ARCHDIOCESE OF ST. LOUIS

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Risk Management Manual Revised 01-11 1

01/11

ARCHDIOCESE

OF

ST. LOUIS

Risk Management Manual

The preservation of Archdiocesan assets, both people and property, is our main objective. This manual contains all information and forms needed to operate an efficient and cost effective Risk Management program.

This manual available from the Archdiocesan Website at www.archstl.org. Go to the Risk Management page. It may be found under the "Publications" listing.

Also, all of the forms contained in this manual may be found on the Risk Management page under the "Forms" listing. These forms are in a format that allows completion on your computer for printing and hard copy submission.

Thank you,

Bob Ryan

Director of Risk Management

Office of Risk Management 20 Archbishop May Drive St. Louis. MO 63119-5738 Phone: 314.792.7200 Fax: 314.792.7209

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01/11

INDEX

Pages I General Risk Management Contacts and Guidelines 3 - 6

II Reporting Claims 7 - 10

III Workers’ Compensation 11 - 25

IV General Liability 26 - 31

V Auto 32 - 37

VI Property 38 - 41

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01/11

I. General Risk Management

Contacts & Guidelines

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01/11

GENERAL RISK MANAGEMENT

GUIDELINES AND CONTACTS

For purposes of this manual, the term Parish/Agency includes all Parishes, Schools, Offices and Agencies of the Archdiocese of St. Louis.

WORKERS’ COMPENSATION:

When an injury occurs to an employee of a Parish or Agency, while in the course and scope of

employment and his/her assigned job duties, please follow the claim reporting procedures under Section II, Reporting of Claims (Page 7). (Volunteers are not covered in this program)

(For Workers’ Compensation Instruction Guidelines, see Section III, Pages 11-25)

GENERAL LIABILITY:

When an injury occurs to someone who is not an employee of a Parish or Agency, please follow the claim reporting procedures under Section II, Reporting of Claims (Page 7)

(For General Liability Instruction Guidelines, see Section IV, Pages 26-31)

AUTO:

When a Parish/Agency vehicle is involved in a motor vehicle accident resulting in personal injury or damage to a third-party vehicle, or to a Parish/Agency vehicle, please follow the claim reporting procedures under Section II, Reporting of Claims (Page 7).

(For Auto Instruction Guidelines, see Section V, Pages 32-37)

To add, delete or change vehicles registered in the program please see Vehicle Change Request (Page 37). Complete all information required on form and include a copy of the title or registered ownership.

PROPERTY:

When damage occurs to Parish/Agency property (building, contents or equipment), please follow the claim reporting procedures under Section II, Reporting of Claims (Page 7).

(For Property Instruction Guidelines, see Section VI, Pages 38-41)

To add, delete or change buildings or contents in the program please see Building Input Form (Page 41). Complete all information required on form.

RISK MANAGEMENT BEST PRACTICES

All locations are encouraged to implement Best Practices concerning processes that will reduce or eliminate the risk of any type of loss. The elimination or reduction of losses is most important in keeping our future insurance premiums as low as possible.

Best Practices include establishing sound Safety practices, the continuous maintenance of property and machinery, correcting known safety defects, adhering to Archdiocesan policies and procedures and, if a loss does occur, timely reporting the loss to our claim administrator, Gallagher Bassett Services, Inc. Historically, there have been a number of claims that have resulted from or made worse by the failure to adhere to Best Practices, or, in other words, because of Poor Practices.

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01/11 Some examples of Poor Practices affecting claims would be:

 Late reporting of Workers’ Compensation claims. (State law requires reporting all injuries to our claims administrator, Gallagher Bassett, within five days of knowledge of the injury).

 Money is stolen from an “off the books” account or resulting from the use of a rubber stamp or other methods of facsimile signatures which are practices that do not comply with the Financial Management Control Manual for Parishes.

 Injuries sustained because of a building or premises defect that should have been repaired.  Contents of building destroyed by rain leaking through a poorly maintained roof..

The following lists the insurance deductibles by line of coverage.

Please note that the Poor Practice deductible will be applied when the Poor Practice is deemed material to a loss.

St. Louis Archdiocesan Self-Insured Program

Priests, Parishes, Agencies and Schools Deductibles

Line of Coverage Best Practice Deductible Poor Practice Deductible* Examples of Poor Practices Auto, General Liability,

Workers’ Compensation

None $5,000 Late Reporting of Claim, Failure to Correct a Known Safety Hazard, All Unlawful Activities.

Auto Comprehensive and Collision

$500 $2,500 Late Reporting of Claim

Property Claim $2,500 $10,000 Late Reporting of Claim. Poor Maintenance of Damaged Building Boiler and Machinery $2,500 $10,000 Late Reporting of Claim, Poor

Maintenance of Boiler and Machinery Clergy Personal

Property

$200 $500 Late Reporting of Claim

Crime – Employee Dishonesty, Forgery, Fraud, Funds Transfer Fraud, Computer Fraud, Other Crime Claims

$10,000 $25,000 Late Reporting of Claim, Failure to Adhere to Process and Procedures Outlined in "Financial Management and Control Manual for Parishes", All Unlawful Activities

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DIRECTORY OF IMPORTANT RISK MANAGEMENT

TELEPHONE NUMBERS

Arthur J. Gallagher Risk Management Services. Inc. - 12444 Powerscourt Dr., Suite 500 St. Louis, MO 63131-3660

Sandy Gross (314.800.2269 or 1.800.877.8218 Fax: 1.866.201.3567) for:

 Certificates of Insurance and specific information on coverages and deductibles  To request cards certifying coverage in our vehicle program

 General Information or Requests

 Workers’ Compensation Treatment Authorization Forms  Risk Management Manuals

Craig Parres (314.800.2243 or 1.800.877.8218) for:  Boiler and Machinery Inspection Questions  Coverage Questions

 Questions pertaining to the rental of autos  Problems or special needs

Alan Schmidt (314.800.2255 or 1.800.877,8218) for:

 Safety inspections and questions regarding safety issues

Gallagher Bassett Services, Inc. – 1630 Des Peres Rd., Suite 500 St. Louis, MO 63131-1849  Worker’s Compensation 314.800.0253 – Valeri Maki

 Worker’s Compensation Supervisor 314.800.0214 – Dennis Bini

 Property, Liability & Auto 314.800.0257 – Robert Granquist, Jr.  Property, Liability & Auto 314.800.0230 – Gary Clifton

 Property, Liability & Auto 314.800.0254 – Kim Stoff  Property, Liability & Auto 314.800.0283 – Josh Bohrer  Property, Liability & Auto 314.800.0255 – Sean Muldoon

 Claim Manager 314.800.0227 – Jeff Voege

 Fax Number 1.866.947.2227

If these individuals are unavailable in an emergency, press 0 and ask the operator to assist in obtaining someone from the department to take your claim report from the Archdiocese of St. Louis (during office hours). For after hours emergency reporting, call 1.800.428.5428 and your call will be re-directed to an adjuster.

Office of Risk Management 20 Archbishop May Drive St. Louis, MO 63119-5738 Phone: 314.792.7200

Fax: 314.792.7209

 Changes in Pastors, or addresses;

also, questions on bills: 314.792.7201 Fred Hummel fhummel@archstl.org  Vehicle & Property changes,

problems or special needs: 314.792.7203 Bob Ryan rryan@archstl.org  Written communication is preferred. Please call only when necessary.

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II.

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Methods of Reporting Claims

1) Toll-free Phone Call

2) Internet

3) Computer Completion

4) Manual Reporting

Workers’ Compensation, General Liability, Auto and Property claims may be reported by means of 1) a Toll-free phone call, 2) use of the Internet, 3) completing the form on your computer, print it and submit hard copy or 4) by manually completing the appropriate claim form.

1) Telereporting – To report a claim by telephone, please see the instructions on Page 9.

2) Internet – To report claims by using the Internet, please complete the “Request for Internet Security to Report Claims” form found on Page 10 and submit the information to Gallagher Bassett. After the submitted information is processed, you will receive instructions for Internet reporting.

3) Computer Completion – To report using your computer you need access to the internet. Go to the Archdiocesan Website, www.archstl.org. Next access the Risk Management page and go to the "Forms" listing. You may download and save the forms to your computer or you may access them each time from the internet. When you access the forms, they will open in Adobe Acrobat Reader. You can then complete the fields on the form. When you have checked the information that you entered, you may then print the form on your printer. The form may then be either mailed or faxed.

4) Manual Claim Reporting – To manually report claims, please complete the appropriate form found in the specific claim category: Workers’ Compensation (Pages 18 & 19), General Liability (Page 31), Auto (Pages 34 & 35), or Property (Page 40). Note - Forms that may be completed using your computer may be found on the Risk Management page of the Archdiocesan website.

Completed Forms Should Be Sent Directly To:

Gallagher Bassett Services, Inc. 1630 Des Peres Road, Suite 200

St. Louis, Mo. 63131-1849 Fax: 1.866.947.2227

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01/11

ARCHDIOCESE OF ST. LOUIS – 000292

Toll-free Claims Reporting Quick Reference Sheet

For Insurance Claims

1.877.263.9897

To report your

Workers’ Compensation

claims quickly and efficiently, please have the following information ready when you call your toll-free claims reporting services. This is a general listing for your quick reference. Thank you for your prompt reporting!

CLAIMANT INFORMATION  Employee name  Social security number

 Address and home phone number  Spouse’s name

 Number of dependents  Date of hire

 Gross pay per week ACCIDENT INFORMATION

 Exact date and time of injury

 Exact location or site code where injury occurred

 Specific description of injury (i.e., employee slipped and fell on wet floor in warehouse)  Safeguards or safety equipment provided to prevent injuries (where applicable)

 Name and address of claimant’s physician  Name and address of hospital

To report your

Liability, Auto and Property

claims quickly and efficiently, please have the following information ready when you call your toll-free claims reporting service. This is a general listing for your quick reference. Additional information may be requested. Thank you for your prompt reporting!

CLAIMANT INFORMATION  Claimant Information  Claimant Name

 Claimant address and phone number LOSS INFORMATION

 Exact date and time of injury or damage

 Exact location where injury or damage occurred  Specific description of injury or damage

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Risk Management Manual Revised 01-11.doc ₁₀

01/11

REQUEST FOR INTERNET SECURITY

TO REPORT CLAIMS

Please complete a separate form for each person who will be reporting claims

through the Internet.

Parish/Agency Information

Parish or Agency Name:

___________________________________

Address:

___________________________________

City, State, and Zip Code:

___________________________________

Risk Management Location Number or Numbers: __________________

(Note-Since security is determined by location, if you are unsure about

your location number/s please contact the Office of Risk Management.)

Individual Requesting Access

Name:

___________________________________

Email Address:

___________________________________

After you have completed this form, send it to:

Office of Risk Management

20 Archbishop May Dr.

St. Louis, MO 63119-5738

After the above information is processed, you will receive instructions from

Gallagher Bassett Services, Inc. for Internet reporting.

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01/11

III.

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01/11

WORKERS' COMPENSATION REPORT

The Archdiocese of St. Louis entered into agreements with various locations that provide medical services at negotiated prices. These providers specialize in the treatment of Workers’ Compensation injuries and will assure that Archdiocesan employees continue to receive quality care. You should use the pre-established Archdiocesan network list.

The Division of Workers’ Compensation allows any employer in the State of Missouri to direct the medical treatment of an employee injured on the job. Therefore it is imperative that you utilize ONLY the Archdiocesan provider list to ensure proper medical care for a work related injury. If this procedure is not followed, payment of bills may be denied by the Archdiocese. In that event, either the

parish/agency or the injured employee would be responsible for payment. If specialized care is required or a provider is not within your area, contact Gallagher Bassett Services Workers’ Compensation

Specialist (See Page 6) for referrals.

When using any of the providers from the approved Archdiocesan list, you must provide the injured employee with the treatment authorization form (Gold form on Page 25; NOTE – This form may not be reproduced, please contact Arthur J. Gallagher Risk Management Services, Inc. for additional copies). If an employee requires more than one treatment, physical therapy or referral to a specialist, these locations will be contacting Gallagher Bassett Services directly to make arrangements. Should you be contacted by one of the medical facilities asking for authorization for additional treatment or referral to a specialist, please refer the person to Gallagher Bassett Services, Inc. for a Workers’ Compensation Specialist (See Page 6).

Select a medical provider from the list below and enter in “Physician/ Facility” space on Workers’ Compensation Treatment Authorization form (Gold page 25). Fill out this information and the parish/agency information in advance. Make these completed forms readily available in case an

emergency. Should an emergency arise, time may be critical. NOTE - Facilities have been arranged in Zipcode order to provide easy access to locations closest to you. These facilities are designated for treatment of employee (workers' compensation) injuries. We have listed Medical Centers and Hospitals at the end of the Treatment Facilities. Medical Centers and Hospitals should be only used for "after hours" injuries or extreme emergencies.

REFERRAL FOR MEDICAL CARE

1. Complete the Archdiocese of St. Louis Workers' Compensation Treatment Authorization form. 2. Designate one of the pre-selected locations, insert its name on the Treatment Authorization form

(if you have not already done so), and give it to the employee. Direct the employee to the OCCUPATIONAL HEALTH AND MEDICINE DEPARTMENT, The Emergency Room should be used only for critical medical emergencies.

3. Send a copy of the Treatment Authorization form to Gallagher Bassett with the Report of Injury. 4. The Workers' Compensation Treatment Authorization form may not be duplicated.

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01/11 PRESELECTED ARCHDIOCESAN PPO NETWORK FACILITIES FOR

WORKERS’ COMPENSATION INJURIES

63010 63077

St Anthony's Urgent Care 636.717.6700 St. Clair Clinic 636.629.7467

3619 Richardson Square Dr 875 N Commercial Ave

Arnold, MO 63010 St. Clair, MO 63077

63011 63090

St Luke's Urgent Care 636.230.8644 St John's Mercy Corp Health 636.239.8844

233 Clarkson Rd 1701 Heritage Hill Dr

Ellisville, MO 63011 Washington, MO 63090

63017 63104

St John's Mercy Corp Health 314.579.9487 Concentra Medical Center 314.421.2557 224 S Woods Mill Rd - 360 South 1617 S Third St

Chesterfield, MO 63017 Saint Louis, MO 63104

63026 63110

Concentra Medical Center 636.349.6850 Barnescare 314.747.5800

128 Matrix Commons 5000 Manchester Ave

Fenton, MO 63026 Saint Louis, MO 63110

Fenton Urgent Care 636.326.6100 63122

714 Gravois Rd St Luke's Urgent Care 314.965.6871

Fenton, MO 63026 455 S Kirkwood Rd

Saint Louis, MO 63122 St Luke's Urgent Care 636.343.5223

508 Old Smizer Mill Rd Big Bend Urgent Care 314.543.5970

Fenton, MO 63026 10296 Big Bend Blvd

Saint Louis, MO 63122 63042

Concentra Medical Center 314.731.0448 63125

463 Lynn Haven Dr Lemay Urgent Care 314.543.5294

Hazelwood, MO 63042 2900 Lemay Ferry Rd

Saint Louis, MO 63125 SSM WorkHEALTH 314.731.9675

1 Village Square Center, Suite A 63128

Hazelwood, MO 63042 St John's Mercy Corp Health 314.729.9995

13303 Tesson Ferry Rd, Suite 50

63043 Saint Louis, MO 63128

Concentra Medical Center 314.434.8174

83 Progress Pky 63139

Maryland Heights, MO 63043 Concentra Medical Center 314.647.0081

6726 Manchester Rd

63080 Saint Louis, MO 63139

Sullivan Medical Office 573.860.6000 965 Mattox Dr

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01/11 PRESELECTED ARCHDIOCESAN PPO NETWORK FACILITIES FOR

WORKERS’ COMPENSATION INJURIES (Continued)

63141 63376 - Continued

St John's Mercy Corp Health 314.989.9199 St John's Mercy Urgent Care 636.477.8757

11700 Studt Rd 107 Piper Hill Dr

Saint Louis, MO 63141 Saint Peters, MO 63376

63143 SSM WorkHEALTH 636.928.9675

SSM WorkHEALTH 314.645.9675 300 St. Peters Centre Blvd., Suite 150

2321 McCausland Ave Saint Peters, MO 63376

Saint Louis, MO 63143

63379

63146 Troy Family Practice 636.528.6755

Barnescare 314.993.3014 900 E Cherry St

11501 Page Service Dr Troy, MO 63379

63601

63147 Mineral Area Reg Med Ctr 573.431.3303

Concentra Medical Center 314.385.9563 1421 E Main St

8340 N Broadway Park Hills, MO 63601

63627

63303 Bloomsdale Family Health 573.483.9500

Concentra Medical Center 636.947.1666 37 Meyer Ln

1551 Wall St, Suite 100 Bloomsdale, MO 63627

Saint Charles, MO 63303

63628

63304 Mineral Area Reg Med Ctr 573.358.1480

SSM St Joseph Medical Park 636.498.7400 55 Nesbit Dr

1475 Kisker Rd Bonne Terre, MO 63628

Saint Charles, MO 63304

63664

St Luke's Urgent Care 636.300.0370 Healthway Primary Care 573.438.2977

1051 Wolfrum Rd 200 Health Way

Saint Charles, MO 63304 Potosi, MO 63664

63366 63670

St John's Mercy Urgent Care 636.379.4329 Ste Genevieve Family Health 573.883.2782 300 Winding Woods Dr, Suite 100 753 Pointe Basse Dr

O Fallon, MO 63366 Sainte Genevieve, MO 63670

63368 Ste Genevieve Family Health 573.883.7424

St Luke's Urgent Care 636.695.2500 930 Park Dr

5551 Winghaven Blvd, Suite 100 Sainte Genevieve, MO 63670 O Fallon, MO 63368

63775

63376 Perryville Family Care Clinic 573.547.7888

Barnescare 636.978.1008 212 Hospital Ln, Suite 101

1901 Trade Center Dr Perryville, MO 63775

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01/11 MEDICAL CENTERS AND HOSPITALS

These facilities should only be used for "after hours" injuries and extreme emergencies

63017 63118

St Luke’s Hospital 314.205.6990 St Alexius Hospital 314.865.7955

232 S Woods Mill Rd 3933 S Broadway

Chesterfield, MO 63017 Saint Louis, MO 63118

63019 63122

Jefferson Regional Medical Center 636.933.1111 Des Peres Hospital 314.966.9666

1400 Hwy 61 South 2345 Dougherty Ferry Rd

Crystal City, MO 63019 Saint Louis, MO 63122

63026 63128

SSM St Clare Health Center 636.496.2100 St Anthonys Medical Center 314.525.1900

1015 Bowles Ave 10010 Kennerly Rd

Fenton, MO 63026 Saint Louis, MO 63128

63031 63131

Northwest HealthCare 314.953.6994 Missouri Baptist Medical Center 314.996.5225

1225 Graham Rd 3015 N Ballas Rd

Florissant, MO 63031 Saint Louis, MO 63131

63044 63136

SSM Depaul Health Center 314.344.6360 Christian Hospital 314.653.5994

12303 Depaul Dr 11133 Dunn Rd

Bridgeton, MO 63044 Saint Louis, MO 63136

63080 63139

Missouri Baptist Sullivan Hospital 573.468.1120 Forest Park Hospital 314.768.3019

751 Sappington Bridge Rd 6150 Oakland Ave

Sullivan, MO 63080 Saint Louis, MO 63139

63090 63141

St John’s Mercy Hospital 636.239.8011 Barnes Jewish West Co Hospital 314.996.8470

901 E Fifth St 12634 Olive Blvd

Washington, MO 63090 Saint Louis, MO 63141

63110 St John’s Mercy Medical Center 314.251.6090

Barnes Jewish Hospital 314.362.9123 615 S New Ballas Rd 1 Barnes Jewish Hospital Plz Saint Louis, MO 63141 Saint Louis, MO 63110

63301

St Louis University Hospital 314.577.8777 SSM St Joseph Health Center 636.947.5111 3635 Vista at Grand Blvd 300 First Capital Dr

Saint Louis, MO 63110 Saint Charles, MO 63301

63117 63367

SSM St Mary’s Health Center 314.768.8360 SSM St Joseph Hospital West 636.625.5300

6420 Clayton Rd 100 Medical Plz

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01/11 MEDICAL CENTERS AND HOSPITALS - Continued

These facilities should only be used for "after hours" injuries and extreme emergencies

63376 63640

Barnes Jewish St Peters Hosp 636.916.9000 Mineral Area Regional Med Ctr 573.756.4581

10 Hospital Dr 1212 Weber Rd

Saint Peters, MO 63376 Farmington, MO 63640

63379 Parkland Health Center 573.760.8475

Lincoln County Medical Center 636.528.8551 1101 W Liberty St

1000 E Cherry St Farmington, MO 63640

Troy, MO 63379

63664

63385 Washington County Mem Hosp 573.438.5451

SSM St Joseph Health Center 636.327.1100 300 Health Way

500 Medical Dr Potosi, MO 63664

Wentzville, MO 63385

63670

63628 Ste Genevieve Co Mem Hosp 573.883.2751

Parkland Health Center 573.358.4675 Highways 61 & 32

7245 Raider Rd Sainte Genevieve, MO 63670

Bonne Terre, MO 63628

63775

Perry County Mem Hosp 573.547.2536 434 N West St

Perryville, MO 63775

IMPORTANT INFORMATION CONCERNING

WORKERS’ COMPENSATION

 Emergency Room Treatment - The E.R. should be used for all life threatening medical emergencies; otherwise it should be avoided because the doctors there do not have special training in Workers’ Compensation. When someone needs treatment after hours or on weekends, the family physician should be contacted.

 If there is no primary care center in your immediate area, (30 miles or less), contact the Gallagher Bassett Services (See Page 6), for assistance in preselecting a medical facility.  When an employee is injured, the Risk Coordinator should be contacted immediately and

requested to notify Gallagher Bassett.

 Prompt reporting will ensure more effective medical direction, thus enabling the employee to return to work sooner, reducing costs for all of us.

 It is most helpful if the Risk Coordinator is in regular contact with the injured worker, making reports to Gallagher Bassett on the employee’s progress.

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WORKERS' COMPENSATION

CLAIMS HANDLING PROCEDURES

It is important to remember that you have several options in submitting your workers' compensation Report of Injury. Please see page 8 before you begin processing. Only you can determine the method of reporting that is easiest and best for you.

(The following is based upon completing a manual form or using the computer completion method.

However, the information needed for reporting under any of the options is the same. This form must be used immediately in reporting all workers’ compensation injuries.)

REPORT OF INJURY FORM

1. All fields that are mandatory must be completed. See field listing beginning on page 20 for fields that are mandatory.

2. This form also contains information that will remain constant and should be included on all First Reports.

3. Under section “General”, the “Location #” is your parish/agency Archdiocesan location code. 4. Information relative to the carrier/claims administrator pertains to the Archdiocese of St. Louis

and Gallagher Bassett and has been prefilled on the sample. 5. Use the word “alleged” on all injuries that are:

A. Suspicious in nature. B. Not witnessed. C. Reported late.

D. Non-visible, such as back strain.

Example: The employee alleges he twisted his back, two weeks ago, picking up a screwdriver. 6. Mail the Report of Injury form to Gallagher Bassett Services, Inc. within 48 hours of the injury.

Do not mail the Report of Injury form to the State Division of Workers' Compensation: this is a Gallagher Bassett Services, Inc. responsibility.

7. Timely reporting of work-related injuries is imperative for proper control of the claim, cost containment, and to ensure quality care for your employee.

8. The Report of Injury (Pages 18 & 19) should be used for all work related injuries. Do not use the Incident Report for reporting these injuries.

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01/11 MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DIVISION OF WORKERS’ COMPENSATION REPORT OF INJURY

P.O. BOX 58 JEFFERSON CITY, MO 65102-0058

(SEE INSTRUCTIONS ON PAGE 2)

G

E

NE

R

AL

EMPLOYER (NAME, ADDRESS, INCL ZIP CODE)

CARRIER ADMINISTRATOR CLAIM NUMBER

REPORT PURPOSE CODE

00

JURISDICTION

MO

JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER

EMPLOYERS LOCATION ADDRESS (IF DIFFERENT)

LOCATION # SIC CODE

EMPLOYER FEIN PHONE #

CA RR IE R CL AI M S AD M IN

CARRIER (NAME, ADDRESS & PHONE NO.)

Safety National

2443 Woodland Parkway, Ste 200 St. Louis, MO 63146

POLICY PERIOD

to

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.)

Gallagher Bassett Services 1630 Des Peres Road, Ste 200 St. Louis, MO 63131

CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN

43-0727872

POLICY SELF-INSURANCE NUMBER ADMINISTRATOR FEIN

36-3365500

AGENT NAME & CODE NUMBER

E M P L O Y E E

NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY # DATE HIRED STATE OF HIRE

ADDRESS SEX MALE FEMALE UNKNOWN MARITAL STATUS UNMARRIED SINGLE DIVORCED MARRIED SEPARATED UNKNOWN

OCCUPATION JOB TITLE EMPLOYMENT STATUS PHONE # # OF DEPENDENTS

NCCI CLASS CODE

WAGE RATE PER DAY WEEK MONTH OTHER

# DAYS WORKED WEEK

FULL PAY FOR DAY OF INJURY?

DID SALARY CONTINUE?

YES NO YES NO O CCUR RE NCE

TIME EMPLOYEE BEGAN WORK

AM

PM

DATE OF INJURY / ILLNESS TIME OF OCCURRENCE

AM

PM

LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN CONTACT NAME PHONE NUMBER TYPE OF INJURY ILLNESS PART OF BODY AFFE CTED

DID INJURY ILLNESS EXPOSURE OCCUR ON EMPLOYER’S PREMISES? YES NO

TYPE OF INUURY/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

DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED?

YES NO YES NO T R E A T- M E N

T PHYSICIAN HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL (NAME & ADDRESS)

INITIAL TREATMENT 0 – NO MEDICAL TREATMENT 1 – MINOR: BY EMPLOYER 2 – MINOR CLINIC HOSPITAL 3 – EMERGENCY CASE 4 – HOSPITALIZED > 24 HOURS

5 – FUTURE MAJ. MED. LOST TIME ANTICIPATED

O

T

HE

RS

WITNESS (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED DATE PREPARED

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01/11 NOTE > This form is both the notice and report of injury as required by Section 287.380, RSMo.

Injuries that require only first aid and result in no lost time need not be reported. Please mail this report to your WORKERS’ COMPENSATION INSURANCE CARRIER or Claims Administrator. If you are self-insured or are not under the Law and do not have an insurance carrier, mail this form to the Division.

PRINT QUALITY > All reports of injury and supporting documents received by the Division will be

processed electronically. All forms submitted to the Division MUST be of clear and legible quality. Handwritten forms will not be accepted. Computer generated forms shall use a minimum type size of

10 points. All documents not meeting the above criteria will be returned.

TO BE ANSWERED ONLY IN CASE OF DEATH

DATE OF DEATH EMPLOYEE’S DEPENDENTS NAME OF DEPENDENT RELATION TO EMPLOYEE ADDRESS OF DEPENDENT

ADDRESS CITY STATE ZIP CODE

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Risk Management Manual Revised 01-11.doc ₂₀

01/11 MANDATORY FIELDS ARE IN BOLD TYPE

Field Names Definition Of Fields New Field Field Status

Employer The name and address of business entity employing or statutorily responsible for the employee.

Mandatory

Carrier Administrator Claim Number

Identifies a specific claim within a carrier administrator’s claims processing system.

Yes Optional

Report Purpose Code 00 – Original 02 – Change/Update

Yes Mandatory Jurisdiction The governing body, territory, who will administer the claim

and whose statues will apply to the claim adjustment process. Example: MO

Yes Mandatory

Jurisdiction Claim Number MO Division of Workers’ Compensation Injury Number Do not use.

Insured Report Number A number used by the insured to identify a specific claim. Optional

Employers Location Address The location where the accident occurred if different than the employer address. Mandatory if different than employer address. Location # A code defined by the employer that is used to identify the

employer’s multiple location of the accident.

Yes Mandatory

Phone # The phone number of the employer. Mandatory

SIC Code The code which represents the nature of the employer’s business

which is contained in the Standard Industrial Classification. Manual published by the Federal Office of Management and Budget.

Yes Optional

Employer FEIN The FEIN (Federal Employer Identification Number) number of the employee’s employer.

Yes Mandatory Carrier The name, address and phone number of the licensed business

entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer and the employee.

Mandatory if applicable. Policy Period The date that the contract/policy under which the claim

occurred became effective and expired.

Yes Mandatory Claims Administrator The name, address and phone number of the self-insured,

carrier or third party administrator responsible for the claim.

Yes Mandatory if applicable. Self-Insured Indicator Check if you are self-insured. Yes Mandatory

if applicable. Carrier FEIN The FEIN (Federal Employer Identification Number) number

of the claims administrator.

Yes Mandatory 36-3365500

Agent Name & Code Number Not used. Yes Not used.

Name The employee’s legally recognized name, which is used on legal documents, employment, Social Security, banking records, etc.

Mandatory

Date of Birth The date the employee was born. (Please provide as much information as you have.)

Mandatory Social Security Number The Social Security number of the employees. Mandatory

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Date Hired The date which the employee was hired. (Please provide as much information as you have.)

Yes Mandatory

State of Hire The state the employee was hired. Yes Optional

Address The mailing address used by the injured employee. Mandatory Phone # A telephone number where the employee can be reached. Mandatory

# of Dependents The number of dependents as defined by the administering

jurisdiction.

Optional

Sex Indicates the sex of the employee. Mandatory

Marital Status Indicates the marital status of the employee. Mandatory Occupational/Job Title Identifies the primary occupation of the employee at the time

of the accident/injury exposure.

Mandatory

Employment Status A code used to indicate the employee’s primary work code status

at the time of the injury with the covered employer.

FT – Full-Time PT – Part-Time

NE – Not Employed OS – On Strike

DS – Disabled RT – Retired

SL – Seasonal VO – Volunteer

PW – Piece Worker UK – Unknown

AD – Apprenticeship Full-Time AP – Apprenticeship Part-Time

Yes Optional

NCCI Class Code A code corresponding to the primary occupation, which the claimant was engaged at the time of the accident/injury exposure.

Yes Mandatory

Rate The weekly rate at which a benefit type is being paid. Mandatory # Days Worked/Week The number of the employee’s regularly scheduled workdays

per week. Mandatory

Full Pay for Day of Injury Indicates whether full wages for the date of the accident/injury or

illness were paid by the employer. Yes Optional

Did Salary Continue Indicates whether full wages for the date of the accident/injury or

illness were paid by the employer. Yes Optional

Time Employee Began Work The time when employee began work. Optional

Date of Injury/Illness The date on which the accident occurred. Mandatory Time of Occurrence The time when the accident occurred. Mandatory Last Work Date The date the employee last worked. This date will not reflect

dates on which the employee was absent from work in a paid status; vacation, comp. Time, sick day, military leave, etc.

Yes Mandatory

Date Employer Notified Date employer notified of the accident/injury exposure. Yes Mandatory Date Disability Began The first day on which the claimant originally lost time from

work due to the occupational injury of disease or as otherwise defined by statute.

Yes Mandatory

Contact Name/Phone Number Name/telephone number of party that can be contacted about

the injury. Mandatory

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Part of Body Affected The part of the body the claimant sustained injury to. Mandatory

Did Injury/Illness exposure occur on employer’s premises?

As requested. Answer yes or no. Optional

Type of Injury/Illness Code Code identifying type of injury. Yes Mandatory Code Part of Body Affected Code Code identifying part of body. Yes Mandatory

Code

Department or Location where accident or illness exposure occurred.

Description of department or location where accident occurred. Optional

All equipment, materials or chemicals employees was using when accident or illness exposure occurred.

Description of equipment, materials, chemicals, etc., employee was using when accident occurred.

Mandatory

Specific activity the employee was engaged in when the accident or illness exposure occurred.

Description of activity employee engaged in when accident occurred.

Mandatory

Work process the employee was engaged in when accident or illness exposure occurred.

Description of work process employee engaged in when accident occurred.

Mandatory

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.

Description of the sequence of events, including any objects or substances that directly injured the employee or made the employee ill.

Mandatory

Cause of Injury Code Code identifying cause of injury. Yes Mandatory Code Date return(ed) to work. The date, following the most recent disability period, on which

the claimant returned to work.

Mandatory If Fatal, give date of death The date of employee died. Mandatory

if applicable

Were safeguards or safety equipment provided? Were they used?

Answer question if application. Yes Optional

Physician/Health Care Provider (Name & Address)

The name and address of the physician or health care provider.

Mandatory

Hospital (Name & Address) The name and address of the hospital. Optional

Witness (Name & Address) Name and phone number of party that witnessed accident/injury. Yes Optional

Date Administrator Notified The date the claim administrator who is processing the claim

received notice of the loss or occurrence.

Yes Optional

Date Prepared The date that this form is completed. Optional

Preparer’s name & Title The name of the person filling out the form and their title. Mandatory Phone Number The phone number of the preparer. Yes Mandatory Initial Treatment A code used to identify the extent of medical treatment

received by the claimant immediately following the accident.

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Risk Management Manual Revised 01-11.doc ₂₃ 01/11 Field Names Definition Of Fields New Field Field Status

(Check only the one that is most applicable.)

DIVISION OF WORKERS’ COMPENSATION CAUSES OF INJURY CODES

CODE CAUSE OF INJURY CODE CAUSE OF INJURY

I. BURN OR SCALD-HEAT OR COLD VI. STRAIN OR INJURY BY

01 Acid Chemicals 52 Continual Noise

02 Hot Object or Substances 53 Twisting

11 Cold Objects or Substances 54 Jumping

03 Temperature Extremes 55 Holding or Carrying

04 Fire or Flame 56 Lifting

06 Dust, Gases, Fumes or Vapors 58 Reaching

07 Welding Operations 59 Using Tool or Machine

08 Radiation 60 Strain or Injury by, NOC

09 Contact with NOC 61 Wielding or Throwing

14 Abnormal Air Pressure 97 Repetitive Motion

II. CAUGHT IN OR BETWEEN VII. STRIKING AGAINST OR STEPPING ON

10 Machine or Machinery 65 Moving Parts of Machine

12 Object Handled 66 Objects Being Lifted or Handled

20 Collapsing Materials (Slides of Earth) 67 Sanding, Scraping, Cleaning Operations

13 Caught in, Under or Between, NOC 68 Stationary Objects

69 Stepping on Sharp Object

III. CUT, PUNCTURE, SCRAPE INJURED BY 70 Striking Against or Stepping on, NOC

15 Broken Glass

16 Hand Tool, Utensil; Not Powered VIII. STRUCK OR INJURED BY

17 Object Being Lifted or Handled 74 Fellow Worker, Patient

18 Powered Hand Tool, Appliance 75 Falling or Flying Object

19 Caught, Puncture, Scrape, NOC 76 Hand Tool or Machine in Use

77 Motor Vehicle

IV. FALL OR SLIP INJURY 78 Moving Parts of Machine

25 From Different Level (Elevation) 79 Object Being Lifted or Handled

26 From Ladder/Scaffolding 80 Object Handled by Others

27 From Liquid or Grease Spills 81 Struck or Injured, NOC

28 Into Openings

29 On Same Level IX. RUBBED OR ABRADED BY

30 Slipped, Did not Fall 94 Repetitive Motion

31 Fall, Slip, Trip, NOC 95 Rubbed or Abraded, NOC

32 On Ice or Snow

33 On Stairs X. MISCELLANEOUS CAUSES

82 Absorption, Ingestion or Inhalation, NOC

V. MOTOR VEHICLE 87 Foreign Matter (Body) in Eye(s)

40 Crash of Water Vehicle 89 Person in Act of A Crime

41 Crash of Rail Vehicle 90 Other Than Physical Cause of Injury

45 Collision or Sideswipe w/Another Vehicle 98 Cumulative, NOC

46 Collision with a Fixed Object 99 Other-Miscellaneous, NOC

47 Crash of Airplane

48 Vehicle Upset

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01/11 DIVISION OF WORKERS’ COMPENSATION CAUSES OF INJURY CODES

CODE PART OF BODY CODE PART OF BODY

I. HEAD IV. TRUNK

10 Multiple Head Injury 40 Multiple Trunk

11 Skull 41 Upper Back Area (Thoracic Area)

12 Brain 42 Low Back Area (Inc. Lumbar & Lumbo-Sacral)

13 Ear(s) 43 Disc

14 Eye(s) 44 Chest (Inc. Ribs, Sternum & Soft Tissue)

15 Nose 45 Sacrum & Coccyx

16 Teeth 46 Pelvis

17 Mouth 47 Spinal Cord

18 Soft Tissue 48 Internal Organs

19 Facial Bones 49 Heart

60 Lungs

II. NECK 61 Abdomen Including Groin

20 Multiple Injury 62 Buttocks

21 Vertebrae 63 Lumbar and/or Sacral Vertebrae

(Vertebrae NOC Trunk) 22 Disc

23 Spinal Cord V. LOWER EXTREMITIES

24 Larynx 50 Multiple Lower Extremities

25 Soft Tissue 51 Hip

26 Trachea 52 Upper Leg

53 Knee

III. UPPER EXTREMITIES 54 Lower Leg

30 Multiple Upper Extremities 55 Ankle

31 Upper Arm (Inc. Clavicle & Scapula) 56 Foot

32 Elbow 57 Toe(s)

33 Lower Arm 58 Great Toe

34 Wrist

35 Hand VI. MULTIPLE BODY PARTS

36 Finger(s) 64 Artificial Appliance

37 Thumb 65 Insufficient Info to Properly Identify –

Unclassified

38 Shoulder(s) 66 No Physical Injury

39 Wrist(s) and Hand(s) 90 Multiple Body Parts

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01/11

ARCHDIOCESE OF ST. LOUIS

WORKERS’ COMPENSATION TREATMENT AUTHORIZATION REFER TO: OCCUPATIONAL HEALTH & MEDICINE DEPARTMENT

PARISH/AGENCY NAME: PARISH/AGENCY ADDRESS: PARISH/AGENCY TELEPHONE #: EMPLOYEE INFORMATION EMPLOYEE NAME: EMPLOYEE ADDRESS: EMPLOYEE TELEPHONE #:

EMPLOYEE SOC. SEC. NO.: EMPLOYEE DATE OF BIRTH: EMPLOYEE OCCUPATION:

DATE OF INJURY: BODY PART:

DESCRIPTION OF ACCIDENT:

Please refer to the Archdiocesan Provider List

OR contact Valerie Maki or Nancy Pfeiffer at Gallagher Bassett for authorization and medical direction: 1-314-965-7810

Physician/Facility: Appointment Date: Telephone #:

TREATMENT AUTHORIZED BY:

(PARISH/AGENCY REPRESENTATIVE)

Form must be signed by a properly designated person (not injured employee)

Upon completion of medical referral, Risk Coordinator must complete a Missouri 1st Report of Injury Form and mail or fax to Gallagher Bassett.

PROVIDER SECTION

Please complete below information and fax to Valerie Maki or Nancy Pfeiffer at 866-947-2227 OR Mail To: Gallaher Bassett Services, 1630 Des Peres Road, Suite 200, St. Louis, MO 63131

DIAGNOSIS:

TREATMENT RECOMMENDATIONS:

RETURN TO WORK STATUS: Light Duty / Full Duty ANTICIPATED RESTRICTIONS:

PROJECTED DATE FOR COMPLETION OF TREATMENT:

PROVIDER SIGNATURE: DATE:

Send bills to: Gallagher Bassett Services P.O. Box 23812

Tucson, AZ 85734

MAY NOT BE PHOTOCOPIED

Request additional forms from Arthur J. Gallagher Risk Management Services, Inc. at 314.800.2269 (See Page 5)

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IV.

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01/11

GENERAL LIABILITY INCIDENT REPORT

General Liability: Is an accident/occurrence to a third party (non employee) that results in injury or damage to that person or their property as a result of an actual or alleged negligent act by an employee or volunteer of the parish/agency while performing duties, or as a result of a defective/dangerous condition of our property.

Claim: Person (third party) that had received medical attention or sustained damage to their person/property and is requesting or expecting payment of their expenses from the parish/agency. Incident: When it is unknown if person (third party) will be presenting a claim. However, due to the severity of the injury or the nature of the potential negligent act/occurrence, it is reasonable to anticipate that a claim could arise in the future.

General Instructions: The Incident Form (page 31) should be used to report any injury on Parish, school or agency premises or at a Parish, school or agency event off site where the injured person is not an employee. A separate form may be used for each injured person. The Incident Form should be used to report any injury, whether it is an incident or actual claim. However, if it is an “Incident Only”, indicate on the top of the form “For Information Only”.

It is important to remember that you have several options in submitting your Incident Report. Please see page 8 before you begin processing . Only you can determine the method of reporting that is easiest and best for you.

However, the information needed for reporting under any of the options is the same. This form must be used immediately in reporting all incidents.)

General Instructions:

Copies of the INCIDENT REPORT FORM should be distributed to all employees and volunteers who have supervisory responsibility for activities of the Parish, School or Agency.

Preparer:

The INCIDENT REPORT should be completed by the Parish/Agency employee or volunteer with supervisory responsibility for the activity at which the INCIDENT occurred at the time of the Incident or as soon as possible.

The PREPARER should complete the top portion of the form promptly after the INCIDENT has occurred and forward it to the RISK COORDINATOR for the Parish, School or Agency.

Risk Coordinator:

The RISK COORDINATOR should review the INCIDENT REPORT , adding his/her comments where indicated, sign the form and forward a copy to Gallagher Bassett. If the matter is urgent, Gallagher Bassett should be contacted by phone. Otherwise, the report should be mailed to Gallagher Bassett within one (1) week of the occurrence.

A claim is a request for compensation for injury or damages from an “INCIDENT”. If the preparer or any individual directly involved with the incident gives any indication that a claim will result, this information is important and should be noted in the Comments Section.

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01/11 Should the RISK COORDINATOR obtain additional information regarding the INCIDENT after the REPORT has been sent to Gallagher Bassett, photocopy the report and add the additional information at the bottom, sending it to Gallagher Bassett Services.

A RISK COORDINATOR is the representative of the Office of Risk Management on the scene in every parish, school or agency. This is an important responsibility. It is preferred that the risk coordinator not be the pastor/administrator. However, the pastor/administrator will always receive copies of all material sent to the risk coordinator from our office.

Besides becoming familiar with the procedures outlined in both the Claims’ and Safety Manuals (so that proper procedure may be followed by those involved when something happens) the RISK

COORDINATOR needs to inform others on the handling of various situations. For example,

employees need to be informed about Workers’ Compensation and, along with volunteers and those who use buildings and facilities, they need to know how to address situations that could develop into liability claims. Finally, they need to make information available and give proper instruction to all of the

operators of vehicles that are covered in our program.

We are all very grateful for the work that has been done thus far. If all of us face the future by joining together to follow these procedures, we may save a great deal of money in the billings we have to pay and, more important, help those around us avoid injuries, which, on occasion, could be serious. Volunteers:

Volunteers are an important part of your agencies and parishes, but they are not covered under Workers’ Compensation. When a volunteer is injured on your premises, an “Incident” Report should be

completed. If the injury is severe, notify a Gallagher Bassett Property, Liability & Auto Specialist (See Page 6) as soon as possible.

There is no medical payments coverage available to your guests or volunteers. We have no liability unless there is negligence on our part. When a guest or volunteer is injured, always show concern for the injured party.

If you do not believe there is negligence, the parish or agency may elect to pay whatever expenses are incurred that are not covered by the injured person’s medical insurance, with parish and/or agency funds. If the parish or agency makes payments, please contact the Office of Risk Management to discuss a proper release. If the medical expenses are substantial or require a lengthy, ongoing medical care, notify the Office of Risk Management, which may elect to provide assistance with payment or medical management of the injury. An Incident Report should still be completed. If the parish and/or agency elects to offer assistance, please indicate this in the Comments Section. If the injured party is demanding payment, please also note.

It is important to remember that you have several options in submitting your workers' compensation Report of Injury. Please see page 8 before you begin processing . Only you can determine the method of reporting that is easiest and best for you.

However, the information needed for reporting under any of the options is the same. This form must be used immediately in reporting all workers’ compensation injuries.

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01/11

ADDITIONAL GUIDANCE FOR RISK

COORDINATOR

General Instructions:

1. Insert Parish/Agency name, address and telephone number on the Incident Report and make multiple copies for distribution to persons who will have responsibility for supervision of Parish/Agency activities. (The “PREPARERS”)

2. Make copies of the RECOMMENDED RISK MANAGEMENT PRACTICES (page 31) and of the Instructions (page 28-29) for distribution to the PREPARERS.

3. Make sure the PREPARERS have your name, address, and telephone number.

4. For times when you will be absent, make sure the Rectory or Agency office has the name, address, and telephone number of an alternate RISK COORDINATOR.

Medical:

If any medical attention is received, indicate when and where. Evidence:

1. Photographs

If a camera is available, it is recommended that photographs of the INCIDENT site be taken. The scene could be altered or changed before the INCIDENT is referred to Gallagher Bassett for its examination.

2. Objects

Take physical control of the object that caused the INCIDENT (banana peel, rock, etc.). If it is liquid, attempt to identify the substance and determine its source. Also, indicate how long present.

Prevention:

Barricade the area or take other immediate steps to prevent future incidents. Make certain corrective measures are visible (lighting, bright paint, rope, tape).

Written Statement:

If the person intends to make a claim, the preparer should obtain a complete written statement from the individual. This would include his or her name, address, telephone number and a description of what happened, including the extent of the injury. The identity of any witnesses should be obtained at that time.

Serious Injuries:

Fatalities or serious injuries that require hospitalization (other than emergency treatment) should be reported by phone to Gallagher Bassett; so an immediate investigation may be conducted.

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01/11

LIABILITY COVERAGE FOR

PERSONS PERFORMING

CHILD ABUSE BACKGROUND CHECKS

The policies of the Archdiocese require that a child abuse screening background check be done for each new employee and volunteer working with or near children and that this screening be done again on the even years thereafter. For information concerning the Archdiocesan policies and requirements, please contact the Safe Environment Program.

Questions have been asked regarding liability insurance coverage for employees or volunteers who are involved in the process of obtaining child abuse screenings or overseeing others in this process.

The liability insurance of the Archdiocese of St. Louis covers, with certain limitations and exclusions, employees and volunteers for their acts or omissions which are within the course and scope of their duties. One exclusion is for claims arising out of sexual misconduct. Thus, if an employee or volunteer is sued for his or her acts or omissions in connection with child abuse screening and the suit is based on a claim of sexual misconduct, there is no insurance coverage for the employee or volunteer.

In order to provide protection for employees and volunteers in the case of a claim of injury based on sexual misconduct where an employee or volunteer is accused of negligence in the child abuse screening process, the Archdiocese will provide indemnification and defense for employees and volunteers for claims arising out of sexual misconduct against them based on their alleged negligent acts or omissions in connection with child abuse screenings. This agreement to provide indemnification and defense does not apply to claims which are covered by the insurance of the Archdiocese. The exclusion for sexual misconduct claims became effective on July 1, 1986 and claims based on occurrences prior to that date are covered in accordance with the provisions of the policies in effect in the respective prior years. If any employee or volunteer receives a claim or a threat of a claim based on his or her role in the child abuse screening process, he or she should follow the procedure for any other claim or threat of a claim, which is to notify his or her supervisor or the pastor, in cases of a parish, who will direct the matter to the Office of Risk Management and the Archdiocesan attorney. The claim will then be reviewed for coverage and the employee or volunteer will be given direction.

RECOMMENDED RISK MANAGEMENT

PRACTICES GENERAL LIABILITY

1. Check for injuries, and secure proper medical assistance if required.

2. Obtain the name, address, and telephone number of anyone who is injured. In the case of a minor, obtain the parent’s name and both home and business phone numbers. The parent should be advised of the injury by phone, immediately.

3. Obtain the names, addresses, and telephone numbers of all witnesses, even those who saw only part of the accident.

4. Avoid discussions of fault and responsibility.

5. Do not discuss insurance and what you believe may or may not be covered. 6. Do not deny or offer payment of medical bills.

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01/11

INCIDENT REPORT, ARCHDIOCESE OF ST. LOUIS

If additional space is required use reverse side (Please PRINT or TYPE)

A. PARISH/AGENCY: ADDRESS:

TELEPHONE NUMBER:

B. INCIDENT DATE: , 20 TIME: am pm C. INJURED PARTY INFORMATION

NAME: ADDRESS:

TELEPHONE: HOME: WORK:

PARENTS NAME:

(If injured person is a minor)

AGE: Male Female

D. WITNESSES: (Attach Schedule of Additional Witnesses)

NAME: NAME:

ADDRESS: ADDRESS:

TELEPHONE: TELEPHONE:

E. WHERE DID INCIDENT OCCUR: DESCRIBE WHAT OCCURRED:

F. DESCRIBE INJURY, IF ANY:

G. PLEASE INDICATE IF ANY EMERGENCY SERVICE OR MEDICAL TREATMENT FOLLOWED: WHERE: ______________________________ WHEN: PREPARER INFORMATION SIGNATURE: TITLE: DATE: TELEPHONE: MAIL TO:

GALLAGHER BASSETT SERVICES, INC. 1630 DES PERES ROAD, SUITE 200

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V. Auto

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VEHICLE CLAIMS HANDLING PROCEDURES

Each vehicle should have an Archdiocesan Vehicle Claim Envelope in the glove compartment. In this envelope, there should be the following documents:

 Vehicle Claims Handling Procedures (this page)

 Gallagher Bassett Accident Report, Auto and Truck (Pages 34 & 35)  Vehicle Accident Identification Card (Page 36)

 Recommended Risk Management Practices for General Liability (Page 30)  A copy of your current Missouri Vehicle Insurance Identification Card

 A few blank pieces of paper to assist you in making a sketch of the accident scene  A pencil or pen (check periodically)

It is important to remember that you have several options in submitting Automobile Accident Report. Please see page 8 before you begin processing . Only you can determine the method of reporting that is easiest and best for you.

(The following is based upon completing a manual form or using the computer completion method. However, the information needed for reporting under any of the options is the same.)

For all accidents:

1. Exchange necessary information with the other driver to enable Gallagher Bassett to contact that party. (Name, address, business and home phone numbers, information pertaining to the vehicle). Identification forms are provided on page 36.

2. Advise the other driver(s) you will report to Gallagher Bassett Services.

3. Contact the Police Department. - Whenever possible do not move the vehicles until the police have made their report.

4. Obtain the police report complaint number.

5. Obtain the name, address and telephone numbers of all witnesses.

6. Diagram - Make a sketch of the accident scene showing measurements and placement of vehicles.

7. Complete all forms enclosed in your Archdiocesan Vehicle Claim Envelope, and send to Gallagher Bassett Services, 1630 Des Peres Road, Suite 200, St. Louis, MO 63131-1849. 8. Vehicle Damage - If minor damage is sustained and the vehicles are driveable, two (2)

estimates are usually acceptable.

A. If damage is over $2,500, the vehicle will require an inspection by an appraiser retained by Gallagher Bassett.

B. If a vehicle is not driveable, report the loss by phone to Gallagher Bassett Services to eliminate additional rental or storage charges.

C. Rental Coverage is afforded to drivers of vehicles in our program only when a vehicle is stolen, in an accident that renders the vehicle undriveable or while an insured vehicle is being repaired for a covered loss.

9. Obtain the identity of any injured parties, including names, addresses and phone numbers. Indicate any visible injury and if anyone requires emergency treatment.

10. Serious Injury - Fatalities or serious injuries that require a hospital admission (and therefore emergency treatment) must be reported by phone to Gallagher Bassett (314.965.7810), so that an immediate investigation can be conducted.

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01/11 VEHICLE ACCIDENT IDENTIFICATION CARD

ARCHDIOCESE OF ST. LOUIS RISK MANAGEMENT PROGRAM All Claims should be reported to: Gallagher Bassett Services, Inc.

1630 Des Peres Road, Suite 200 St. Louis, MO 63131-1849 Phone: 314.965.7810 Archdiocesan Employee Name:

Parish/Agency Name: Address:

Phone #: Home

Work

**This form should be kept in all vehicles covered by the Archdiocese of St. Louis Risk Management Program**

Fill out this form promptly. Several copies should be kept in the glove compartment of each vehicle in our program. In case of an accident, one should be given to each driver.

WHEN YOU ARE INVOLVED IN A MOTOR VEHICLE ACCIDENT, OBTAIN THE FOLLOWING INFORMATION FROM THE OTHER DRIVER(S).

Name: Address:

Phone #: Home

Work Drivers License #:

Insurance Carrier & Policy #: (Copy from Insurance I.D. Card)

**This form should be kept in all vehicles covered by the Archdiocese of St. Louis Risk Management Program**

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01/11

OFFICE OF RISK MANAGEMENT

VEHICLE CHANGE REQUEST

(Submit One Form For Each Vehicle Bought or Sold)

PLEASE PRINT OR TYPE

Parish/Agency Name:

Complete Address:

Person Completing Form:

Phone:

Name as it appears on title or vehicle registration form:

Name of primary operator of vehicle:

Parish or Agency # if vehicle is so titled:

Check One:

Add Vehicle

Delete Vehicle Effective Date:

Is this vehicle replacing another:

Yes

No

(Please submit separate form for deleted vehicle.)

Vehicle Information (See title or vehicle registration):

Year:

Make:

Model:

V.I.N.:

Check Type of Vehicle and Complete Required Information:

Auto

Pickup

Van (Pass. Capacity) _______

Trailer

Truck (GVW) _____

Bus (Pass. Capacity) _______

Please attach a copy of title or registered ownership after the necessary fees have

been paid to the Department of Revenue (title or registration must be in the name of

the parish, agency or priest shown above). If the vehicle is leased, a copy of the lease

must be attached (lease must be in the name of the parish, agency or priest shown

above).

Mail or fax to:

Office of Risk Management

20 Archbishop May Drive

St. Louis, MO 63119-5738

Fax: 314.792.7209

If you need assistance, please call 314.792.7203

NOTE: In the event of a loan or leasing company, you must request that Arthur J. Gallagher provide evidence of coverage to the respective loan or leasing company.

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