Workers Compensation Claim Kit - Oklahoma

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

BHHC OK Claims Kit Introductory Letter – 09/07/2017 (page 3 of 17)

BHHC Requirements for OK Posting Notice – 06/01/2018 (page 4 of 17)

OK Form CC-1A – Oklahoma Workers’ Compensation Notice and Instruction to Employers and Employees

(English – 12/18/2014 Spanish – 11/21/2019) (pages 5-6 of 17)

OK Form CC-2 – Employer’s First Notice of Injury – 04/18/2018 (page 7 of 17)

BHHC Employee’s Authorization for Release of Information (English & Spanish) – 06/10/2019 (pages 8-9

of 17)

BHHC Medical History Request – 02/16/2014 (page 10 of 17)

BHHC General Employee Accident Report – 02/16/2014 (page 11 of 17)

BHHC General Supervisor Accident Report – 02/16/2014 (page 12 of 17)

BHHC General Witness Accident Report – 02/16/2014 (page 13 of 17)

BHHC Express Scripts First Fill Form (English & Spanish) – 12/2018 (pages 14-15 of 17)

BHHC Workers’ Compensation Fraud Posters (English & Spanish) – 08/10/2018 (pages 16-17 of 17)

P.O. Box 881236, San Francisco, CA 94105 | Phone: (888) 495-8949 | bhhc.com

Dear Policyholder:

Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC). We look forward to working with you to fulfill all your workers compensation needs.

Enclosed you will find documentation necessary for the processing and administration of a claim in the event of a workplace injury, as well as important information regarding workers compensation requirements for your state (i.e. posting notices, compliance laws, etc). Please utilize the documents included to collect valid information regarding the injured employee and incident, and send the documents in when reporting the claim or upon request. Any completed document should be sent directly to BHHC using mail, e-mail, or fax. The assigned claims professional will forward necessary documentation onto the appropriate state entity.

It is critical that you promptly report all new claims using one of the following methods:

Online: 1. Go to our website: www.bhhc.com

2. Highlight “Workers Comp” in the menu 3. Highlight “Claims Center” 4. Click “Report a Claim”

Phone: (800) 661-6029 Fax: (800) 661-6984 E-mail: newclaim@bhhc.com

Oklahoma state law recommends employers report every industrial injury or occupational disease claim to their workers compensation carrier as soon as possible or within 5 days of employer knowledge of injury. State law also requires that employers authorize initial medical treatment within 24 hours of knowledge that an occupational injury of illness has been sustained or reported, regardless of the legitimacy of the claim. Failure to comply may result in the loss of “medical control” and a significant increase in the potential claim cost.

We will attempt to contact you and the injured worker within 24 hours of receiving the First Report of Injury. Your cooperation in allowing the injured employee to speak with one of our Claims Professionals is appreciated.

Should you have any questions regarding the contents of this kit, a claim, or claim reporting, please contact our Customer Care Center at (888) 495-8949. Questions regarding your insurance policy or coverage should be directed to your broker or agent. We thank you for choosing BHHC as your workers compensation carrier and look forward to providing you superior customer service and compassionate care for your injured workers.

BERKSHIRE HATHAWAY HOMESTATE COMPANIES

BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY BROOKWOOD INSURANCE COMPANY CONTINENTAL DIVIDE INSURANCE COMPANY CYPRESS INSURANCE COMPANY OAK RIVER INSURANCE COMPANY REDWOOD FIRE AND CASUALTY INSURANCE COMPANY

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

WORKERS’ COMPENSATION POSTING REQUIREMENTS

Form CC-1A – Oklahoma Workers’ Compensation Notice and Instruction to Employers and Employees

• Post in one or more conspicuous at all business locations • Print the English version on peach colored paper and the Spanish version on tan colored paper • Must contain the name and address of the insurance carrier and the policy expiration date

To complete the form, please enter the following information in the spaces provided: • Name of Your designated insurance company/carrier • Your policy expiration date • Signature of a company representative

For your convenience, our other contact information has been entered on the Poster

(85A Oklahoma Statutes § 41)

CC-Form-1A Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees

All employees of this employer who are entitled to benefits of the Administrative Workers' Compensation Act are hereby notified that this employer has complied with all rules of the Workers' Compensation Commission and that this employer has secured payment of compensation for all employees and their dependents in accordance with the Act. All employees are further notified this employer will furnish first aid, medical, surgical, hospital, optometric, podiatric, and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee, as well as payments of compensation to any injured employee or the employee’s dependents as provided in the Act.

Any employee who has suffered a compensable injury covered by the Administrative Workers' Compensation Act is entitled to vocational rehabilitation services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform work for which the person has previous training or experience.

The Oklahoma Workers' Compensation Commission has a Counselor Division to provide information to injured workers, employers, and other interested persons.

Mediation is available to help resolve certain workers’ compensation disputes. For information, call the Counselor Division at 405-522-5308 or In-State Toll Free 855-291-3612.

Signature of Employer

Insurer Name and Address

Employee's Responsibilities In Case of Work Related Injury

If accidentally injured or affected by cumulative trauma or an occupational disease arising out of and in the course of employment, however slight, the employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. If this employer is a corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the person in charge of business at the location of operations where the injury occurred. Unless oral or written notice is given to the employer within thirty (30) days, the claim for compensation may be forever barred.

The employee may file a claim for compensation with the WORKERS’ COMPENSATION COMMISSION for an accidental injury, death, cumulative trauma or occupational disease or illness occurring ON OR AFTER February 1, 2014. Forms to file a compensation claim should be furnished by this employer and also are available from the Workers’ Compensation Commission. The forms are posted on the Commission’s website, www.wcc.ok.gov.

A claim for compensation must be filed with the Commission within the time specified by law, or be forever barred. Based on law effective May 28, 2019, a claim for compensation for any accidental injury must be filed with the Commission within one (1) year of the date of injury or, if the employee has received benefits under Title 85A for the injury, six (6) months from the date of the last issuance of such benefits; a death claim must be filed within two (2) years of the date of death; a claim for compensation for occupational disease or illness must be filed within two (2) years of the last injurious exposure; and a claim for compensation for cumulative trauma must be filed within one (1) year of the date of injury.

Claims for compensation for accidental injury, death, cumulative trauma or occupational disease or illness occurring BEFORE February 1, 2014 may be filed with the WORKERS’ COMPENSATION COURT OF EXISTING CLAIMS and are subject to different notice of injury requirements and claims filing deadlines than those for accidental injury, death, cumulative trauma or occupational disease or illness occurring on or after February 1, 2014. Failure to comply with applicable notice requirements and deadlines may operate to forever bar the claim. Contact the WORKERS’ COMPENSATION COURT OF EXISTING CLAIMS for additional information.

Employer's Responsibilities

The employer must provide employees with immediate first aid, medical, surgical, hospital, optometric, podiatric, and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee. This applies to care for all injuries and illnesses arising out of and in the course of employment, regardless of their character. Within ten (10) days after the date of receipt of notice or knowledge of death or injury that results in the loss of time beyond the shift or medical attention away from the work site, the employer or the employer’s representative MUST send a report thereof to the Workers’ Compensation Commission via Electronic Data Interchange as specified in Commission rules.

No agreement by any employee to pay any portion of the premium paid by the employer to a carrier or a benefit fund or department maintained by the employer for the purpose of providing compensation or medical services and supplies as required by the workers’ compensation laws, shall be valid. Any employer who makes a deduction for such purposes from the pay of any employee entitled to benefits under the workers’ compensation laws shall be guilty of a misdemeanor.

No agreement by any employee to waive workers' compensation rights and benefits shall be valid.

Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both.

Workers' Compensation Commission 1915 North Stiles Avenue

Oklahoma City, Oklahoma 73105-4918 Tele. 405-522-5308 (OKC) · 918-295-3732 (TU) · In-State Toll Free 855-291-3612

Web Site · www.wcc.ok.gov

This notice must be posted and maintained by the employer in one or more conspicuous places on the work premises. Rev. 11-21-19

Date of Expiration of Insurance Policy (Not applicable to employers authorized to self-insure.)

CC-Form-1A Aviso e Instrucción de Compensación de Trabajadores de Oklahoma para Empresarios y Trabajadores

Se notifica por la presente a todos los empleados de esta empresa que tengan derecho a los beneficios de la Ley de Compensación para Trabajadores Administrativos que este empleador ha cumplido con todas las reglas de la Comisión de Compensación de Trabajadores, y que este empleador ha asegurado el pago de compensación a todos los empleados y sus dependientes en conformidad con la ley. Asimismo, se notifica a todos los empleados que este empleador proporcionará primeros auxilios, servicios médicos, quirúrgicos, hospitalarios, de optometría, podología y enfermería, medicina, muletas y otros aparatos que sean razonablemente necesarios en relación con la lesión sufrida por el trabajador, así como los pagos de compensación a cualquier empleado lesionado o sus dependientes conforme a lo dispuesto por la ley. Cualquier empleado que haya sufrido una lesión indemnizable amparado por la Ley de Compensación para Trabajadores Administrativos tiene derecho a los servicios de rehabilitación vocacional, esto incluye la re-capacitación e inserción laboral si el empleado ya no pudiese realizar el trabajo para el cual tuviese formación o experiencia previa como consecuencia de la lesión.

La Comisión de Compensación de Trabajadores de Oklahoma cuenta con una División de Asesoría para proporcionar información a los trabajadores lesionados, empleadores y otras personas interesadas. Existe la posibilidad de mediación para ayudar a resolver disputas de compensación para ciertos trabajadores. Para obtener más información, llame a la División de Consejería al 405-522-5308 o al número gratuito (dentro del estado) 855-291-3612.

Firma del Empleador

Nombre y Dirección del Asegurador

Responsabilidades del empleado en caso de sufrir una lesión relacionada trabajo De resultar dañado o afectado por trauma acumulativo o una enfermedad profesional que surja del empleo y en el transcurso de su desempeño, por leve que sea, el empleado debe notificar al empleador inmediatamente. Si este empleador es una sociedad, se debe notificar a cualquier socio. Si este empleador es una corporación, la notificación se hará a cualquier agente o funcionario de la corporación autorizado a recibir tal notificación. Se notificará también a la persona a cargo de los negocios en el lugar de operaciones donde se haya producido la lesión. De no haber notificado verbalmente o por escrito al empleador dentro de los treinta (30) días, el reclamo de indemnización puede prescribir de forma definitiva.

El empleado puede presentar un reclamo de indemnización ante la COMISIÓN DE COMPENSACIÓN DE TRABAJADORES por una lesión accidental, muerte, trauma acumulativo o enfermedad profesional o enfermedad accidental que ocurra EL 1 de febrero de 2014, O DESPUÉS de esa fecha. Este empleador debe suministrar los formularios para presentar un reclamo de compensación, y también se encuentran disponibles en la Comisión de Compensación de Trabajadores. Los formularios se encuentran publicados en el sitio web de la Comisión, www.wcc.ok.gov. El reclamo de compensación debe ser presentado ante la Comisión en el plazo fijado por la ley, o prescribirá para siempre. En virtud con la Ley vigente al partir del 28 de mayo de 2019, los reclamos de indemnización por cualquier lesión accidental se deben presentarse ante la Comisión dentro de un (1) año transcurrido a partir de la fecha de la lesión; o, si el empleado ha recibido beneficios bajo el Título 85A por la lesión, seis (6) meses desde la fecha de la última emisión de dichos beneficios; un reclamo de muerte debe presentarse dentro de los dos (2) años a partir de la fecha de la muerte;los reclamos de indemnización por males o enfermedades profesionales se deben presentar dentro de los dos (2) años transcurridos a partir de la última exposición perjudicial; y los reclamos de indemnización por trauma acumulativo se deben presentar dentro de un (1) año transcurrido a partir de la fecha de la lesión. Se prohíben los reclamos de indemnización adicional a menos que sean presentados dentro de un (1) año transcurrido a partir del último pago de compensación por discapacidad o dos (2) años desde la fecha de la lesión, el período que sea mayor. Los reclamos de indemnización por lesiones, muerte, trauma acumulativo o males o enfermedades profesional accidentales que ocurrieran ANTES del 1 de febrero de 2014 se pueden presentar ante el TRIBUNAL DE RECLAMOS EXISTENTES DE COMPENSACIÓN AL TRABAJADOR y estarán sujetos a diferentes requisitos de notificación de la lesión y distintos plazos para presentar reclamos a los requeridos para los correspondientes a lesiones accidentales, muerte, trauma acumulativo o males o enfermedades profesionales que ocurrieran a partir del 1 de febrero de 2014. El incumplimiento de los requisitos y los plazos de notificación aplicables puede resultar en la prescripción definitiva del reclamo. Póngase en contacto con el Tribunal de Reclamos Existentes de Compensación al Trabajador para obtener información adicional.

Responsabilidades del Empleador El empleador debe proporcionar a los empleados primeros auxilios, servicios médicos, quirúrgicos, hospitalarios, de optometría, podología, así como servicios de enfermería, medicina, muletas y otros aparatos que sean razonablemente necesarios en relación con la lesión sufrida por el empleado. Esto es aplicable al cuidado de todas las lesiones y enfermedades que surjan del empleo y el transcurso de su desempeño, independientemente de su carácter. El empleador o su representante, DEBERÁ enviar, dentro de los diez (10) días a partir de la fecha de recepción de la notificación o el conocimiento de la muerte o lesión que resulte en pérdida de tiempo más allá del turno o atención médica fuera del lugar de trabajo del empleado lesionado, un informe sobre esto a la Comisión de Compensación de Trabajadores, a través del Intercambio Electrónico de Datos, como se especifica en las reglas de la Comisión. Se invalidará cualquier acuerdo hecho por un empleado para pagar cualquier porción de la prima pagada por el empleador a un operador, fondo de prestaciones o departamento mantenido por el empleador con el fin de indemnizar o proveer servicios y suministros médicos, tal como lo requieren las leyes de compensación de los trabajadores. Cualquier empleador que realice una deducción del pago de cualquier empleado con derecho a prestaciones en virtud de las leyes de compensación de los trabajadores para tales propósitos será culpable de un delito menor.

Se invalidará cualquier acuerdo hecho por un empleado para renunciar a los derechos y beneficios de compensación del trabajador.

Toda persona que cometa fraude de compensación del trabajador, será culpable, de ser condenada, de un delito grave punible con pena de prisión, una multa o ambas.

Comisión de Compensación de Trabajadores 1915 North Stiles Avenue Ste 231

Oklahoma City, Oklahoma 73105-4918 Tel. 405-522-5308 (OKC) · 918-295-3732 (TU) · Línea gratuita (dentro del estado) 855-291-3612

Sitio Web · www.wcc.ok.gov

Este aviso debe ser publicado y mantenido por el empleador en uno o más lugares visibles en el lugar de trabajo. Enmendado 11-21-19

Fecha de Vencimiento de la Póliza de Seguro (No aplicable a los empleadores autorizados para auto-asegurarse.)

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

$UserLastFirstName$ www.bhhc.com $ClaimNumber$

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

AUTHORIZATION FOR THE RELEASE OF INFORMATION

AUTORIZACIÓN PARA LA LIBERACIÓN DE INFORMACIÓN

Claim Number / Número de Reclamo Date of Injury / Fecha de la Lesión

Employee / Empleado Date of Birth / Fecha de Nacimiento

I hereby authorize the divisions of Berkshire Hathaway Homestate Companies, their representative or bearer, to review, inspect, copy, and/or photograph any and all of the following documents: Por este medio autorizo las divisiónes de Berkshire Hathaway Homestate Companies, su representante o portador, a revisar, inspeccionar, copiar, y/o fotografiar cualquier y todo de los siguientes documentos: 1. Any and all medical records, including but not limited to office and hospital records, laboratory results, diagnostic reports and films,

psychiatric records, medical correspondences, doctor’s and nurse’s notes, and medical histories relevant to my workers’ compensation claim. I also hereby give permission to Berkshire Hathaway Homestate Company representatives to contact the attending physicians involved in the treatment of all related conditions. Cualquier y todo expediente médico, incluyendo pero no limitado, a los expedientes de la oficina y hospitales, resultados de laboratorios y filminas, expedientes psiquiátricos, correspondencia médica, notas de los doctores y enfermeros(as), e historiales médicos relevantes a mi reclamo de compensación de trabajadores. También, por este medio le doy permiso a los representantes de Berkshire Hathaway Homestate Company para comunicarse con el médico tratante envuelto en el tratamiento de todas las condiciones relacionadas.

2. All employment and human resource information including but not limited to: hiring and employment records, payroll and income statements, documentation related to this or any other relevant injury and any other information pertinent to providing benefits and services necessary for the completion of this claim. Toda información del empleo y de recursos humanos, incluyendo pero no limitado a: expedientes de contratación y empleo, declaraciones de nómina e ingresos, documentación relacionada a esta o cualquier otra lesión relevante, y cualquier otra información pertinente que provea los beneficios y servicios necesarios para completar este reclamo.

The released information is required for the following reasons: La información liberada es requerida por las siguientes razones: 1. To provide for adequate preparation, investigation, evaluation, review, and discovery of a claim for workers’

compensation benefits. Specifically, to determine the causation and the nature and extent of any possible pre-existing, concurrent or aggravating medical conditions with potential medical, legal, or factual implications in the this work-related injury or injuries.

Para proporcionar una preparación, investigación, evaluación, revisión, y descubrimiento adecuado del reclamo de beneficios de compensación de trabajadores. Específicamente, para determinar la causa y la naturaleza y extensión de cualquier posible condición médica pre-existente, concurrente o agravante con potencial médico, legal, o implicaciones fácticas en esta lesión o lesiones relacionadas al trabajo.

2. To provide the treating physician, consultant or evaluator with medical information necessary to provide you with the best possible medical care and medical advice.

Para proporcionar al médico tratante, consultor, o evaluador con la información médica necesaria para proporcionarle el mejor cuidado médico posible y consejería médica.

(CONTINUED ON PAGE 2)

(CONTINÚA EN LA PÁGINA 2)

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

$UserLastFirstName$ www.bhhc.com $ClaimNumber$

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

AUTHORIZATION FOR THE RELEASE OF INFORMATION (PAGE 2)

AUTORIZACIÓN PARA LA LIBERACIÓN DE INFORMACIÓN (PÁGINA 2)

Claim Number / Número de Reclamo Date of Injury / Fecha de la Lesión

Employee / Empleado Date of Birth / Fecha de Nacimiento

3. To facilitate recovery of all benefits paid toward your workers’ compensation claim from any third party responsible for this injury.

Para facilitar la recuperación de todos los beneficios pagados por su reclamo de compensación de trabajadores de cualquier tercer parte responsable de esta lesión.

4. To ensure that you are accurately compensated for any amount of lost wages, time or resources while undergoing

evaluation, treatment and recovery for this injury.

Para asegurar que usted se encuentra compensado correctamente por cualquier cantidad de salarios, tiempo, o recursos perdidos mientras se somete a la evaluación, tratamiento, y recuperación de esta lesión.

5. To obtain any information necessary to appropriately determine further actions as a result of the injury or condition and

to prevent further issues for you and other employees. Para obtener cualquier información necesaria para determinar apropiadamente acciones adicionales como resultado de la lesión o condición, y para prevenir problemas adicionales para usted y otros empleados.

This consent and authorization is effective immediately, and is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon, and if not earlier revoked, it shall terminate on conclusion of the claim without express revocation.

Este consentimiento y autorización es efectivo inmediatamente, y está sujeto a la revocación del abajo firmante en cualquier momento excepto a la extensión en que se hayan tomado acciones en dependencia con esto de aquí en adelante, y si no es revocado anteriormente, terminará con la conclusión del reclamo si no se presenta una revocación expresa.

A copy or fax is as valid as the original. Una copia o fax es tan válida como el original. -

(Names, addresses, and phone numbers of providers) (Nombres, direcciones, y números de teléfonos de los proveedores) I have read this authorization and fully understand its entire contents. I have asked questions about anything that was not clear to me and I am satisfied with the answers I have received. I understand that I have a right to receive a copy of this authorization upon my request. He leído esta autorización y entendido completamente su contenido en su totalidad. He hecho preguntas sobre todo lo que no estaba claro para mí y estoy satisfecho con las contestaciones que he recibido. Yo entiendo que tengo derecho a recibir una copia de esta autorización una vez lo solicite.

Signed / Firma

Date / Fecha

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

MEDICAL HISTORY REQUEST

Employee Name: Date of Injury: Employer Name: Completion Date:

Please complete this form by providing your medical history for the past 5 years. This will help ensure that we are able to provide all of your medical records to your current treating physician for you to receive the proper care for your work injury.

Thank you for your cooperation.

Past Injuries, Disabilities, or Other Medical Conditions

Hospitalizations HOSPITAL NAME, ADDRESS AND PHONE DATES ADMITTED

Treating Physicians or Groups DOCTOR OR GROUP NAME, ADDRESS AND PHONE DATES OF TREATMENT

EMPLOYEE’S ACCIDENT REPORT To be completed by the injured worker

Employee name Employer name

Date of accident Time of accident Time you began work on day of accident Location of accident (specify if off-site address)

How did the injury occur? What job duties were you performing? Please describe in your own words.

What part(s) of your body was injured (indicating right and/or left)?

Have you sought any medical treatment for these injuries? If so, specify where and when.

Have you ever injured this part of your body before (yes or no)? If so, please describe how and when the previous injury(s) occurred.

What witnesses were present when the accident occurred? Please provide names if applicable.

Who did you report the injury to? When was the injury reported? Please provide name(s) and job title(s).

What did you do after the accident occurred?

The above report is true and correct: SIGNATURE: DATE FORM COMPLETED:

SUPERVISOR’S REPORT OF EMPLOYEE ACCIDENT

Employee name Employer name

Date of accident Time of accident Date accident reported Did the employee report the accident immediately? YES NO Location of accident (specify if off-site address)

How did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were reported as injured?

Has the employee sought any medical treatment for these injuries? If so, specify where and when.

What witnesses were present when the accident occurred (including self)?

Do you have any reason to question the legitimacy of the accident? If so, please explain:

Indicate working conditions present that led to accident (please check all that apply): Unused/unavailable lifting equipment Wet/slippery floor Unused/unavailable PPE (gloves, hardhat, goggles, etc.) Poor housekeeping Unused/unavailable sharps container Interaction with co-worker Unguarded or improperly guarded equipment Interaction with patient or resident Electrical exposure Interaction with customer Obstructed view Chemical exposure Lack of training Motor vehicle accident Defective tools or equipment Other: __________________________

What changes could be made to eliminate or reduce the hazard(s) identified above?

The above report is true and correct: Prepared by: Title: Date prepared:

WITNESS’ REPORT/STATEMENT OF EMPLOYEE ACCIDENT

Employee name Witness name & phone number Witness Address

Date of accident Time of accident Location of accident (specify if off-site address)

Did you witness the above-reported accident? If so, how did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were injured? Describe the type of injury (strain, bruise, etc.)

What did the injured employee say at the time of injury? Did the injured employee complain of pain at the time of injury? If they complained of pain, please specify the body part(s).

What did the employee do after the accident occurred?

Were any other witnesses present at the time of the accident? If so, please list them below.

The above report is true and correct: Signature of witness: Date signed:

NOTE: Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties.

© 2018 Matrix Healthcare Services, Inc. | An Express Scripts Company. All Rights Reserved. CRP1806_0245 EME46657 OT48016O

Workers’ Compensation Temporary Prescription ID Card

To the Injured Worker:

On your first visit, please give this notice to any

pharmacy listed on the back side to speed the processing

of your approved workers’ compensation prescriptions.

Questions or need assistance locating a participating retail

network pharmacy? Call the Express Scripts Patient Care

Contact Center at 800.945.5951.

Atención Trabajador Lesionado:

En su primera visita, por favor entregue esta notificación a

cualquier farmacia enumerada al reverso para acelerar el

procesamiento de sus recetas aprobadas de compensación

para trabajadores (según las pautas establecidas por su

empleador).

Si tiene cualquier duda o necesita ayuda para localizar una

farmacia de venta al por menor participante de la red, por

favor llame al Centro de Contacto para Atención a Clientes

de Express Scripts, al 800.945.5951.

To the Pharmacist:

Express Scripts administers this workers’ compensation prescription program. Please follow the steps below to submit a claim. Standard first fill shall not exceed a 14-day supply or a cost of $150. This form is valid for up to 30 days from date of injury (DOI). Limitations may vary. For assistance, call Express Scripts at 888.786.9640.

Pharmacy Processing Steps

Step 1: Enter BIN number 003858

Step 2: Enter processor control WC

Step 3: Enter the group number as it appears above

Step 4: Enter the injured worker’s nine-digit ID number

Step 5: Enter the injured worker’s first and last name

Step 6: Enter the injured worker’s date of injury

Thank you for using a participating retail network

pharmacy. Even though there is no direct cost to you, it’s important that we all do our part to help control the rising cost of healthcare.

Please see other side for a list of participating retail network pharmacies.

To the Supervisor: Please fill in the

information requested for the injured worker.

Employee Information

________________ ______ _________________________ First M Last

_______________________________________________ Street Address or PO Box

___________________ __________________ __________ City State ZIP

Employer Name

________________________________________________

Express Scripts

ID#: _____________________________________

Your SSN is your temporary ID number; present to the pharmacy at the time

prescription is filled. You will receive a new ID number shortly.

Date of Injury: _______ / _______ / _______ MM/DD/YYYY

G3YA Group #:

Employee Date of Birth: _______ / _______ / _______

© 2018 Matrix Healthcare Services, Inc. | An Express Scripts Company. All Rights Reserved. CRP1806_0245 EME46657 OT48016O

A & P Acme Pharmacy Albertson’s Albertson’s/Acme Albertson’s/Osco Albertson’s/Sav-On Amerisource Bergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg’s Bi-Lo Bi-Mart BJ’s Wholesale Club Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs Cash Wise Coborn’s Costco Cub CVS D&W Dahl’s Dierbergs Discount Drugmart Doc’s Drugs Dominicks

Drug Emporium Drug Fair Drug Town Drug World Eckerd Econofoods EPIC Pharmacy

Network FamilyMeds Farm Fresh Farmer Jack Food City Food Lion Fred’s Gemmel Giant Giant Eagle Giant Foods Hannaford Harris Teeter H-E-B Hi-School Pharmacy Hy-Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs Kroger LeaderNet (PSAO)

Longs Drug Store Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare Network

Pharmaceuticals Northeast Pharmacy

Services Osco P & C Food Markets Pamida Park Nicollet Pathmark Pavilions Price Chopper Publix Quality Markets Raley’s Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam’s Club

Sav-On Save Mart Schnucks Scolari’s Sedano Shaw’s Shop ‘N Save Shopko ShopRite Snyder Stop & Shop Sun Mart Super Fresh Super Rx Target Texas Oncology Srvs The Pharm Thrifty White Times Tom Thumb Tops Ukrop’s United Drugs United Supermarkets Vons Waldbaums Walgreens Walmart Wegmans Weis Winn Dixie

Participating Retail Network Pharmacies

BHHC Workers Compensation Division • Representing Financial Strength & Integrity

$1000 Reward!For information leading to the arrest and conviction of

any co-worker, health care professional, or attorney representing a fraudulent workers compensation claim to

Berkshire Hathaway Homestate Companies (BHHC)*

In most states, it is a felony to make or cause to be made a knowingly false or fraudulent material statement in order to obtain workers compensation benefits. BHHC believes that

any party engaging in such fraud should be prosecuted to the fullest extent of the law, including jail sentences.

Please do your part to help! Putting criminals out of operation benefits all of us, including keeping your employer’s premium rates reasonable.

Call our toll-free fraud hotline immediately if you have information on a fraudulent claim:

1 (800) 300-JAIL

*Maximum reward of $1,000 per conviction. In the event that more than one individual submits information regarding the same fraudulent claim, BHHC will equally divide the reward among those providing information used in obtaining the conviction. BHHC reserves the right to determine what information, if any, will be provided to the appropriate law enforcement agency. Criminal prosecutions are the sole responsibility of the authorities and may or may not be pursued at their discretion. Any

issues regarding the intrepretation of this policy shall be resolved by BHHC at their sole discretion. Program subject to change or termination without prior notice.

BHHC Workers Compensation Division • Representing Financial Strength & Integrity

$1000 RECOMPENSA!INFORMACIÓN QUE LLEVA AL ARRESTO Y A LA CONDENA DE CUALQUIER COMPAÑERO DE TRABAJO, PROFESIONAL DE CUIDADO MEDICO, O ABOGADO QUE REPRESENTE UN

RECLAMO FRAUDULENTO EN CONTRA DE BERKSHIRE HATHAWAY HOMESTATE COMPANIES*

En la mayoría de los estados es un delito grave hacer que haga una declaración de material fraudulento para obtener beneficios de Compensación al Trabajador. Berkshire

Hathaway Homestate Companies cree que cualquier persona que se involucre en tal fraude debe ser procesado con todo el rigor de la ley, incluyendo

SER SENTENCIADO A LA CARCEL.

Ayúdenos de su parte. El poner a estos delincuentes fuera de operaciones nos beneficia a todos, incluso esto ayuda a mantener los réditos bajos de la aseguranza de su empleador.

Si usted tiene información sobre un reclamo fraudulento por favor llame de inmediato a nuestra LINEA GRATUITA DE FRAUDE.

(800) 300-JAIL

*La recompensa máxima es de $1,000 por convicción. En caso de que más de una persona presente informaciones sobre la misma demando fraudulenta. Berkshire Hathaway dividirá la recompensa por partes iguales entre aquellas persones que aportaron informaciones para obtener la convicción. Berkshire Hathaway se reserva el

derecho de determinar qué informacion presentará a la agencia judicial correspondiente. El proceso de crímenes es la responsibilidad exclusiva de las autoridades, que pueden decidir si el proceso debe entablarse or no. Cualquier disputa que pudiera surgir en la interpretación de esta ofreta será resuelta por la propia Compañia de

Seguros Berkshire Hathaway. Este programa está sujeto a cambios a cancelación sin aviso previo.