SCHOOL POOL FOR EXCESS LIABILITY LIMITS

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SCHOOL POOL FOR EXCESS LIABILITY LIMITS

JOINT INSURANCE FUND

ACCASBOJIF, BCIPJIF, & GCSSDJIF

I F

S

L

L

E

P

ACCASBO BCIP GCSSD SEJIF

C

LAIM

C

OORDINATOR

MANUAL

REVISED OCTOBER 2013

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Section 14

SAMPLE

COMPLETED

CLAIM FORM-

WORKERS’

COMPENSATION

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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.

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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.

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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

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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

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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

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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

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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

Figure

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