Protected Self-Insurance Program

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Diocese of Pensacola-Tallahassee

The Ecclesiastical Province of Miami, Inc.

A Florida Not-for-Profit Corporation

Diocese of Pensacola-Tallahassee

The explanations contained here are for general information. The actual insurance coverage applicable is subject exclusively to the terms and conditions contained in the insurance policies contracted between The Ecclesiastical Province of Miami, Inc. and the various insurance companies.

Protected

Self-Insurance

Program

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Diocese of Pensacola-Tallahassee 11 N. “B” Street

Pensacola, FL 32502

REVISED January 2010

Diocese of Pensacola-Tallahassee

Dear Pastors, Administrators and Principals:

As you are aware, our Diocese is part of the Ecclesiastical Province of Miami (EPM) self-insurance program in partnership with five other dioceses in Florida.

The self-insurance program represents a tremendous improvement over regular commercial insurance coverage. Under the self-insurance plan, whatever amount of money we spend as a result of any “regular” loss we incur comes out of our own self-insurance fund. No self-insurance company is involved. It is our own funding, which pays for the loss or claim.

By the same token, any loss or claim that can be prevented means we are not wasting our own money. Careful attention in eliminating risk is money saved for each parish. We must be prudent stewards of the church property, which has been provided by the generosity of our Catholic people.

In addition to the self-insurance feature, the dioceses must purchase excess insurance coverage for protection in the event of a catastrophe, such as a named windstorm or hurricane, a devastating fire, or serious personal injuries due to negligence.

Please study this booklet so that you are familiar with the self-insurance program. It is essential that each of us take positive steps to protect the Diocese against liability claims by addressing all safety recommendations aimed at reducing risk.

With gratitude for your continuing cooperation and with kindest personal regards, I remain.

Sincerely yours in Christ,

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What Protected Self-Insurance Is

A program to provide property, general liability (including directors and officers and errors and omissions), automobile liability, workers compensation, and crime coverage under one comprehensive plan for all parishes and agencies of The Diocese.

The term “Diocese” as used in this booklet includes all parishes, schools, diocesan institutions, cemeteries and agencies (nursing homes, housing projects, etc.) of the Diocese insured under the EPM program. Billings collected by the Diocese will be utilized to pay the losses incurred, to provide the necessary administrative service, and to purchase excess insurance to cover a catastrophe or series of catastrophes. The Self-Insurance program demands an increased awareness of and responsibility for establishing and maintaining safe conditions and a prompt correction of improper, hazardous or unsafe conditions. The benefits are obvious for the continued well – being and safety of the people of the Diocese, the protection of property and the cost of the program.

To assist the Diocese in reducing and controlling risks, AJG Loss Control service will provide Safety Reports, Risk Improvement Surveys, and/or training sessions as needed or requested. These reports may suggest remedial steps necessary at facilities under your control. They will frequently point out the existence of hazardous conditions that should be controlled to prevent a loss.

It is the responsibility of the Pastor, the Principal or Administrator of the entity to take the steps necessary to reduce the hazards that are identified as well as any other that they may notice themselves.

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What Is Covered

Property Coverage

Property owned by the Diocese including buildings, their contents and equipment, fine arts, money and securities, valuable papers, accounts receivables, business income, builders risk, and extra expense.

Buildings

Buildings are covered for risks of direct physical loss up to the lesser of the cost to repair or replace the damage property (with materials of like kind and quality) or 115% of the value on schedule at time of the loss.

Contents

Coverage on contents is identical to the coverage provided for buildings, subject to a similar valuation limitation.

Glass

Glass, including school and church windows, is covered. Glass broken as a result of vandalism is covered on an occurrence basis.

Limited Fine Arts

Stained and art glass, paintings and other art objects are also covered up to $5,000 per item ($2 million maximum per occurrence) unless specifically declared and scheduled in which case they are covered up to their declared value. Contact the Pastoral Center if you wish to add additional coverage under Fine Arts.

Sacred Vessels

All sacred vessels such as the ciborium, monstrance, and chalice are covered.

*Property to be covered by insurance must be listed

on the Schedule or otherwise it may not be covered. Property of others in the care, custody and control of the insured or for which the insured is liable via a written contract is also covered.

Priests Personal Effects Coverage

This coverage is supplementary to individual policies, which are advisable to have if personal effects exceed $20,000 in value, such as

furnishings, chalices, coin collections, golf clubs, cameras, musical instruments and other personal belongings.

New Construction (Builders Risk)

New construction is covered upon reporting to AJG and prior to commencement of construction. Building structures and materials owned by the Diocese and intended to be part of said structure on the job site are included. A charge will be made based on the cost of construction. (A limit of $10,000,000 per occurrence applies).

Property of the contractors and their employees, such as tools, equipment, sheds, and machinery is

not covered.

The contractor shall provide a Certificate of Insurance, which will verify General Liability, Auto Liability and Workers’ Compensation coverage. The certificate for the General Liability policy should include coverage for Premises and Operations, Contractual and Completed Operations, and name the Bishop and the Diocese as an additional insured for limits not less than $1,000,000. For Auto Liability $1,000,000 coverage is also required as well as statutory limit for Workers’ Compensation Coverage. The certificate/policy should also provide at least 30 days notice of cancellation to the Diocesan Pastoral Center Insurance Office (Pastoral Center.)

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What Is Covered

General Liability Coverage

General Liability provides coverage for personal injury and property damage where the Diocese, parishes, institutions, cemeteries, and agencies covered by the program may be legally liable (injury to employees is covered by Workers’ Compensation – not General Liability).

The following is included:

Premises and Operations, including food service, Special Events sponsored by the Diocese, the parishes, or institutions, such as meetings, parties, bazaars, picnics or outings. Festival/Carnival rides operators

need to sign a special contract and provide insurance. See special conditions section.

Large and/or unusual events may require separate insurance. Please contact your Diocesan Insurance Office/ Pastoral Center.

Coverage protects employees (but not their personal property) while acting within the scope of their employment/assigned activity.

Directors and Officers Liability for Diocesan Boards.

Errors & Omission, including Employment Practices Liability for school leaders (principals and teachers), nursing home nurses, counselors, etc. (excluding other medical practitioners).

The term “Personal Injury” includes libel, slander, false arrest, defamation of character, invasion of privacy, wrongful eviction, discrimination, shock and mental anguish, and contractual liability on written contracts.

Host Liquor Liability for parish or institution sponsored affairs is included.

Premises Medical Payments are excluded

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Automobile Coverage

Automobile liability involving Diocesan owned or leased or rented vehicles is covered by this program if the Diocese, parish, institution, cemetery or agency is held legally liable for personal injury, including property damage, as a result of operating the vehicle.

Personal Injury Protection

• P.I.P. – Florida No-Fault Statutory Coverage is included. • Uninsured/Underinsured Motorist Coverage are excluded.

• The Diocese waives any Uninsured Motorist/Underinsured Coverage. There is no coverage.

• Auto Medical Payments are excluded in the program.

Auto Physical Damage

Collision coverage is provided to all covered vehicles if the vehicle is damaged in a collision with another vehicle or object. Collision coverage is written on an actual cash value basis. $1,000 deductible. No deductible for windshield damage.

Comprehensive coverage is provided on an actual cash value basis for repair or replacement costs as a result of fire, theft, vandalism, glass breakage, hail, windstorm, explosion, and flood. $1,000 deductible. No deductible for windshield damage.

Leased and or Rented Cars are also covered when rented for Diocesan business purposes.

15-Passenger Vans are excluded. 12-Passenger vans built on a 15-passenger van frame are also

excluded.

Other Coverage

Workers’ Compensation

Coverage is afforded under the Florida Workers’ Compensation statutes for payment of medical costs, and compensation to employees for injury arising out of the performance of their duties. Priests and religious are exempt from Workers’ Compensation.

Fidelity Bond

Coverage includes all employees, priests, religious and volunteers.

Money and Securities

Limited Money and Securities Coverage is included

What Is Covered

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What Is Not Covered

• Property owned by third parties, including employee owned property. • Priest-owned personal automobiles.

• Priest and religious liability when on personal business.

• Certain types of property loss of a degenerative nature, such as wear and tear, deterioration, loss due to termites, corrosion, mechanical or electrical breakdown, etc.

• Unexplained loss of money, securities, property, or mysterious disappearances. • War risk, nuclear damage, pollution liability, mold and asbestos.

• Student accident medical reimbursement insurance programs covered by separate policy. • Uninsured/Underinsured Motorist Coverage.

• All aircraft and any water craft over 26 feet.

Please refer to diocesan insurance personnel or Arthur J. Gallagher & Company should you have any other questions about what is covered or not covered under the province/diocesan self insurance program.

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Any hired buses, carnival operators and their equipment, etc., must be properly covered by insurance provided by the contracted service. A certificate of insurance must be obtained by the parish, school, institution or agency contracting for the service. The parish or institutions, the Bishop, and the Diocese, must be named in the certificate as “Additional Insured.” This certificate must be submitted to the parish or institution with the contract and a copy of the certificate should be forwarded to the Diocese-Pastoral Center 10 working days prior to the event for review as needed.

Other Contracted Services

Companies such as lawn maintenance, exterminator service, janitorial service, etc., working on Diocesan property must provide insurance certificates showing current insurance coverage for general liability and workers’ compensation, prior to commencing work. The Pastor, Principal or Administrator is responsible for obtaining the first certificate and renewals thereof.

Limits of at least $1,000,000 should be required. Higher limits may be needed in certain cases.

Contact your Chancery office (Pastoral center) when in doubt.

If any Diocesan property is rented or provided to others for gatherings, the individual organization will be required to provide a certificate of insurance naming the entity, the Diocese, and the Bishop as

“Additional Insured.”

No certificates are required from parish organizations.

Facilities Use

The Space Usage Agreement Form (to be obtained from the Diocesan office ) is to be completed for any use of Diocesan property along with a certificate of insurance showing proof of General Liability with limits no less than $1,000,000, and Workers Compensation coverage and Auto Liability coverage where applicable. Also the Diocese, the entity and the Bishop needs to be named as an additional insured on all certificates.

Motor Vehicle Reports

MVRs are to be obtained for you by Arthur J. Gallagher & Co. - MIAMI telephone 800-488-3003 or FAX 305-716-3293. MVRs are to be requested on every person, employees and volunteers, whose occupation requires either driving a Diocesan vehicle or their own on behalf of the Diocese including all parishes, schools, institutions and agencies of the Diocese on a regular basis. The name, date of birth and the driver’s license number are required, forms can be obtained by contacting your Chancery office (Pastoral center). Please allow 3 business days for processing.

Any license record that shows 6 points or more during the last 36 months, a DUI, a suspended or revoked status will not be approved to drive on Diocesan business. In compliance with current privacy standards, the entity will only receive a yes or no response from AJG. Drivers that wish to get a copy of their MVR will need to request it from the Florida Department of Motor Vehicles directly.

Special Conditions to Be Considered

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Who provides what in our Diocese

• Risk Management consulting and evaluations (AJG – Miami) • Review Contracts and Certificates of Insurance (AJG – Miami) • Claims handling – Third-Party Administrator (Gallagher Bassett)

• Subrogation; Collection of claims against others for damages (Gallagher Bassett)

• Risk Control Assessment, safety inspections, and accident avoidance recommendations (AJG – Safety and Loss Control)

• Safety training seminars (AJG – Safety and Loss Control)

• Issue certificates of insurance as required by the Diocese or other agencies (AJG – Miami) • Motor vehicle reports on drivers (AJG – Miami)

Special Features of the Program

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Loss Prevention Services

Loss Prevention Services play an important role in reducing accidents and property loss. These services cover a wide range of activities that include assessments, preventive measures, training and management tools.

The AJG Loss Control Team will continue to develop, maintain and manage these services to provide a maximum benefit to each entity throughout the Diocese. Each entity is encouraged to participate with these resources and contact AJG for support. Listed below are core

elements for Risk Management:

Risk Management Coordinator

The Risk Management Coordinator (RMC) is the point of contact for their entity (Church, Mission, School or Charity) for information and training resources that reduce exposure to risk of injury or property loss. Each location should appoint a RMC. If they are able, Pastors and Principals or Managers are always welcome to take this role, but if they are not, it will only be successful if their delegate has their support. Good candidates include the Parish Office Manager or Senior Level Maintenance Person. The RMC will help facilitate successful Loss Control Programs with minimal time investment. RMC duties include:

• To be the point of contact and conduit for their location and help disseminate Loss Control initiatives and information.

• To help facilitate the Worker Protection Training Program • Foster a culture committed to reducing accidents and injuries • Call AJG Risk Management Consultant for support

• Meet once a year in person and three more times a year through Risk Management Coordinator Webinars

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Accident Kit

The Red Accident Kit was developed and sent to all entities. It contains key telephone numbers, Guidance Documents, Accident Forms, Voluntary Statement Form, and a disposable camera to help manage and collect data for any type of accident or property loss. By using these forms, critical information can be collected to help manage any potential claim. The forms themselves do not guarantee any particular coverage but assist in the overall investigation of what led to the loss. The forms also help determine what steps can be taken to prevent future losses. Each location should have at least one Accident Kit located in a central location that is easily accessible to staff members. Supervisory staff members should be trained on its contents and location. The kit includes guidance on the following:

• How to handle medical emergencies

• How to report an accident or incident to Gallagher Bassett

• How to be prepared before, during and after an accident or property loss

• Where to send a worker if an injury is non-life threatening for follow up medical treatment • Tools and forms used to accurately record information related to an injury or property loss

Safety and Loss Control Site Visit

AJG Risk Control Services schedules and conducts on site exposure assessment and analysis at Diocesan affiliated properties. An initial meeting with the Pastor, Principal or Director is held where the Safety Metric is applied to measure participation in Loss Control resources. This is followed by a review and assessment of operational risks, property and grounds conditions.

A Risk Control Report is generated that summarizes the site exposure assessment and recommendations are explained with a risk assessment code as to the gravity and importance. The Risk Assessment Codes (RAC) consists of:

• RAC 1 – Critical - Can cause death, severe injury, illness, or major property damage. • RAC 2 – Important - May cause injury or illness, or property damage.

• RAC 3 – Marginal - Probably would not cause an immediate hazard to personnel safety or health, but is, nevertheless, in violation of a recognized code or standard.

All report recommendations are tracked in a database by location. When the Church addresses the report

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findings through corrective actions or interim controls, the reply form should be completed and faxed as directed, so that the recommendation can be closed.

This entire process is a valuable tool in reducing the claims frequency and severity. These cost avoidance efforts are essential elements in protecting people and driving claims cost down. Active participation in these efforts can also benefit the Self Insurance Program when various underwriters evaluate coverage rates and costs.

Safety Metric

The Safety Metric is a systematic approach in measuring five (5) key loss control and safety program activities. The five key areas are:

• Accident Investigation and Claims Management • Worker Compensation Accident Management • Safety Education and Training

• Vehicle Inspections • Self Inspections

Scores indicate whether the location is using the available resources to help manage and prevent accidents and property loss. It is the goal of AJG to help all entities succeed in achieving the highest possible results. Please contact the AJG Loss Control Services listed in Appendix A for more information and details on the Safety Metric. Locations must score in the Exceptional Range as one of several qualifiers for the Loss Prevention Grant Program.

Worker Protection Training Program

This program was developed to help all Diocesan entities conduct Safety Education. When implemented in a consistent manner the training will help improve worker behavior or actions to reduce exposures to risk of injury in the course of their duties. The topics address risks that challenge churches, schools and other diocesan entities. This is a low time investment educational tool that provides safety awareness training to workers, both paid staff and volunteers. Participation in this program is measured on the Safety Metric. The Worker Protection Training Program contains twelve monthly topics to be completed in a two-step process: • Step one – a self-study to be distributed to each staff member at the beginning of the month. This can be

accomplished by printing a copy and distributing through interoffice mail or through electronic mail.

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• Step two – a discussion of the topic, approximately two weeks later at a regularly occurring staff meeting, where 15 minutes is set aside on the agenda. A leader of the meeting or other delegate uses the

discussion handout as a guide to discuss the subject material.

• The discussion handout includes a ten-question “Knowledge Check.” Have each attendee complete the Knowledge Check and retain as a record of training.

Protecting Our Parishes, Missions and Schools Bulletin

These one page safety information bulletins are developed and distributed throughout the Diocese. This single topic bulletin is intended to address operational risks and emerging trends in the areas of loss control and risk management. The information provides an additional booster in safety awareness for staff members and volunteers.

The Protecting Our Parishes, Missions and Schools bulletins are to be shared with employees, volunteers, committees and others that will benefit from this resource. This bulletin can easily be distributed through email or posted in prominent locations such as a break rooms and bulletin boards.

Compass Lesson Learned Bulletin

Each month a one page “Lesson Learned” education and communication bulletin is developed and

distributed throughout the Diocese. This single topic bulletin profiles a loss involving an accident or incident that has occurred in the Ecclesiastical Province of Miami. The location and those involved are not identified. It is the intent of the bulletin to provide a summary of the loss including what lead to the incident and what can be learned from it. Each entity should review, discuss and determine if they too may be at risk of the same peril. The bulletin provides suggestions and remedies to help prevent future occurrences.

The Compass Lesson Learned bulletins are to be shared with employees, volunteers, committees and others that will benefit from this resource. These bulletins can easily be distributed through email or posted in prominent locations such as a break rooms and bulletin boards.

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Loss Prevention Grant Program

I. Purpose:

The Loss Prevention Grant program is established to provide onetime financial assistance to Parishes, Schools, and other Diocesan entities that have demonstrated active participation in the Diocesan Self-Insurance Loss Control Program. The intent of this program is to help fund projects that protect people and property, and reduce exposure to risks.

II. Scope:

This grant program is available to all Diocesan entities who meet eligibility criteria in Section III below. The Loss Prevention Grant application submittal window begins October 1 and ends November 30 each year, contingent upon approved funding. Any application received after November 30 will not be considered.

Grant funding is available for up to $5,000 as a onetime financial assistance grant. All grants are subject to the approval of the Diocesan Loss Prevention Grant Review Team (Grant Review Team).

Examples of Loss Prevention Projects that would be considered include, but are not limited to: • Fire alarms/detection systems, installation and modifications (not monthly monitoring fees). • Security system upgrades, alarms, CCTV (not monthly monitoring fees).

• Repair or replacement parts required for electrical equipment code compliance. • Playground fall cushioning material, replacement equipment, or parts.

• Walkway or walking surface improvements. • Handrail Installations.

• Hurricane shutters or windstorm protection improvements.

• Parking lot improvements, lighting, resurfacing, striping or pothole repairs. • Purchase and installation of non-slip mats for entry/exit ways.

• Purchase of Personal Protective Equipment. • First Aid, CPR and AED training and equipment.

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III. Eligibility Criteria:

a. Diocesan entities must have attained an exceptional performance level on the Safety Metric Report. An exceptional level is a score between 85% and 100%.

b. Loss Prevention Grant application must include supporting documentation. c. All projects for consideration must be completed by June 30.

d. All applications must include appropriate Pastor, Principal or Director signature. All Schools attached to a Parish must have both Pastor and Principal signatures.

e. Each location submitting an application must be in compliance with the Internal Review Improvement Requirements.

f. All accounts receivable with the Diocese must be current and in good standing.

IV. Procedures

a. Each entity must receive an exceptional score (85%-100%) on Safety Metric Report to be considered eligible.

b. The Loss Prevention Grant Application must be completed with supporting documentation. Grant application must be submitted before November 30 of each year. Applications without supporting documentation as to cost, project purpose, and scope will not be considered.

c. Proper signatures of the entity applying for the grant must be submitted on the grant application to be considered.

d. Grant awards are a onetime financial assistance for a project or purchase. Ongoing projects or service contracts will not be considered.

e. Grant applications are subject to Grant Review Team approval.

f. Grants are subject to available funding each year. Priority will be given to those projects that are determined to have the greatest opportunity to reduce exposure to risk.

g. The Grant Review Team has the discretion of approving all or portion of the amount requested up to the $5,000 maximum limit.

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h. The Grant Review Team will consist of representatives from the Diocesan Building Commission, Building Department, Insurance Department and a Loss Control Consultant.

i. The Grant Review Team will process all eligible applications and a decision letter will be sent in January each year. Funds will be disbursed January through March each year.

j. All Loss Prevention Grant funded projects must be completed by June 30. A onetime, ninety (90) day extension may be granted upon request.

k. Grant funds can only be used for approved projects. Copies of paid receipts for all grant funds must be submitted to the Grant Review Team when the project is complete. If this requirement is not met, all funds must be returned to the Loss Prevention Grant Program.

Consultation Program

Through the course of daily activities our Parishes, Missions and Schools face numerous operational risks and AJG stands ready to provide assistance. Each entity is encouraged to contact AJG for consultative services for any area that may affect protecting people or property. We can assist through phone consultations and on site visits. Some examples of services include:

• Playground safety inspections and audits

• Parking lot surveys to include layout, traffic flow, signage, parking stops, speed control and lighting surveys

• Property and inventory control programs • Facility security assessments

• Environmental control and compliance assistance, such as asbestos, lead paint, indoor air, and hazardous materials

• Retreat Center safety assessments

• Accident investigations to include root cause analysis to minimize reoccurrence

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Appendix A

Important Names & Addresses

How To Report A Claim

Report all accidents, injuries, and property losses immediately to:

Gallagher Bassett by calling 877-376-2561.

You will need our client ID which is: 06004

Inquires to an already filed claim should be as follows

• 800-541-3322

If you are sued

All suit papers should be hand-delivered or faxed to the Diocesan Financial Administrator (CFO) at the Pastoral Center and a copy forwarded by Registered Mail to the Gallagher Bassett office as soon as they are received.

General Insurance Questions

1. In case of general insurance questions such as: a) Is it covered?

b) Do we need separate insurance?

c) Should we sign this contract? Arthur J. Gallagher & Co. will not provide any legal advice. Only questions regarding the insurance implications of the contract will be answered

d) Large events that may require separate insurance

Coverage Questions, Requests for Certificates of Insurance, MVR checks…..call

• Tony Abella, Sr. (Extension 102) • Maria Vergho (Extension 136) • Ampy Jimenez (Extension 269) • Virginia Gomez (Extension 125)

Arthur J. Gallagher Risk Management Services, Inc.

1-800-488-3003 305-592-6080 FAX: 305-716-3293

Gallagher Bassett Services

Call all New Claims to

1-877-376-2561

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Safety and Loss Control Services

2. This includes inquiries about

• Loss control Recommendations and Inspections

• School safety issues for elementary and high schools including playground equipment safety • Fire and burglar alarm systems

For any question, please contact

Fred Schriefer – Senior Loss Control

Arthur J. Gallagher Risk Management Safety and Loss Control 1-561-319-2525

Li Vasquez-Noone – Technical Assistant

Arthur J. Gallagher Risk Management Safety and Loss Control 1-800-239-8454

Miscellaneous Issues/Questions

3. Examples:

a) Additions/deletions of property or vehicles b) Billings

c) Auto ID Cards

Please contact the Chancery (Pastoral Center) first and they will advise if any other contact should be made.

Appendix A

Important Names & Addresses

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Property (Building and Contents) = $5,000

Except Named Windstorm, where deductible is 5% of the value of the affected building. Deductibles of 5% apply to both the stated value of the building and contents separately.

Auto(Collision and Comprehensive) = $1,000

Windshield damage = $0

Priests Personal Effects = $250

Appendix B

Property Deductible

DEDUCTIBLES

Claim Type Deductible Reporting _Period

Notify insurance immediately

Worker’s Compensation $0 1-877-376-2561 General Liability $0 1-877-376-2561 Auto $1,000 1-877-376-2561 Crime/Fiduciary $5,000 1-877-376-2561 Property (Fire, Lightening, etc.) $5,000 1-877-376-2561

Priests Personal effects $250 1-877-376-2561 Property (Hurricane, Named Wind Storm) _{building/content}5% of value of 1-877-376-2561

Flood 5% of value / excess of separate National _{Flood Insurance Policy, if applicable}

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Appendix C

Accident Kit Forms

• Accident / Incident Report • Voluntary Statement

• Medical Treatment Authorization

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Risk Management

Accident/Incident Report

(A copy of this report is not authorization for medical treatment.)

Instructions: All must complete sections 1 & 2.

Worker’s Compensation claim, complete sections 3, 6, 7, and 8 below. (3A and 3B must be completed).

Student Accident/Incident, Visitor Accident/Incident or Volunteer Accident/Incident, complete sections 4, 6, 7, and 8 below.

Auto or Church Property Claim, complete sections 5, 6, 7, and 8 below (as appropriate).

Please Print: Numerical Parish/School Code:

1. School/Parish Name

School/Parish/Agency  Workers' Compensation

 Student Accident

 Prop Loss

 Auto

 Visitor Accident/Incident

Person Injured:

 Employee

 Visitor

 Student

 Volunteer

Social Security No.

2. Accident

Date of Loss: MM/DD/YY _____/_____/_____

Time of Loss:

_______ a.m. _______ p.m.

Location of Loss (Be specific) 3. Employee (Workers’ Compensation Claims)

Name of Employee: Date of Birth:

_____/_____/_____

Type of injury (Cut, Bruise, Etc.)

Occupation & Organization: Part of Body Injured:

Home Address: City: State: Zip: Phone No.:

3A—Does Employee wish to seek medical attention today:

 Yes

 No

A “No” answer above does not waive the employee’s right to request medical attention at a later date.

If “Yes”, Designate referral: (Name

of Physicians, Clinic, Hospital) 3B—Will Employee require _{time off from work:}

 Yes

 No

Expected return to work date:

_____/_____/_____

4. Claimant (Student, Accident/Incident, Visitor Accident/Incident or Volunteer Accident/Incident)

Name: Date of Birth:

_____/_____/_____

Time injury first reported:

Address: City: State: ZIP: Phone No.:

5. Property (Church Owned) Attach picture of damaged or stolen property, Police and/or Public Safety report

Describe damaged or stolen property:

Estimated cost of damage or value of stolen item:

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6. Witness(es)

Name:

Address: City: State: Zip: Phone No.:

Name:

Address: City: State: Zip: Phone No.:

7. Describe Accident/Incident

(To be completed by claimant. If claimant is unable to write, ask the following questions then write their response.)

A. What were you doing when injury/loss occurred?

B. How did the injury/loss occur?

C. Object or substance that , in your opinion, directly injured or caused loss?

D. Was training received and, if applicable, was personal protective equipment worn?

E. What could have been done to avoid this mishap?

F. State corrective action/lesson learned or recommendation.

8. Signatures

Signature of Employee/Claimant: Date:

Signature of Entity Representative: Date:

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Diocese of Pensacola-Tallahassee

11 N. “B” Street

Pensacola, FL 32502

Voluntary Statement

Name (Last, First, MI):

Address City, State, Zip:

Phone Number(s):

Date/Time:

Location where statement was made:

I certify that the facts contained herein are true and correct to the best of my knowledge.

X

Signature of the Person Making the Statement

Diocese of Pensacola-Tallahassee

11 N. “B” Street

Pensacola, FL 32502

Voluntary Statement

Name (Last, First, MI):

Address City, State, Zip:

Phone Number(s):

Date/Time:

Location where statement was made:

I certify that the facts contained herein are true and correct to the best of my knowledge.

X

Signature of the Person Making the Statement

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Voluntary Statement

Name (Last, First, MI):

Address City, State, Zip:

Phone Number(s):

Date/Time:

Location where statement was made:

I certify that the facts contained herein are true and correct to the best of my knowledge.

X

Signature of the Person Making the Statement

Diocese of Pensacola-Tallahassee

Date:

To Whom It May Concern:

The Diocese of Pensacola-Tallahassee has chosen Gallagher Bassett Services, Inc. as their third party

administration company to handle their WC claims. Any emergency medical care to stabilize the injuries to an injured worker will be authorized.

No additional prescription drugs are to be provided to the injured worker without pre-authorization from Gallagher Bassett Services, Inc. The Diocese of Pensacola-Tallahassee utilizes First Script’s pharmacy network.

First Script Network Services Pharmacy Assistance: 1-866-445-7344 The Diocese of Pensacola-Tallahassee acknowledges the reimbursement rate for these services will be for treatment of workers’ compensation injuries only, in accordance with the State of Florida Workers’ Compensation Health Care Provider Reimbursement statute.

All services following initial treatment must be pre-approved by Gallagher Bassett Services, Inc. Copies of all reports should be sent to the carrier as listed below.

Medical Treatment Authorization

Diocese of Pensacola-Tallahassee

Carrier/Administrator/ Authorization:

Gallagher Bassett Services, Inc. P.O. Box 1880

Fort Myers, FL 33902-1880 Phone: 800-541-3322 Billing Address for all providers:

Tucson, AZ 85734 Employee Personal Information

Name: Address: Phone:

Insurance Information

Date of Injury:

Employer at time of injury: Diocese of Pensacola-Tallahassee

Parish/School/Organization: Phone:

Signature of Injured Worker Date

Diocese of Pensacola-Tallahassee

Date:

To Whom It May Concern:

The Diocese of Pensacola-Tallahassee has chosen Gallagher Bassett Services, Inc. as their third party

administration company to handle their WC claims. Any emergency medical care to stabilize the injuries to an injured worker will be authorized.

No additional prescription drugs are to be provided to the injured worker without pre-authorization from Gallagher Bassett Services, Inc. The Diocese of Pensacola-Tallahassee utilizes First Script’s pharmacy network.

First Script Network Services Pharmacy Assistance: 1-866-445-7344 The Diocese of Pensacola-Tallahassee acknowledges the reimbursement rate for these services will be for treatment of workers’ compensation injuries only, in accordance with the State of Florida Workers’ Compensation Health Care Provider Reimbursement statute.

All services following initial treatment must be pre-approved by Gallagher Bassett Services, Inc. Copies of all reports should be sent to the carrier as listed below.

Medical Treatment Authorization

Diocese of Pensacola-Tallahassee

Carrier/Administrator/ Authorization:

Fort Myers, FL 33902-1880 Phone: 800-541-3322 Billing Address for all providers:

Tucson, AZ 85734 Employee Personal Information

Name: Address: Phone:

Insurance Information Date of Injury:

Employer at time of injury: Diocese of Pensacola-Tallahassee Parish/School/Organization:

Phone:

Signature of Injured Worker Date

(26)

Pensacola, FL 32502

D1

Appendix D

Safety Checklists

• Monthly Safety Self-Inspection • Monthly Vehicle Safety

(27)

Pass Fail N/A

Main Entrances/Travel Paths No water on entrance/exit floor Mats secured and in place

No tripping hazards (carpets/cords/equipment) Door closure properly adjusted

Parking Lot

Outside sidewalks even and level No potholes in travel path Handicap ramp available

Parking bumpers secured and color-coded Parking stalls/aisle marked

Traffic control signs legibly posted Landscaping not blocking driver’s vision Playground

Proper ground-covering around equipment’s fall pattern No broken steps, hand-holds, rungs, seats

Equipment anchored securely without movement (anchors covered) Spacing of equipment provided between equipment (minimum of 6 feet) Bolts/fasteners tight and not protruding more than 1/8 inch

No metal or sharp objects from equipment No trip hazards

Gate and playground secured Restrooms/Kitchens

Floor surface free from water or wet conditions Towel dispenser filled and properly located No plumbing leaks

Clean and in good sanitary condition Water fountain – no water on floor

Potable/Non-Potable water sources clearly identified Florida DEP/Health Department requirements met Security

Employees have ID badges displayed Mechanical rooms locked

Electrical panels secured from unauthorized entry

Secondary doors locked from outside entry (open from inside) Perimeter protection secured

Monthly Safety Self-Inspection Checklist

(28)

Updated Nov 2008

Traffic Control

Traffic flow is normal

Any vehicle blocking traffic or flow Traffic flow marked (cones, flaggers)

Traffic flagger wearing orange vest with flag/paddle Teachers available to take students from drop-off Bus drop area is clear

Students clear of bus stop or parent drop-off area

Maintenance Shop

Aisle way clear

Stock, equipment and tools stored in an orderly fashion Portable power-tool cords free from splices/cuts

Only extension cords with ground fault circuit interrupters (GFCI) used Electrical installations meet code (no breakers tripping)

Guards on woodworking equipment Guards on portable power tools

Flammable/combustible liquids stored outside or in fire cabinets Material Safety Data Sheets (MSDS) available on all chemicals used

Personal protective equipment (eyes, face, hearing and hand protectors) available Overhead storage properly secured position to avoid head injuries or collapse Ladders in good condition and not damaged

Shop secured when unattended

Pesticides stored outside in properly ventilated room

Flammable Liquids/Chemicals (Custodian Work Areas) Flammables stored in proper containers

Fire Extinguishers in place

Fire extinguisher pressurized (in the green)

Annual service tag in place and current for fire extinguishers and fire panel Custodian Closets locked

No leaking chemicals or odors in Custodian Closet

Aerosols kept out of reach of all students (check classrooms)

Chemicals in Science Lab secured in cabinet (shelf has raised lip to prevent falling) No glass containers used for chemicals (or chemical handling)

Chemical containers properly marked

Follow Up with Self-Inspection Safety Deficiency Tracker

Correct the deficiency and attach a record of the correction to this form for future reference. Maintain a copy of these inspection reports in the workplace.

Inspected by: Date:

(29)

Monthly Vehicle Safety Checklist

Lights

Front Left – working Front Right – working Back Left – working Back Right – working High Beams – working Low Beams – working Hazards – working Under the Hood Oil Level – full Break fluid – full Transmission Fluid – full Washer Fluid – full

Battery – no signs of leaks, corrosion, or short circuits Tires

Front Left Front Right Back Left Back Right Spare

Safety Equipment

Windshield Wipers – operating and in good condition Seat Belts – as required and operational

Horn – operational

Fire Extinguisher – fully charged and secured First-Aid Kit – full and secured

Tire Jack/Lug Wrench – on board and secured Manufacturer Schedule for Maintenance

Records support scheduled maintenance is up to date

Note: Any failed item should be corrected before operation of vehicle.

Make: Model:

License Plate: Mileage:

(30)

Pensacola, FL 32502

E1

Appendix E

Loss Prevention Grant Application

• Loss Prevention Grant Application

(31)

Loss Prevention Grant Application

Location Name: ____________________________________________________________ Location Address: __________________________________________________________ Name of Person Submitting Application: ________________________________________ Date Application Submitted: __________________________________________________ Grant Amount Requested: ____________________________________________________ Please describe the purpose and use of grant funds, attach additional sheet if necessary:

__________________________________________________________________________ __________________________________________________________________________ Anticipated Project Completion Date: __________________________________________ Attach Supporting Documentation (Required): Scope of the project, description of item(s) to be purchased, cost estimates from vendor/contractor.

Eligibility Criteria:

Attained an exceptional performance level on Safety Metric Report. Exceptional level is a score of 85-100%. Score_______ Score Date__________

Loss Prevention Grant application must be submitted within period of October 1 thorough November 30. Loss Prevention Grant application must include supporting documentation.

All projects for consideration must be completed by June 30.

All applications must include appropriate Pastor, Principal or Director signature. All Schools attached to a Parish must have both Pastor and Principal signatures.

Each location submitting an application must be in compliance with the Internal Review Improvement Requirements.

All accounts receivable with the Diocese must be current and in good standing.

Pastor Signature: ________________________________ Date: _____________ Principal Signature (School Only): ___________________ Date: _____________ Director Signature: _______________________________ Date: _____________

(32)

Protected Self-Insurance Program

Diocese of Pensacola-Tallahassee

The Ecclesiastical Province of Miami, Inc.

A Florida Not-for-Profit Corporation

Diocese of Pensacola-Tallahassee

Protected

Self-Insurance

Program

Diocese of Pensacola-Tallahassee

Table of Contents

What Protected Self-Insurance Is

What Is Covered

Property Coverage

What Is Covered

General Liability Coverage

Automobile Coverage

Other Coverage

What Is Covered

What Is Not Covered

Other Contracted Services

Facilities Use

Motor Vehicle Reports

Special Conditions to Be Considered

Who provides what in our Diocese

Special Features of the Program

Loss Prevention Services

Loss Prevention Services

Risk Management Coordinator

Accident Kit

Safety and Loss Control Site Visit

Loss Prevention Services

Safety Metric

Worker Protection Training Program

Loss Prevention Services

Protecting Our Parishes, Missions and Schools Bulletin

Compass Lesson Learned Bulletin

Loss Prevention Services

Loss Prevention Grant Program

Loss Prevention Services

Loss Prevention Services

Consultation Program

Loss Prevention Services

Appendix A

Important Names & Addresses

General Insurance Questions

Gallagher Bassett Services

Call all New Claims to

1-877-376-2561

Safety and Loss Control Services

Miscellaneous Issues/Questions

Appendix A

Important Names & Addresses

Appendix B

Property Deductible

Appendix C

Accident Kit Forms

Risk Management

Accident/Incident Report

Instructions: All must complete sections 1 & 2.

Diocese of Pensacola-Tallahassee

11 N. “B” Street

Pensacola, FL 32502

Voluntary Statement

Name (Last, First, MI):

Address City, State, Zip:

Phone Number(s):

Date/Time:

Location where statement was made:

I certify that the facts contained herein are true and correct to the best of my knowledge.

X

Signature of the Person Making the Statement

Diocese of Pensacola-Tallahassee

Diocese of Pensacola-Tallahassee

11 N. “B” Street

Pensacola, FL 32502

Voluntary Statement

Name (Last, First, MI):

Address City, State, Zip:

Phone Number(s):

Date/Time: