the South Carolina Workers

Compensation Commission within ten (10) days after compensation begins or is

terminated. The insurance company must serve Form 15 on the claimant when

compensation begins.

3.

South Carolina Supplemental Report of Varying Temporary Partial Payments Form

15S- (rev 03/1997)- Supplemental payments shall be reported on a Form 15S, which is to

be filed with the document stopping that period of temporary partial compensation.

4.

South Carolina Receipt of Compensation- Form 17 (rev 03/1997)- This form must be

filed with the South Carolina Workers Compensation Commission no later than thirty-one

(31) days from the date the claimant returned to work in order to terminate temporary

compensation after the first 150 days after employer’s notice of injury. Within the

150-day period, obtain form to document that claimant agrees he or she is able to return to

work.

5.

South Carolina Form 20- Statement of Earning of Injured Employee- This form is

required in any admitted case to initiate TTD. If the case is denied, this must be done

within thirty (30) days from the hearing request. This form is mandatory on all claims

involving lost time or permanent benefits.

6.

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

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H

OW TO FILE A WORK INJURY OR

I

LLNESS

C

LAIM

Workers compensation claims can be reported in several different ways, you can:

Complete and submit the

South Carolina First Report of Injury or Illness- Form 12A- (rev

04/2006)-

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.

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S.C. WORKERS’ COMPENSATION COMMISSION – FIRST REPORT OF INJURY OR ILLNESS CARRIER/ADMINISTRATOR CLAIM

NUMBER

OSHA LOG NUMBER

REPORT PURPOSE CODE

JURISDICTION

JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER

EMPLOYER (NAME & ADDRESS INCL ZIP)

LOCATION #

INDUSTRY CODE

EMPLOYER FEIN

EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)

PHONE #

CARRIER/CLAIMS ADMINISTRATOR POLICY PERIOD TO

CARRIER (NAME, ADDRESS, & PHONE #)

CHECK IF APPROPRIATE

SELF INSURANCE

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)

CARRIER FEIN

POLICY/SELF-INSURED NUMBER

ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER

EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

DATE HIRED

STATE OF HIRE

OCCUPATION/JOB TITLE

EMPLOYMENT STATUS

ADDRESS (INCL ZIP)

SEX Male Female Unknown PHONE

# OF DEPENDENTS

MARITAL STATUS Unmarried/Single/Divorced Married Separated

Unknown NCCI CLASS CODE

DAY MONTH FULL PAY FOR DAY OF INJURY? YES NO RATE

PER:

WEEK OTHER:

DAYS WORKED/WEEK

DID SALARY CONTINUE? YES NO OCCURRENCE/TREATMENT AM TIME OF OCCURRENCE

AM TIME EMPLOYEE BEGAN WORK

PM DATE OF INJURY/ILLNESS

( ) CANNOT BE DETERMINED PM

LAST WORK DATE

DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN

CONTACT NAME/PHONE NUMBER

TYPE OF INJURY/ILLNESS

PART OF BODY AFFECTED

DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S PREMISES?

YES NO

TYPE OF INJURY/ILLNESS CODE

PART OF BODY AFFECTED CODE

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL

CAUSE OF INJURY CODE

NO DATE RETURN(ED) TO WORK

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

WERE THEY USED?

YES YES NO INITIAL TREATMENT 0 NO MEDICAL TREATMENT 1 MINOR: BY EMPLOYER 2 MINOR CLINIC/HOSP 3 EMERGENCY CARE 4 HOSPITALIZED > 24 HOURS PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)

5 FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

OTHER

WITNESSES (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED

DATE PREPARED

PREPARER’S NAME & TITLE

PHONE NUMBER

WCC FORM 12A

REV. DATE 04/06

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South Carolina Workers’ Compensation Commission 1612 Marion St. P.O. BOX 1715 Columbia, SC 29202-1715 803-737-5722

EMPLOYER’S INSTRUCTIONS

DO NOT ENTER DATA IN SHADED FIELDS

DATES:

Enter all dates in MM/DD/YYYY format.

INDUSTRY CODE:

This is the code which represents the nature of the employer’s business, which is contained in the Standard

Industrial Classification Manual or the North American Industry Classification System, published by the Federal

Office of Management and Budget.

CARRIER:

The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of

the employer of the claimant.

CLAIMS ADMINISTRATOR:

Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering

the claim.

AGENT NAME & CODE NUMBER:

Enter the name of your insurance agent and his/her code number if known. This information can be found on

your insurance policy.

OCCUPATION/JOB TITLE:

This is the primary occupation of the claimant at the time of the accident or exposure.

EMPLOYMENT STATUS:

Indicate the employee’s work status. The valid choices are:

Full-Time On Strike Unknown Volunteer

Part-Time Disabled Apprenticeship Full-Time Seasonal

Not Employed Retired Apprenticeship Part-Time Piece Worker

DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupation injury or disease or as

otherwise designated by statute.

CONTACT NAME/PHONE NUMBER:

Enter the name of the individual at the employer’s premises to be contacted for additional information.

TYPE OF INJURY/ILLNESS:

Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm).

PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(e.g. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)

If the accident or illness exposure did not occur on the employer’s premises, enter address or location.

Be specific.

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South Carolina Workers’ Compensation Commission

1612 Marion St. P.O. BOX 1715 Columbia, SC 29202-1715

803-737-5722

EMPLOYER’S INSTRUCTIONS – cont’d

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS

EXPOSURE OCCURRED:

(e.g. Acetylene cutting torch, metal plate)

List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating

when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush,

and paint.

Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed

do not have to be directly involved in the employee’s injury or illness.

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE

OCCURRED:

(e.g. Cutting metal plate for flooring)

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,

such as sanding ceiling woodwork in preparation for painting.

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

Describe the work process the employee was engaged in when the accident or illness exposure occurred, such

as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (e.g.

walking along a hallway).

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF

EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE

THE EMPLOYEE ILL:

(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against

the hot metal.)

Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and

name any objects or substance that directly injured the employee or made the employee ill. For example:

Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The

worker’s right wrist was broken in the fall.

DATE RETURN(ED) TO WORK:

Enter the date following to most recent disability period on which the employee returned to work.

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South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5723 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Address:

City: State: Zip:

Home Phone: ( ) - Work Phone: ( ) -

Employer's Name:

Address:

City: State: Zip:

Insurance Carrier:

Preparer’s Name: Law Firm: Preparer’s Phone #: ( ) -

Date of injury: (m/d/yyyy) Date of Notice to Employer of Injury: (m/d/yyyy)

I. Payment of Temporary Compensation Check one: Initial period Additional period Corrected compensation rate

(choose A, B, or C)

A. Temporary Total at the compensation rate of $ per week. For this period of disability, disability began on (m/d /yyyy) and the date of first payment was (m/d/yyyy).

B. Temporary Partial at the compensation rate of $ per week. Note: When the Temporary Partial compensation rate will vary, report the first payment here. Supplement this report throughout the period of Temporary Partial compensation by filing a Form 15S with the Form 18, which shall be filed six months after the date of injury and each six months thereafter until the file is closed.

For this period of disability, disability began on (m/d/yyyy), and the date of first payment was (m/d/yyyy).

Calculation of Temporary Partial Rate: Average weekly wage before injury $

ߌ Current weekly wage________________ $

= Difference in wages before injury and now $ 0.00

x .6667_____________________________ $ 0.00

Temporary Partial Compensation Rate $ 0.00 C. Salary in lieu of Temporary Total Partial (choose one) compensation in the amount of $ per week. For this period of disability, disability began on (m/d/yyyy) and the date of first payment of salary in lieu of temporary compensation was (m/d/yyyy).

THIS SECTION MAY BE USED ONLY WITHIN 150 DAYS AFTER NOTICE TO EMPLOYER OF INJURY. ATTACH DOCUMENTATION AS TO THE REASON OF THE TERMINATION.

II. Termination of Temporary Compensation Temporary compensation payments were stopped on (m/d/yyyy) for the following reason:

Claimant has returned to work at least 15 days and no temporary partial compensation is due. Claimant agrees he/she is able to return to work and has signed a Form 17.

Based on a good faith investigation, the claim is denied. Reason for denial:

Claimant has been released to return to work without restrictions and employment has been offered.

Claimant has been released to work at limited duty and employer has provided limited duty work consistent with the terms upon which the Employee has been released.

Claimant has refused medical treatment, examination, or evaluation. Note: Benefits must be resumed if claimant accepts the treatment, examination, or evaluation. Additional report must be filed if compensation is resumed.

I certify that this form has been served on the claimant per R.67-211.

Signature of Claims Administrator Date (m/d/yyyy)

III. Notice to Injured Worker or Legal Representative when Temporary Compensation Has Been Stopped:

The employer’s representative may stop temporary compensation within 150 days of the date of notice of injury for the above reasons. However, if you believe that the temporary compensation should not have been stopped, you may request a hearing by signing below and returning this form to SCWCC Judicial Department at the address at the top of this form. A hearing will be held within 60 days of receipt of your request to determine if temporary compensation has been properly terminated.

MY SIGNATURE BELOW INDICATES THAT I DO NOT AGREE WITH THE TERMINATION OF TEMPORARY COMPENSATION. I REQUEST A HEARING TO DETERMINE WHETHER I AM ENTITLED TO FURTHER TEMPORARY COMPENSATION PAYMENTS.

Check one: Form 15(II) Has Has not been received.

Signature of Claimant or Legal Representative Date (m/d/yyyy)

Employer’s representative must complete and file Form 15 with Claims Department within ten days after compensation begins or is terminated. Employer’s representative must serve theForm 15 on the claimant when compensation begins per R.67-211. Employer’s representative must prepare and serve Form 20 within thirty days of beginning compensation per R.67-1603. Employer’s representative must serve per R.67-211 two copies of the Form 15 on claimant immediately on termination of compensation with documentation attached as to the reason for the termination. Injured worker may contest termination of compensation by completing section III of the Form 15 and filing it with Judicial Department.

WCC Form # 15

Rev. 10/04

15

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South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5723 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Address:

City: State: Zip:

Home Phone: ( ) - Work Phone: ( ) -

Employer's Name:

Address:

City: State: Zip:

Insurance Carrier:

Preparer’s Name: Law Firm: Preparer’s Phone #: ( ) -

Date of injury:

(m/d/yyyy)

Supplemental Report of Varying Temporary Partial Payments

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

From through , Claimant was paid $ per week as temporary partial compensation. The weekly wage before the injury was $ . The weekly

wage for this period was $ .

In an ongoing period of temporary partial, when the compensation rate varies from week to week, the employer’s representative shall report the first payment on a Form 15 according to R.67-503. Supplemental payments shall be reported on a Form 15S, to be filed with the document stopping that period of temporary partial compensation or with the Form 18, which shall be filed six months after the date of injury and each six months thereafter until the file is closed. R.67-503.

WCC Form # 15S

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South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5723 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Address:

City: State: Zip:

Home Phone: ( ) - Work Phone: ( ) -

Employer's Name:

Address:

City: State: Zip:

Insurance Carrier:

Preparer’s Name: Law Firm: Preparer’s Phone #: ( ) -

Date of injury: (m/d/yyy)

1.

Temporary Compensation Paid:

Number of Weeks

From

To

Amount

$

$

$

$

$

2. The claimant returned to work on

With restrictions but at a salary not less than before the injury.

(m/d/yyyy)

Without restrictions.

3.

The claimant agrees he or she was able to return to work on

.

(m/d/yyyy)

I agree that I was disabled for the period(s) indicated and I was paid compensation as shown above.

I UNDERSTAND THAT

MY WEEKLY TEMPORARY COMPENSATION CHECKS WILL STOP; HOWEVER, I GIVE UP NO RIGHTS TO

COMPENSATION FOR FUTURE DISABILITY, FOR PERMANENT DISABILITY, DISFIGUREMENT OR MEDICAL CARE.

The effect of this form has been fully explained to me, and I have received a copy of it. I understand that I should not sign this

form until 15 days after I have returned to work or agree I was able to return to work.

Claimant’s Signature

Employer’s Representative Signature

(Check one)

Witness

Claimant’s Attorney

Date Agreement Signed

File this form with the Claims Department no later than 31 days from the date the claimant returned to work to terminate temporary

compensation after the first 150 days after employer’s notice of the injury according to R.67-505. Within the 150 period, obtain Form 17 to

document that claimant agrees he or she is able to return to work.

WCC Form # 17

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South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5723 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Address:

City: State: Zip:

Home Phone: ( ) - Work Phone: ( ) -

Preparer's Name:

Employer's Name:

Address:

City: State: Zip:

Insurance Carrier:

Preparer’s Phone #: ( ) -

Date of Injury:

month day year A. Total Wages Paid

1. Check Applicable Method:

Report of earnings of injured employee based on four completed quarters.

Report of earnings of injured employee who did not complete four quarters based on actual time worked.

Report of earnings of similar employee. Injured employee did not work sufficient time before alleged injury. Hire date: Report of earnings of injured employee based on alternative method because Form 20 results in a compensation rate that is not fair and just (attach documentation to show how average weekly wage and compensation rate were calculated).

2. List total wages paid as reported to the Employment Security Commission on the Employer Quarterly Contribution and Age Reports during the four quarters immediately preceding the quarter in which the injury occurred. Do not include the quarter during which the injury occurred.

Quarter Ending Date Total Wages Paid

1st $

2nd $

3rd $

4th $ Total Paid 2. $0.00

3. List total value of other allowances of any character made in lieu of wages during four quarters above. 3. $

4. Add lines 2 and 3. TOTAL WAGES PAID: 4. $0.00

5. List total number of weeks paid to employee during the four quarters immediately preceding the quarter in

which the injury occurred. 5.

B. Average Weekly Wage

6. To calculate average weekly wage, divide total wages (line 4) by total weeks paid (line 5).

AVERAGE WEEKLY WAGE: 6. $

C. Compensation Rate

7. The general rule for calculating the compensation rate is to multiply average weekly wage (line 6) by .6667. Estimate compensation rate by multiplying average weekly wage (line 6) by .6667. See part 8 below to

determine the actual compensation rate. 7. $0.00

8. The compensation rate is as follows (choose one):

When average weekly wage (line 6) is less than $75.00, the compensation rate is the average weekly wage. Enter average weekly wage on line 8.

When the estimated compensation rate (line 7) is less than $75.00 and average weekly wage (line 6) is more than $75.00, the compensation rate is $75.00. Enter $75.00 on line 8.

When the estimated compensation rate (line 7) is more than the maximum compensation rate for the year in which the injury occurred, enter the maximum compensation rate for the year in which the injury occurred on line 8.

Employee is within the exceptions listed in S.C. Code Ann. Section 42-7-65. List applicable exception here and enter appropriate compensation rate on line 8.

The calculated compensation rate (line 7) applies. Enter amount from line 7 on line 8.

WEEKLY COMPENSATION RATE: 8. $

Employer’s representative shall prepare a Form 20 and serve per R.67-211 a copy on the claimant within thirty days of beginning temporary compensation. See R.67-1603 when no temporary compensation is paid. NOTE: Average weekly wage represents average gross pay before taxes and other deductions. WHEN THE CLAIMANT DOES NOT AGREE WITH THE COMPENSATION RATE ON LINE 8, HE OR SHE SHOULD CONTACT THE EMPLOYER’S REPRESENTATIVE TO TRY TO REACH AN AGREEMENT AS TO THE COMPENSATION RATE. IF NO AGREEMENT CAN BE REACHED, THE CLAIMANT SHOULD CONTACT THE CLAIMS DEPARTMENT AT (803)737-5723.

WCC Form # 20

Rev. Date 3/97

20

STATEMENT OF EARNINGS OF INJURED EMPLOYEE

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W

ORKERS

C

OMPENSATION

I

NJURY

M

EDICAL

A

UTHORIZATION

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

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W

ORKERS

C

OMPENSATION

M

ANAGED

C

ARE

P

ROGRAMS

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.

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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,

high-quality 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.

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(To create a card for your wallet, cut along outer line and fold in half.)

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.

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.

CARRIER / TPA EMPLOYER

SOCIAL SECURITY NUMBER DATE OF INJURY

INJURED WORKER NAME

Prescription Card

NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. #

Tmesys Pharmacy

Help Desk 800.964.2531

First Fill

Temporary Pharmacy Card

Making it easy to get your workers’ compensation prescriptions filled.

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 . .

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.

Questions?

Call 1.866.599.5426

¿Necesitas ayuda en

español? Llame al

1.866.599.5426

(14)

(Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.)

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.

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.

PORTADORA EMPLEADOR

NUMERO DE SEGURO SOCIAL FECHA DE LA LESIÓN

NOMBRE DEL TRABAJADOR LESIONADO

Prescription Card

NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. #

Tmesys Pharmacy

Help Desk 800.964.2531

First Fill Temporary Pharmacy Card

En Primer Relleno Tarjeta Temporal de Farmacia

Hacerlo fácil de llenar sus recetas de la compensación del trabajador.

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 . .

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.

¿Preguntas? Llame al

1.866.599.5426

Need help in English?

(15)

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