WORKERS’ COMPENSATION
Claims Kit
Dear Customer,
Thank you for choosing ProSight Specialty Insurance as your Workers’ Compensation Insurance carrier. We pride ourselves on providing excellent service and will do our very best to meet your Workers Compensation Claims needs.
ProSight Specialty Insurance writes our Workers’ Compensation policies through our New York Marine and General Insurance Company underwriting company, which is the name you will see listed on your policy.
ProSight has partnered with a leading Workers’ Compensation claims service provider, Gallagher Bassett Services, to assist us in the administration of claims. Gallagher Bassett will be your primary point of contact for claims. To determine which office will be handling your claims, please refer to the map included with this packet.
Please make sure to include your Policy Number on all correspondence.
For your convenience, the following documents can be found inside your claims kit:
• Instructions on how to report a claim
• Claim Handling Map
• List of Claim office locations, mailing addresses, and claim contacts
• How to locate a Physician
• Pharmacy cards
• Links to your state’s Workers’ Compensation forms and Web Pages Please do not hesitate to contact us should you have any questions or concerns. Workers’ Compensation Claims Department
ProSight Specialty Insurance 412 Mt. Kemble Avenue Morristown, NJ 07960
Phone: 800-774-2755 Fax: 855-657-3534
Need to Report a Claim?
By e-mail:
[email protected]
By phone:
(800)-774-2755
Press ‘1’ to report a claim
(Available anytime- days, nights & weekends)
Press ‘2’ to inquire about a claim
(Available 8:00am to 5:00pm EST)
By fax:
(800)-326-2864
By Mail:
ProSight Specialty Insurance Claims Department
412 Mt. Kemble Avenue
Suite 300C
Morristown, NJ 07960
Additional Instructions:
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EXPERIENCED PROFESSIONALS.
Workers’ Compensation
Claim Handling
California Nevada Texas Florida Maine Pennsylvania Louisiana New York New Jersey Oregon Washington Idaho Ohio Kansas Arizona New Mexico Utah North Dakota South Dakota Oklahoma Montana Wyoming Colorado Iowa Minnesota Michigan Indiana Wisconsin Missouri Illinois Nebraska Massachusetts Rhode Island New Hampshire Vermont Connecticut Delaware Maryland Virginia West Virginia Kentucky Tennessee North Carolina South Carolina Georgia Alabama Mississippi ArkansasProSight Specialty Insurance
Gallagher Bassett Services
LWP Claims Solutions
Monopolistic
Alaska
Mailing
Workers’ Compensation Claims Department
ProSight Specialty Insurance
412 Mt. Kemble Avenue
Morristown, NJ 07960
[email protected]
Phone: 800-774-2755
Fax: 855-657-3534
Claims Handling Offices |
ProSight Specialty Insurance
Contacts
WC Claims Manager: Melissa Kovacsy
[email protected]
Lost Time Adjuster: Patrick Gano
[email protected]
Medical Only Adjuster: Melinda Bullock
[email protected]
Alabama
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Massachusetts
Michigan
Minnesota
Missippi
Missouri
Nebraska
New Hampshire
New Jersey
New York
North Carolina
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Virginia
West Virginia
Wisconsin
Mailing
Wilton Adjustment Service, Inc. – 425
625 E. 34th Avenue, Suite 400
Anchorage, AK 99503
Phone: 907-276-3311
Fax: 907-276-7877
Contacts
Branch Manager:
Joanne Pride, x 3412
[email protected]
Adjuster:
McKenna Wentworth, x 3452
[email protected]
Medical Only:
Shea Loescher, x 3317
[email protected]
Claims Handling Offices |
Alaska
Mailing
Gallagher Bassett Services- 007 (Phoenix)
PO Box 10849
Scottsdale, Arizona 85271
Phone: 480-586-9500
Fax: 480-443-8416
Toll Free: 800-231-3759
Contacts
Branch Manager: Bruce Martin
[email protected]
Claims Handling Offices |
Arizona
Mailing
Gallagher Bassett Services -162
900 Fort Street, Suite 420
Honolulu, HI 96813-4511
Phone: 808-532-7362
Fax: 808-545-5967
Toll Free: 877-492-9645
Contacts
Nadine Kurihara-Nakasu, Branch Manager
[email protected]
Claims Handling Offices |
Hawaii
Mailing
Gallagher Bassett Services – 193
720 East Park Blvd., Suite 125
Boise, ID 83712
Phone: 208/345-8090
Fax: 208/345-3996
Toll Free: 866/217-1192
Contacts
Regina Pearson, Branch Manager
[email protected]
Claims Handling Offices |
Idaho
Mailing
Gallagher Bassett – 080 (Missoula)
2501 Catlin Street, Suite 200
Missoula, MT 59801
Phone: 855-335-7892
Fax: 406-721-2735
Contacts
Regina Pearson
208-515-3835
[email protected]
Claims Handling Offices |
Montana
Mailing
Gallagher Bassett Services – 156
P.O. Box 70030
Las Vegas, NV 89170
Phone: 702-789-4500
Toll Free: 866-889-4755
Fax: 866-823-4130
Contacts
Charles Rostad, Branch Manager
[email protected]
(UPS, Federal Express, etc)
2110 E. Flamingo Road, Suite 314
Las Vegas, NV 89119
Claims Handling Offices |
Nevada
Mailing
Gallagher Bassett Services - 046
2424 Louisiana NE, Suite 220
Albuquerque, NM 87110
Phone: 505-837-2180
Fax: 505-837-2187
Toll Free: 866-859-2180
Contacts
Regina Pearson, Branch Manager
[email protected]
Claims Handling Offices |
New Mexico
Mailing
Gallagher Bassett Services - 132
6303 Waterford Blvd., Suite 120
Oklahoma City, OK 73118
Phone: 405/843-7244
Fax: 405/843-8658
Toll Free: 800/943-7244
Contacts
Stacy Goble, Branch Manager
[email protected]
Claims Handling Offices |
Oklahoma
Mailing
Gallagher Bassett Services – 155 (Portland)
4550 Kruse Way, Suite 155
Lake Oswego, OR 97035
Phone: 503-675-6575
Fax: 503-675-6574
Toll Free: 877-800-3059
Contacts
Eric Sorem, Branch Manager
[email protected]
Claims Handling Offices |
Oregon
Mailing
Gallagher Bassett Services - 025 (Dallas)
6404 International Parkway, Suite 2300
Plano, Texas 75093
Phone: 972-931-6277
Fax: 972-931-6256
Toll Free: 800-382-0166
Contacts
Terry Tarter, Branch Manager
[email protected]
Claims Handling Offices |
Texas
Navigating the Coventry Medical
Provider Directory Website
Use this search tool to locate Medical Providers
ONLY If your claims are administered by
Gallagher Bassett
• Go to www.firsthealth.com/welcome
• Enter Login ID: GBMCS
• A new page will appear, click on the link “Channeling Tools”
• The next page will give you four options to choose from:
• Address Search: This option is a radius search from a centralized address.
• Name Search: Allows the user to look up a certain provider in the database by name or phone.
• Region Search: This option allows the user to search in a specific region such as city, county, zip code, etc.
• Quick Search: A search using a limited number of specialties for providers who provide initial treatment to a maximum radius of 35 miles around an address. Creates output to a custom Worksite Poster or Directory.
• Worksite Posters: This option allows the user to make a Worksite Poster with the closest network providers while following all jurisdictional regulations and guidelines.
ADDRESS SEARCH
Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties and/or distance. Once you click on “find providers” your results will be displayed.
NAME SEARCH
Use the Name Search tab if you already know a Provider’s name, group affiliation or phone REGION SEARCH
Use this feature if you are searching for a provider in a specific area. QUICK SEARCH
Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine,
Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific address.
WORKSITE POSTER (WSP)
This page is used to create Worksite Posters or batches of Posters. For your convenience, you can upload your Locations and create your posters!
Temporary Prescription Services ID
For Claims Administered by Gallagher Bassett
Attached you will find a prescription form (also called a temporary pharmacy
card) that must be given to each and every employee when there is an on the
job injury. Employees simply call the First Script number to locate a local
pharmacy where they can get their Workers Compensation prescription(s) filled.
It is a good idea to distribute these forms to your Supervisors, Team Leaders,
and your Human Resources department so they are familiar with the form.
Chances are they will receive the notices of injury and will likely be responsible
for handing the form to the injured employee.
PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES
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Programa de Beneficio Farmacéutico
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Dear Policyholder:
For your convenience, we have included the following website addresses to your state’s Workers’ Compensation web page. From the links below, you can access any forms that you might need when submitting a Workers’ Compensation claim.
Alabama http://dir.alabama.gov Alaska http://www.labor.alaska.gov/wc/ Arizona http://www.ica.state.az.us/ Arkansas http://www.awcc.state.ar.us/ California http://www.dir.ca.gov/dwc/ Colorado http://www.colorado.gov/ Connecticut http://wcc.state.ct.us/ Delaware http://www.delawareworks.com/ DC http://www.does.dc.gov/does/ Florida http://www.myfloridacfo.com/wc Georgia http://sbwc.georgia.gov/portal/ Hawaii http://hawaii.gov/labor/rs/ Idaho http://www.iic.idaho.gov/ Illinois http://www.iwcc.il.gov/ Indiana http://www.in.gov/wcb/ Iowa http://www.iowaworkforce.org Kansas http://www.dol.ks.gov/wc/about.html Kentucky http://www.labor.ky.gov/ Louisiana http://www.laworks.net/ Maine http://www.maine.gov/wcb/ Maryland http://www.wcc.state.md.us/ Massachusetts http://www.state.ma.us/wcac/ Michigan http://www.michigan.gov/wca Minnesota http://www.doli.state.mn.us/ Mississippi http://www.mwcc.state.ms.us/ Missouri http://labor.mo.gov/ Montana http://erd.dli.mt.gov/ Nebraska http://www.wcc.ne.gov Nevada http://dirweb.state.nv.us/WCS/wcs.htm New Hampshire http://www.labor.state.nh.us/ New Jersey http://lwd.state.nj.us/labor/wc/wc_index.html New Mexico http://www.workerscomp.state.nm.us/ New York www.wcb.state.ny.us North Carolina http://www.ic.nc.gov/forms.html North Dakota http://www.workforcesafety.com/ Ohio http://www.ohiobwc.com/ Oklahoma http://www.owcc.state.ok.us/ Oregon http://www.cbs.state.or.us/wcd/ Pennsylvania http://www.portal.state.pa.us Rhode Island http://www.dlt.ri.gov/wc/ South Carolina http://www.wcc.sc.gov/Pages/default.aspx South Dakota http://dlr.sd.gov/workerscomp/ Tennessee http://www.tn.gov/labor-wfd/ Texas http://www.tdi.state.tx.us/forms/ Utah http://www.laborcommission.utah.gov/ Vermont http://www.labor.vermont.gov/ Virginia http://www.vwc.state.va.us/portal/ Washington http://www.lni.wa.gov/ West Virginia http://www.wvinsurance.gov/ Wisconsin http://dwd.wisconsin.gov/wc/ Wyoming http://doe.wyo.gov/aboutus/
