The following state forms have been included in your claims kit packet:

13 

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(1)

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 Iowa

state-mandated forms, and a step-by-step process to follow in case an employee sustains an

injury.

When a claim occurs, see the attached instructions for reporting a claim to our Claims

Intake Unit. The contact information for the Claims Intake Unit is listed on the “How to

File an Injury” form included in this packet. The Tower Group claim office which will be

handling your claim is located in Chicago, Illinois. 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 Iowa workers

compensation process.

The following state forms have been included in your claims kit packet:

1.

Iowa Form- Employer’s First Report of Injury-(FROI)-

If the employee claims at

least three (3) days of lost time, then the employer must file a report of injury with

the commission within four ( 4) days (not including Sundays and legal holidays)

after receiving notice or knowledge of the occurrence. The failure to timely file this

report can lead to a $1,000 fine per occurrence.

2.

Wage Statement-

Please complete and send a copy of employees Wage

Statement to Tower Group Companies at the time of injury.

3.

Iowa Authorization To Release Information Regarding Claimants Seeking

Workers Compensation Benefits- Form 14-0043- (11/04)-

This form must be

signed by the employee and provided to health care providers, former and current

employers, etc., to authorize them to release information, including but not limited

to, the employee’s medical records.

We thank you for your business and look forward to being of service to you.

Very truly yours,

Tower Group Companies

(2)

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

Iowa Form- Employer’s First Report of Injury-(FROI)-

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.

(3)

Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS

Jurisdiction Code______________

Jurisdiction Claim Number_______________

¤ IAIABC FORM 1.2 (12/98)

Claim Administrator Name: Claim Representative Business Phone Number:

Insurer Name (if different than claim administrator):

Claim Administrator Claim Number: Insurer FEIN:

CLAIM ADMIN

Mailing Address, City, State, & Postal Code:

Claim Administrator FEIN: Claim Type Code:

Employer Name: Employer FEIN: Insured Report Number:

Industry Code:

Employer Type Code: __ Employer (E) __ Lessor (L) Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code:

Insured Location Number: Employer UI Number:

EMPLOYER

Nature of Business: Employer Contact Name and Business Phone Number:

Coverage Effective Date:

POLICY

Insured Name (parent company if different than employer): Insured FEIN: Insured Postal Code: Policy/Contract Number:

Coverage Expiration Date:

Self Insurance License/ Certificate Number:

Gender: Tax Filing Status (check one):

Employee Name (First, Middle, Last, & Suffix): Date of Birth:

__ Male (M) ____ Single (A) ____ Married/Filing Joint (C) __ Female (F) ____ Single/Head of Household (B) ____ Married/Filing Separate(D) Date of Hire:

Educational Level (grade completed): _______ [GED = 12]

Employment Status (check one): Employee ID Number (check one):

Mailing Address, City, State, & Postal Code:

ID # ______________________ Phone Number (include area code):

Marital Status: (check one)

___ Unmarried (U) ___ Married (M) ___ Separated (S) Occupation Description:

Employee’s Authorization to Release the Following: Manual Classification Code:

Medical Records __ yes __ no

EM

PLOYEE

Department Where Regularly Worked:

____ Piece Worker ____ Volunteer ____ Seasonal ____ Apprenticeship/Full-Time ____ Apprenticeship/Part-Time ____ Regular Employee/Full-Time ____ Part-Time ____ Other

____ Social Security Number ____ Employment VISA Number ____ Passport Number ____ Green Card

____ Employee ID Assigned by Jurisdiction Social Security Number __ yes __ no Average Wage $ ___________ (check one): Salary Continued In Lieu of Compensation: ___ yes ___ no Employee Number of Dependents: __________

___ hourly ___ daily ___ semi-monthly ___ monthly

___ bi-weekly ___ annual ___ weekly Full Wages Paid for Date of Injury: ___ yes ___ no

Employee Number of Exemptions: ___________ (check one)

___ Entitled

WAGE

Number of Days Regularly Worked Per Week: _______ Discontinued Fringe Benefits: $_____________

___ Withholding Describe the nature of the injury. (ex. amputation, burn, cut, fracture):

_____________________ Date of Injury

_____________________ Date Employer Had Knowledge of the Injury _____________________ Date Claim Administrator Had Knowledge of the Injury _____________________ Initial Date Last Day Worked

_____________________ Initial Return to Work Date (if applicable) _____________________ Employee Date of Death (if applicable) _____________________ Time of Injury

_____________________ Time Employee Began Work Pre-Existing Disability Code:

Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system):

___ Yes ___ No ___ Unknown Accident Premises Code:

___ Employer (E)

Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure):

___ Lessee (L) ___ Other (X) Accident Site Organization Name:

Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil):

Accident Site Street, City, State, & Postal Code:

Accident Location Narrative (if no street address):

Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties:

ACCIDENT/INJURY

Accident Site County/Parish: Witness Name & Business Phone Number:

Initial Treatment Code (check one):

___ no medical treatment (0) ___ minor/on-site treatment (1)

Initial Medical Provider Name:

___ clinic/hospital visit (2)

Managed Care Organization Name or ID Number:

___ emergency care (3) ___ hospitalization > 24 hours (4)

MEDICAL

___ future medical treatment/lost time anticipated (5)

Initial Medical Provider Physical Address, City, State, & Postal Code:

ICD Primary Diagnostic Code (if known):

(4)

This section is to provide information valuable in handling this claim. POSTING REQUIREMENTS

The Iowa Occupational Safety and Health Act requires that employees be informed of the job safety and health protection provided under the Act. The poster, “Safety and Health Protection on the Job,” is to be used for this purpose, and must be posted in a prominent place in the establishment to which the employees usually report to work. The poster briefly states the intent and coverage of the Act and the responsibilities of employers and employees to maintain safe and healthful working conditions.

The Iowa Occupational Safety and Health Act

The following is a summary of the recordkeeping, reporting and posting responsibilities of employers under Iowa’s Occupational Safety and Health Act.

RECORDKEEPING REQUIREMENTS

Regulations issued under the Iowa Occupational Safety and Health Act of 1972 require establishments subject to the Act to maintain records of recordable occupational injuries and illness. Such records must consist of: (a) a log and summary of occupational injuries and illnesses and (b) a supplementary record of each occupational injury and illness.

EMPLOYERS WHO MUST KEEP OSHA RECORDS

Employers with 11 or more employees (at any one time in the previous calendar year) in the following industries must keep OSHA records. The industries are identified by name and by the appropriate Standard Industrial Classification (SIC) code: LOG AND SUMMARY OF OCCUPATIONAL INJURIES AND ILLNESSES.

Each recordable occupational injury and occupational illness must be entered on a log and summary of cases (0SHA Form No. 200) as early as practicable but no later than six working days after receiving information that a recordable case has occurred. A multi-unit employer may maintain the log and summary of occupational injuries and illnesses at a place other than the establishment if there is a copy of the log and summary available in the establishment complete and current to a date within 45 calendar days. If an equivalent of OSHA Form No 200 is used, such as a printout from data-processing equipment, the information shall be as readable and comprehensible to a person not familiar with the data-processing equipment as the OSHA Form No. 200 itself. Logs must be kept current and retained for 5 years following the end of the calendar year to which they relate.

x Agriculture, forestry, and fishing (SIC’s 01-02 and 07-09)

x Oil and gas extraction (SIC 13 and 1477)

x Construction (SIC’s 15-17)

x Manufacturing (SIC’s 20-39)

x Transportation and public utilities (SIC’s 41-42 and 44-49)

x Wholesale trade (SIC’s 50-51)

x Building materials and garden supplies (SIC 52)

x General merchandise and food stores (SIC’s 53 and 54)

x Hotels and other lodging places (SIC 70)

x Repair services (SIC’s 75 and 76) SUPPLEMENTARY RECORD OF OCCUPATIONAL INJURIES AND

ILLNESSES. To supplement the Log and Summary of Occupational Injuries and Illnesses, each employer must have available a record for each occupational injury or illness at each establishment within six working days after receiving information that a recordable case has occurred, OSHA Form No. 101 may be used for this purpose. State of Iowa Form No. 14-0001 [(IAIABC Form 1.2 (12/98)], workers' compensation or other reports are acceptable as records if they contain the information required on OSHA Form No 101. These records must be available in the establishment without delay and at reasonable times for examination by representatives of the Iowa Division of Labor Services, the U.S. Department of Labor and the U.S. Department of Health, Education and Welfare. The records must be maintained for a period of not less than 5 years following the end of the calendar year to which they relate.

x Amusement and recreation services (SIC 79)

x Health services (SIC 80), and

x State and local government (Above SIC ‘s plus 91-97).

If employers in any of the industries listed above have more than one establishment with combined employment of 11 or more employees, records must be kept for each individual establishment.

All employers, including small employers and those in exempted SIC’s, must continue to meet the requirement to report fatalities or multiple (3 or more) hospitalizations and all occupational injuries or occupational illnesses that result in a workers' compensation case.

If an employer is notified in writing by the Bureau of Labor Statistics about having been selected to participate in a statistical survey, such employer, including small employers, and those in exempted SIC’s, must maintain a log and summary of all occupational injuries and illnesses for that year. The notification will contain the necessary form and instructions to comply with the survey requirements.

The Iowa Workers’ Compensation Act

The following is a summary of the recordkeeping and reporting responsibilities of employers under the Iowa Workers’ Compensation Act.

RECORDS AND REPORTS

Every employer shall keep a record of all injuries sustained by employees in the course of their employment resulting in incapacity for longer than one day. An employer with notice or knowledge of an injury which temporarily disables an employee for more than three (3) days or results in permanent total disability, permanent partial disability or death is required to electronically file a report with the Workers' Compensation Commissioner within four (4) days from such event when such injury is alleged by the employee to have been sustained in the course of employment.

All books, records, and payrolls of an employer are required to be open for inspection by the Workers' Compensation Commissioner for purposes of administration of the Iowa Workers’ Compensation Act.

The Workers' Compensation Commissioner may require an employer to appear and show cause why the employer should not be subject to a civil penalty of $1,000.00 per occurrence for failure to comply with the reporting or inspection requirements. Upon hearing, if the facts indicate, the commissioner may enter an order requiring payment of such penalty. Unless voluntarily paid, the commissioner may petition the district court for entry of judgment on the order. The employer’s insurance carrier shall be responsible in the same manner and to the same extent as the employer when a report of injury has been submitted to the employer’s insurance carrier and not filed by them with the Workers' Compensation Commissioner.

The employer is required to furnish to an employee, on request, one statement of earnings, wages, or salary for the year preceding the injury. An employer may be subject to a civil penalty of $1000.00 per offense for refusal to furnish such wage statement.

ANNUAL SUMMARY. Each employer subject to the recordkeeping requirements must prepare a summary of the occupational injury and illness experience of the employees in each of the employer’s establishments at the end of each year based on the information contained in the log and summary of occupational injuries and illnesses for the particular establishment. OSHA Form No. 200 shall be used for this purpose. The summary shall be signed and posted in a place accessible to the employees no later than February 1 and shall remain in place until March 1. For employees who do not report to work at a single establishment, or who do not report to any fixed establishment on a regular basis, employers shall satisfy the posting requirement by presenting or mailing a copy of the annual summary during the month of February to all such employees who receive pay during that month. Summaries must be retained for 5 years following the end of the calendar year to which they relate.

EMPLOYEES NOT IN FIXED ESTABLISHMENTS. Employers of employees engaged in physically dispersed operations such as occur in construction, installation, repair or service activities who do not report to any fixed establishment on a regular basis but are subject to common supervision may satisfy the recordkeeping provisions with respect to such employees by:

(a) Maintaining the required records for each operation or group of operations which is subject to common supervision (field superintendent, field supervision, etc.) in an established central place;

(b) Having the address and telephone number of the central place available at each worksite; and

(c) Having personnel available at the central place during normal business hours to provide information from the records maintained there by telephone and by mail.

(Note: This regulation does not automatically apply to all construction, installation, repair or service activities. If in doubt about applicability to your operations, contact the Iowa Division of Labor Services.)

Records for personnel who do not primarily report or work at a single establishment, and who are generally not supervised in their daily work, such as traveling salespersons, technicians, engineers, etc., shall be maintained at the location from which they are paid or the base from which personnel operate to carry out their activities.

REPORTING REQUIREMENTS

Regulations issued under the Iowa Occupational Safety and Health Act require all employers subject to the Act to report to the Iowa Workers' Compensation Commissioner any occupational injury or illness which temporarily disables an employee for more than three days or which results in permanent total disability, permanent partial disability, or death. The report must be filed electronically in conformity with EDI requirements with the Iowa Division of Workers' Compensation within four days from such event when the injury or illness is alleged by the employee to have been sustained in the course of the employee’s employment. A report to the Iowa Division of Workers' Compensation is considered to be a report to the Iowa Division of Labor Services. The Iowa Division of Workers' Compensation shall forward all such reports to the Iowa Division of Labor Services.

In addition, employers must report to the Iowa Labor Commissioner within 8 hours each accident or health hazard that results in one or more fatalities or hospitalization of three or more employees.

Those establishments selected to participate in the annual Occupational Injuries and Illnesses Survey will be required to prepare a report (OSHA Form No 200-S) based on entries contained on the Log and Summary of Occupational Injuries and Illnesses.

INSTRUCTIONS

An employer with notice or knowledge of an injury which temporarily disables an employee for more than THREE (3) days or results in permanent total disability, permanent partial disability or death is required to electronically file a first report of injury with the Iowa DIVISION OF WORKERS' COMPENSATION within FOUR (4)

days from such event when such injury is alleged by the employee to have been sustained in the course of the employee’s employment. A report to the Iowa DIVISION OF WORKERS' COMPENSATION is considered to also be a report to the Iowa DIVISION OF LABOR SERVICES. The Iowa DIVISION OF WORKERS' COMPENSATION forwards the report to the Iowa Division of Labor Services. Employers should report ALL injuries to their insurance carrier or third party administrator. ALL REPORTS MUST BE FILLED IN COMPLETELY AND SIGNED. PLEASE TYPE OR PRINT LEGIBLY.

This form contains all items requested on OSHA form No 101, “Supplementary Record of Occupational Injuries and Illness.”

THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER Iowa Code § 22.11.

(5)

W

A G E

S

T A T E M E N T

Employer:

Employee:

Please provide the

52 weeks

of wages prior to the date of injury of

Date employee ceased to work:

Date Hired

Number of Hours employee is scheduled to work per week:

Claim Number

Is employee paid by hour, day, week or month

At what rate:

Does Employee work Overtime

Yes

No If yes, is Overtime mandatory

Yes

No

State the date and amount of any pay increases during the past 52 weeks

Date

Amount

Date

Amount

Date

Amount

Date

Amount

Dates Incl of each

Week Pd

Wkd

Hrs

Regular

Pay

Overtime

Pay

Dates Incl of each

Week Pd

Wkd

Hrs

Regular

Pay

Overtime

Pay

From

To

Yr

From

To

Yr

1

27

2

28

3

29

4

30

5

31

6

32

7

33

8

34

9

35

10

36

11

37

12

38

13

39

14

40

15

41

16

42

17

43

18

44

19

45

20

46

21

47

22

48

23

49

24

50

25

51

26

52

SUBTOTAL

SUBTOTAL

GRAND TOTAL

This is a correct statement of Employee’s earnings as actually taken from Payroll Records

Employer’s Signature

Title

Date

(6)

AUTHORIZATION TO RELEASE INFORMATION

REGARDING CLAIMANTS SEEKING WORKERS' COMPENSATION BENEFITS

Name

of

Patient:

Date

of

Birth:

SECTION I. AUTHORIZATION FOR RELEASE OF INFORMATION AND FOR REDISCLOSURE

I authorize

to disclose and deliver to:

the following information related to me: Any and all information EXCEPT substance abuse (drug or alcohol), mental

health, and AIDS-related information, unless specifically authorized to be released in section II of this form.

NOTE:

If the information includes mental health treatment, substance abuse treatment or HIV-related information it will

not be released unless the undersigned patient agrees to the release on the reverse side of this form.

I understand the information is being disclosed and may be used only for legal and/or litigation purposes relating to

claims and/or suit against

I understand that this Authorization may be used to obtain information from health care providers, schools, former and

current employers, providers of vocational rehabilitation services, the Social Security Administration, and the Iowa

Department of Workforce Development. I understand that I have a right to inspect the disclosed information at any

time. This authorization is effective until the conclusion of a contested case on the claim. I understand that I may

revoke this Authorization, except to the extent that action has already been taken in reliance upon it, by giving written

notice to the health care provider or record keeper. I also understand that if I revoke, the revocation will take effect on

the day it is received in writing by the entity from whom disclosure is sought.

I understand that if the person or entity that receives the information requested is not covered by the federal privacy

regulations or is not an individual or entity who has signed an agreement with such a person or entity, the information

described above may be redisclosed and will no longer be protected by the regulations.

Iowa and Federal law provide that I have a right to prohibit redisclosure of confidential medical information and further

disclosure may not be had without my express written authorization, except as indicated below. I understand that the

Recipient of this Authorization, WITHOUT FURTHER AUTHORIZATION, may redisclose this information to:

Parties and their legal counsel, insurers, experts, potential experts, but only after they have been advised of their

obligations under the law and this authorization, including the prohibition against redisclosure of this

information; Agents, employees or representatives of the parties, but only after they are involved in

conducting the prosecution or defense of the case, and only after they have been advised of their

obligations under the law and this authorization, including the prohibition against redisclosure of this

information; Administrative agency and court officials hearing the claim, and their support staff.

I SPECIFICALLY AUTHORIZE AND CONSENT TO ANY SAID DISCLOSURE AND REDISCLOSURE DESCRIBED

ABOVE.

Claimant or Legal Representative

Date

(7)

SECTION II. SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR

FEDERAL LAW CONCERNING MENTAL HEALTH, SUBSTANCE ABUSE TREATMENT OR AIDS-RELATED

INFORMATION

I acknowledge that information to be released may include material that is protected by Federal and/or State law

applicable to substance abuse, mental health, and/or AIDS-related information. I SPECIFICALLY AUTHORIZE the

release of confidential information relating to: [Place "YES" or "NO" in ALL applicable boxes:]

___ Substance Abuse (Drug or Alcohol) information from all health care providers and facilities and any

other person or entity in possession of records concerning me.

___ Mental Health information from all health care providers and facilities and any other person or

entity in possession of records concerning me.

___ HIV or AIDS-related information, Diagnosis, and test results from all health care providers and

facilities and any other person or entity in possession of records concerning me.

Furthermore, I SPECIFICALLY AUTHORIZE disclosure and re-disclosure of this confidential information to all of the

persons referred to in the REDISCLOSURE Section I.

In order for the above information to be released you must sign here AND at the end of Section I

Signature of Claimant or Legal Representative

Date

Street

Address

City/State/

Zip

Code

Printed Name and Relationship of Claimant's Legal Representative

Federal and/or State law specifically require that any disclosure or REDISCLOSURE of substance abuse, alcohol or

drug, mental health, or AIDS-related information must be accompanied by the following written statement:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR

Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further

disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise

permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT

sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or

prosecute any alcohol or drug abuse patient.

See also Chapter 228 of the Iowa Code and Section 141.23(3) of the Iowa Code and other applicable laws.

14-0043 (11-04) This form my be used in connection with claims under the jurisdiction of the Iowa Workers’

Compensation Commissioner.

(8)

W

ORKERS

C

OMPENSATION

M

ANAGED

C

ARE

P

ROGRAMS

Tower Group Inc. 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 Inc. 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 Medial 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 x4680. Provide the Coventry representative your

employer information, the specific provider specialty you need and your geographic area (city, state and zip

code). The Coventry representative will provide verbally provide you with a list of providers meeting your

requirements or an electronic provider directory can be forward to you via e-mail.

2.

Internet Access:

For the standard national workers compensation network

go to

www.talispoint.com/cvty/twrgrp

and select the Coventry Integrated Network to search for providers in your geographic network.

You will be able to generate provider directories as well as determine whether a specialty physician

is a member of the Network. If you participate in a Specialty Network, such as a MPN or HCN,

select the applicable network from the drop down box.

(9)

a.

For the

Texas HCN

Specialty Network

go to

www.talispoint.com/cvty/twrgrp

and click

on any of the search buttons. In order to select the proper Texas HCN network, please select the

Coventry HCN from the Networks drop down box.

b.

For the

California MPN

Specialty Network

go to

www.talispoint.com/cvty/twrgrp

and

click on any of the search buttons. In order to select the proper CA MPN network, please select the

First Health Select CA MPN from the Networks drop down box.

c.

For large panel card production or if you require additional information regarding web

access please contact Tower Group Inc. 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 Inc. 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 adjuster, or Tower Group Inc Managed Care Services, if you have any questions regarding these

programs.

(10)

Re: Important Information about your Workers’ Compensation Prescriptions

This letter is provided to inform you that your employer’s workers’ compensation, Tower Group

Companies, has selected PMSI as its workers’ compensation pharmacy partner.With PMSI, you can

choose to pick-up your medications for your work-related injury at a nearby pharmacy through a

program known as Tmesys

®

,

or have them delivered to your home through the mail.

Within the next few weeks, you will receive a new workers’ compensation pharmacy card in the mail.

You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your

next refill or new prescription for your work-related injury.

If you do not receive your new pharmacy card within two weeks, please call Tmesys at 1.866.599.5426

and we will be happy to assist you or send another card. If you are interested in finding out about how

to receive your prescriptions through the mail, please call 1.800.304.1764.

To help you transition to the new pharmacy program, we have

provided answers to some frequently asked questions:

Q: How do I know if my pharmacy participates with the new program?

A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the

Pharmacy Center on our website, www.pmsionline.com/pharmacy-center. Click on “Pharmacy

Locator” and select how you would like to search for a nearby pharmacy. You may also call the

helpdesk at 1.866.599.5426 to find a network pharmacy near you.

Q:

How does this affect my workers’ compensation claim?

A:

Using PMSI’s program for your workers’ compensation medications will enable you to continue to

receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy,

as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you

can have your prescriptions delivered to your home through our convenient mail order program.

Q: Who do I call with questions about the program?

A: PMSI has representatives available to help you with any questions that you may have about the

pharmacy program. Please call our help desk at 1.866.599.5426 to speak to a representative. If you

have any questions about your workers’ compensation claim, we will help you reach your claims

adjuster for assistance.

We look forward to serving you and meeting your workers’ compensation medication needs.

Sincerely,

PMSI

¿Necesitas ayuda en

español? Llame al

(11)

(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

(12)

(

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?

(13)

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