SCHOOL POOL FOR EXCESS LIABILITY LIMITS
JOINT INSURANCE FUND
ACCASBOJIF, BCIPJIF, & GCSSDJIF
I F
S
L
L
E
P
ACCASBO BCIP GCSSD SEJIFC
LAIM
C
OORDINATOR
MANUAL
REVISED OCTOBER 2013
Section 14
SAMPLE
COMPLETED
CLAIM FORM-
WORKERS’
COMPENSATION
CLAIM EXAMPLE
Workers’ Compensation Accident
Member District Name:
ABC District
Date of Accident:
January 26, 2013
Description of Accident:
A football coach was teaching his
players how to perform a “bull rush”
by demonstrating the technique.
Unfortunately, the student lineman
was real big and the coach’s knee
gave way before the student did.
Consequence:
The coach tore the medial meniscus in
his damaged right knee requiring an
extensive surgery and putting the
coach out of commission for eight
weeks.
TO: QualCare, Inc. 100 Decadon Drive
Egg Harbor Township, NJ 08234
PHONE: 888-342-3839
FAX NUMBER: 609-927-0991
(Only for Workers' Compensation ) NUMBER OF PAGES SENT (#)
FROM: (Name of Claim Coordinator) (Name of District)
This is a: ____ New Claim
____ Additional Information on Existing Claim
(Claim Number, if known)
Date of Loss: ______________________________
Claimant Name: ____________________________
Always complete this form whenever transmitting Workers' Compensation Claims to QualCare
QUALCARE, INC.
F:\DATA\Risk\WINWORD\School Pool for Excess Liability Limits\Claim Coord Manual Rev 07 12\Section 9-Forms\Employee Authorization for Medical Attention.doc
School District
Employee’s Authorization for Medical Attention
____________________________________ , is authorized to leave the premises of the Board of Education to seek medical attention for an injury or illness reported to the first undersigned at _________ a.m. p.m., on / / .
The Board of Education is not in a position to determine whether or not the injury is compensable within the meaning of the New Jersey Worker’s Compensation Law. However, it is the intent of the Board of Education to provide its employees and authorized treating physicians with an answer to the question of compensability as soon as possible. Therefore, the employee receiving this form is required to have the treating medical provider complete this form at the time of his/her initial treatment.
First Undersigned: ______________________________ Date: _________________ (Claim Coordinator, Principal, Nurse or Supervisor)
Second Undersigned: ___________________________ Date: _________________
(Injured Employee)
Initial Complaint: _________________________________________________________ ________________________________________________________
Instructions to Medical Provider
Please complete and sign this form, then fax it and the Workers’ Compensation Treatment And Status Report to our Claim Administrator and to the Board of Education at the addresses and facsimile numbers shown below. Your prompt attention to this request will help speed up all processes resulting in a more efficient delivery of services to our employee and faster processing of claim activity.
Signed: ______________________________________ Date: _________________
(Medical Provider)
Fax Completed Form To:
Qual-Lynx School District Name and Address ACCASBOJIF/BCIPJIF/GCSSDJIF Claims 100 Decadon Drive Egg Harbor Twp., NJ 08234 Phone: 609-653-8400 Fax: 609-926-9270 (General) 609-601-3196 (Worker’s Comp)
Copy To District Claim Coordinator Copy To Medical Provider
One Hurt Guy
1:30 1 26 2013
Splint N. Time 1/26/2013
One Hurt Guy 1/26/2013
I hurt my knee whowing my players how to bull rush
1/26/2013
ABC School District 123 Anywhere Strret Anywhere, NJ 08888
CLAIM TRANSMITTAL FORM
TO: Qual-Lynx 100 Decadon Drive Egg Harbor Twp., NJ 08234 PHONE: 609-653-8400 FAX NUMBER:(Only for Workers’ Compensation)
609-601-3196 FAX NUMBER: (All other claim reports
and information transmitted)
609-926-9270 NUMBER OF PAGES SENT (#)
FROM: (Name of Claim Coordinator) (Name of District)
PHONE: (Telephone number)
FAX: (FAX number)
DATE:
FORM OF TRANSMISSION Fax
(check which applies) Telephone
This is a:
New Claim Additional Information on Existing Claim (Claim Number, if known)
Date of Loss:
(Date of Incident)
Claimant Name:
(Name of claimant or district)
Claim Type:
Property/Theft/Employee Dishonesty Liability or Automobile Physical Damage
Workers’ Compensation (employee injured on the job)
Department: (please check the appropriate box)
Administration
Facilities/Maintenance/Custodial Food Service
Instructional Staff Transportation
Always complete this form whenever transmitting claim information to Qual-Lynx
2013 1 Agrate D. Esektir 555-1234 555-1236 9/26/98
One Hurtin Guy
f:/d/r/w/gcssdjif/forming/98-99/clmcoord/clmtrns.doc 2
Check All Claim Forms Which Are Attached
Incident Reporting Form Worker’s Compensation Claim Forms Property Loss\Claim Form Liability Loss Claim Form
Other relevant information, please explain:
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Tort Notice Information - See Below.
Tort Notice Section
(Third Party Liability Claims) Initial letter and form sent to claimant (third party) with copies to the Fund’s Claim Administrator and Attorney.
Completed form received, date stamped, copied and sent to the Fund’s Claim Administrator and Attorney.
ABC School District
123 Anywhere Strret
Anywhere, NJ 08888
CLAIM TRANSMITTAL FORM
TO: Qual-Lynx 100 Decadon Drive Egg Harbor Twp., NJ 08234 PHONE: 609-653-8400 FAX NUMBER:(Only for Workers’ Compensation)
609-601-3196 FAX NUMBER: (All other claim reports
and information transmitted)
609-926-9270 NUMBER OF PAGES SENT (#)
FROM: (Name of Claim Coordinator) (Name of District)
PHONE: (Telephone number)
FAX: (FAX number)
DATE:
FORM OF TRANSMISSION Fax
(check which applies) Telephone
This is a:
New Claim Additional Information on Existing Claim (Claim Number, if known)
Date of Loss:
(Date of Incident)
Claimant Name:
(Name of claimant or district)
Claim Type:
Property/Theft/Employee Dishonesty Liability or Automobile Physical Damage
Workers’ Compensation (employee injured on the job)
Department: (please check the appropriate box)
Administration
Facilities/Maintenance/Custodial Food Service
Instructional Staff Transportation
Always complete this form whenever transmitting claim information to Qual-Lynx
2013 1 Agrate D. Esektir 555-1234 555-1236 ■ 9/26/98
One Hurtin Guy
■
f:/d/r/w/gcssdjif/forming/98-99/clmcoord/clmtrns.doc 2
Check All Claim Forms Which Are Attached
Incident Reporting Form Worker’s Compensation Claim Forms
Property Loss\Claim Form Liability Loss Claim Form
Other relevant information, please explain:
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Tort Notice Information - See Below.
Tort Notice Section
(Third Party Liability Claims) Initial letter and form sent to claimant (third party) with copies to the Fund’s Claim Administrator and Attorney.
Completed form received, date stamped, copied and sent to the Fund’s Claim Administrator and Attorney.
ABC School District