ATTENTION! FAILURE TO UNDERSTAND YOUR RESPONSIBILITIES UNDER THIS POLICY MAY RESULT IN YOUR COMPANY BEING SUBJECT TO STATE FINES!

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1 MIDWEST FAMILY GROUP MIDWEST FAMILY MUTUAL INSURANCE COMPANY MIDWEST FAMILY ADVANTAGE INSURANCE COMPANY Telephone Fax Westown Parkway Suite 305, West Des Moines, IA Mailing Address: P.O. Box 9425 Minneapolis, MN INSTRUCTIONS: This packet is designed to help you with the claim process for your Workers Compensation policy through Midwest Family Mutual. The forms necessary to file your claim are attached to this packet. You can also find a copy of all forms required by your state attached to your policy. If you need additional copies of any of the attached forms, please contact your agent. Please be advised that all of the forms mentioned below are REQUIRED. Failure to submit all the required forms in their entirety may result in delays in payments and/or fines from the state. The following forms MUST be received in our office as soon as possible after an injury, failure to do so on your part could result in delays in payments and possibly fines to you;./ FIRST REPORT OF INJURY The employer must complete this form immediately after an injury. Fill this form out as completely as possible, and fax it to us immediately, even if you have little to no information on the occurrence. THIS FORM IS DUE WITHIN 24 HOURS OF INJURY, OR YOU MAY INCUR FINES!./ EMPLOYEE REPORT OF INJURY The employee must complete this form in its entirety, immediately../ SUPERVISORS REPORT OF ACCIDENT The employer must complete this form immediately after an injury. Fill this form out as completely as possible, and fax it to us immediately, even if you have little to no information on the occurrence../ MEDICAL AUTHORIZATION The employee must complete this form in its entirety, immediately. We prefer to have you fax the loss report to us. If you do fax it, do not duplicate the process by mailing it also. Our mailing address and fax number are listed below. If you need to notify your agent, please send them a photocopy of the report. Workers Compensation Claims Midwest Family Mutual PO Box 9425 Minneapolis, MN Fax: ATTENTION! FAILURE TO UNDERSTAND YOUR RESPONSIBILITIES UNDER THIS POLICY MAY RESULT IN YOUR COMPANY BEING SUBJECT TO STATE FINES!

2 WORKERS COMPENSATION REPORTING TIPS ATTENTION YOU MAY BE FINED IF YOU DO NOT REPORT ONTHEJOB INJURIES ON TIME! You must complete an Employer s First Report of Injury IMMEDIATELY after an onthejob occurs forward the report to Midwest Family Mutual Insurance Company s home office. The form must be in our office within 24 hours after an injury has occurred. You may be fined if you do not submit the report within that time. You must send or fax the initial loss report to us immediately, even if you do not have all the information about the injury. Do not wait for medical bills. Do not withhold the loss report because you believe the claim is questionable. If an employee is injured but does not initially lose work time, and then later does lose work time because of the injury, call us immediately. DO NOT WITHHOLD THE LOSS REPORT FOR ANY REASON. SEND OR FAX IT TO US IMMEDIATELY AFTER THE INJURY OCCURS. As a Workers Compensation carrier, we have limited time to make the initial lost time payment from the last day worked. If we have the Employer s First Report of Injury in our office, but fail to make the payment in the time allowed, we may be fined by the state. If we cannot make the payment because you failed to send the Employer s First Report of Injury on time, you may be fined. We prefer to have you fax the loss report to us. If you do fax it, do not duplicate the process by mailing it also. Our mailing address and fax number are listed below. If you need to notify your agent, please send them a photocopy of the report. Workers Compensation Claims Midwest Family Mutual PO Box 9425 Minneapolis, MN Fax: We appreciate your cooperation. If you have any questions, or need additional Workers Compensation Loss Report forms, please call the home office and ask for Workers Compensation Claims. We look forward to servicing your account. TollFree Workers Compensation Claims

3 EMPLOYER S FIRST REPORT OF INJURY OR DISEASE Fatal Injuries: Employers subject to ch.102, Wis. Stats., must report injuries resulting in death to the Department and to their insurance carrier, if insured, within one day after the death of the employee. NonFatal Injuries: If the injury or occupational illness results in disability beyond the threeday waiting period, the employer, if insured, must notify its insurance carrier within 7 days after the injury or beginning of disability. Medicalonly claims are to be reported to the insurance carrier only, not the Department. Electronic Reporting Requirement: All workrelated injuries and illnesses resulting in compensable lost time, with the exception of fatalities, must be reported electronically to the Department via EDI or Internet by the insurance carrier or selfinsured employer within 14 days of the date of injury or beginning of disability. Employer may fax claims for fatal injuries to the Imaging Fax Server number on this form. Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s (1)(m), Wisconsin Statutes]. (Please read the instructions on page 2 for completing this form) Employee Name (First, Middle, Last) Social Security Number Sex INJURY INFORMATION WAGE INFORMATION EMPLOYER EMPLOYEE M F Employee Street Address City State Zip Code Birthdate Date of Hire County and State Where Accident or Exposure Occurred? Department of Workforce Development Worker s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI Imaging Server Fax: (608) Telephone: (608) DWDDWC@dwd.wisconsin.gov Employee Home Telephone No. ( ) Occupation Employer Name WI Unemployment Ins. Acct No. SelfInsured? Nature of Business (Specific Product) Yes No Employer Mailing Address City State Zip Code Employer FEIN Name of Worker s Compensation Insurance Co. or SelfInsured Employer Insurer FEIN Name and Address of Third Party Administrator (TPA) Used by the Insurance Company or SelfInsured Employer TPA FEIN Wage at Time of Injury Specify per hr., wk., mo., yr., etc. In Addition to Wages, Meals No. of Meals/wk. $ Per: Check Box(es) if Room No. of Days/wk Employee Received: Tips Avg. Weekly Amt. $ Is Worker Paid for Overtime? Yes No If Yes, After How Many Hours of Work Per Week? For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work, and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks. No. of Weeks: Gross Amount Excluding Tips: $ If PieceWork, No. of Hrs. Excluding Overtime: Start Time Hours Per Day Hours Per Week Days Per Week Employee s Usual Work Schedule When Injured: : AM PM Employer s Usual FullTime Schedule for This Type of Work at Time of Employee s Injury: PartTime Employment Information: Injury Date Are there Other PartTime Workers Doing the Same Work With the Same Schedule? Yes No If yes, how many? Time of Injury : AM : PM Number of FullTime Employees Doing The Same Type Of Work: Last Day Worked Date Employer Notified Date Returned to Work Estimated Date of Return Did Injury Occur Because of: Substance Failure to Use Failure to Abuse Safety Devices Obey Rules Did Injury Cause Death? Date of Death Was This a Lost Time or Other Yes No Compensable Injury? Yes No Was Employee Treated in an Emergency Room? Yes No Was Employee Hospitalized Overnight as an InPatient? Yes No Name and Address of Treating Practitioner and Hospital: Case Number from the OSHA Log: Injury Description Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were Involved. What Happened to Cause This Injury or Illness? (Describe How The Injury Occurred) What Was The Injury or Illness? (State the Part of Body Affected and How It Was Affected) Report Prepared By Work Phone Number ( ) Position Date Signed WKC12 (R. 02/2009) SEND REPORT IMMEDIATELY DO NOT WAIT FOR MEDICAL REPORT

4 EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS The employer must complete all relevant sections on this form and submit it to the employer s worker s compensation insurance carrier or third party claim administrator within seven (7) days after the date of a workrelated injury which causes permanent or temporary disability resulting in compensation for lost time. The employer s insurance carrier or the thirdparty claim s administrator may request that this form also be used to immediately report any injury requiring medical treatment, even though it does not involve lost work time. For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality. An employer exempt from the duty to insure under s , Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department of Workforce Development within 14 days of the date of work injury. MANDATORY INFORMATION In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to the sender if the mandatory information is not provided. Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the Date of Hire is the date the employee was hired for the job on which he or she was injured. Employer Section: Provide all requested information to identify the injured worker s employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or selfinsured employer responsible for the worker s compensation expenses for this injury. Also identify the third party claim administrator, if one is used for this claim. Wage Information Section: Provide the information requested regarding the injured employee s wage and hours worked for the job being performed at the time of injury. Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached, if additional information is needed. This form was designed to include information required by OSHA on form 301. If this section is completed and retained, the employer will not have to complete the OSHA 301 form.

5 IWIF Employee's Report of Injury (To be completed by the employee only.) Employee's name: Male Female Last First Middle Date of birth: / / Home telephone # ( ) Home address: City: State: Zip Code: Present classification: How long employed here: Social Security No.: Weekly salary: Location of accident: Address Area (loading dock, bathroom, etc.) Date of accident: Time of accident: Describe fully how accident occurred: (including events that occurred immediately before the accident): Describe bodily injury sustained (be specific about body part(s) affected): Recommendation on how to prevent this accident from recurring: Name of supervisor: Phone# Last First Name(s) of witness(es): Phone# (Attach witness(es) report(s)) When did you report the accident to your supervisor? To whom did you report the injury? Do you require medical attention? Yes: No: Maybe: Name of your treating physician: Phone# Signature of employee: Date: 204A 01/03 Form may be copied as needed

6 IWIF Supervisor's Accident Investigation (To be completed by the employee's supervisor or other responsible administrative official) Location where accident occurred Employer's Premises: Yes No Date of accident or illness Job site: Yes No Who was injured? Employee Time of accident a.m. NonEmployee p.m. Length of time with firm Job title or occupation Name of dept. normally assigned to How long has employee worked at job where injury or illness occurred? What property/equipment was damaged? Property/equipment owned by: What was employee doing when injury/illness occurred? What machine or tool was being used? What type of operation? How did injury/illness occur? List all objects and substances involved. Part of body affected/injured? Any prior physical conditions? If so, what? Yes No Nature and extent of injury/illness and property damaged (be specific) PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS Failure to lockout Improper maintenance Poor housekeeping Failure to secure Improper protective equipment Poor ventilation Horseplay Inoperative safety device Unsafe arrangement or process Improper dress Lack of training or skill Unsafe equipment Improper guarding Operating without authority Unsafe position Improper instruction Physical or mental impairment Other Supervisor's corrective action to ensure this type of accident does not recur: Was employee trained in the appropriate use of Personal Protective Equipment/Proper safety procedures?... Yes No Was employee cautioned for failure to use Personal Protective Equipment/Proper safety procedures?... Yes No Did employee promptly report the injury/illness?... Yes No Is there modified duty available?... Yes No Supervisor's name Supervisor's signature Phone# Date 204C 01/03 Form may be copied as needed

7 WISCONSIN WORKERS COMPENSATION Workers Compensation is a system of benefits provided by law to most workers who have jobrelated injuries or illnesses. Benefits are paid for injuries that are caused, in whole or in part, by an employee s work. IF YOU SUFFER FROM A WORKRELATED INJURY OR ILLNESS, YOU SHOULD TAKE THE FOLLOWING STEPS: GET MEDICAL ASSISTANCE. By law, your employer must pay for all necessary medical services required to cure or relieve the effects of the injury or illness. The employee may choose two physicians, surgeons, or hospitals. Where necessary, the employer must also pay for physical, mental, or vocational rehabilitation, within prescribed limits. NOTIFY YOUR EMPLOYER. You must notify your employer of the accidental injury or illness immediately, either orally or in writing. To avoid possible delays, it is recommended the notice also include your name, address, telephone number, Social Security number, and a brief description of the injury or illness. LEARN YOUR RIGHTS. Your employer is required by law to report accidents immediately to the Workers Compensation Commission. Once the accident is reported, you should receive a handbook that explains the law, benefits, and procedures. If you need a handbook, please call the Commission or go to the Web site. If you must lose time from work to recover from the injury or illness, you may be entitled to receive weekly payments and necessary medical care until you are able to return to work that is reasonably available to you. It is against the law for an employer to harass, discharge, refuse to rehire or in any way discriminate against an employee for exercising his or her rights under the Workers Compensation or Occupational Disease Acts. FRAUD Collecting workers compensation benefits you are not entitled to is a theft. If you file a fraudulent claim, you may be penalized under the law. A suspected fraud claim can be reported by anyone. If you have reason to suspect someone is committing workers compensation fraud, call 1 (608) All suspected violations will be investigated. Insurer Name: Midwest Family Mutual. Phone Number For more information contact: State of Wisconsin Department of Workforce Development P.O. Box 7901 Madison, WI (608) WI WC EE 0313

8 MIDWEST FAMILY GROUP MIDWEST FAMILY MUTUAL INSURANCE COMPANY MIDWEST FAMILY ADVANTAGE INSURANCE COMPANY Telephone Fax Westown Parkway Suite 305, West Des Moines, IA Mailing Address: P.O. Box 9425 Minneapolis, MN AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS PURSUANT TO 45 CFR (HIPAA) Patient Name: DOB: SS#: Claim No.: Date of Accident: 2/26/2007 TO: Any physician, surgeon, dentist, hospital, rehabilitation/convalescent/custodial facility, ambulance, nurse, other health care provider or insurance company. I,, authorize you to disclose and release the following protected health information: Any and all inpatient admissions, all ER visits, outpatient clinic notes, diagnostic testing, radiology films, consults, doctors orders, progress notes (excluding psychotherapy notes), nurses notes, laboratory testing, social service records, reports, correspondence, consultations, memoranda, treatment plans, admission records, discharge summaries, medical summaries, diagnoses, and/or any writing of any kind. This protected health information is disclosed for the following purposes: verifying, evaluating, negotiating and or other pertinent legal uses, with respect to the patient s insurance claim made to Midwest Family Mutual Insurance Company. You are authorized to release the above records, or copies thereof, to any representative of Midwest Family Mutual Insurance Company at the following address: Midwest Family Mutual Insurance Company PO Box 9425 Minneapolis, MN This authorization shall be in force and effect until the earlier of one year from the date signed or the date the claim has been legally concluded at which time this authorization expires. I have the right to revoke this authorization, in writing, by sending written notification to you with copy to Midwest Family Mutual Insurance Company at the above address. I understand that a revocation is not effective to the extent that you have relied on my authorization to disclose protected health information. I acknowledge that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Subpart E of the Regulations promulgated by the U.S. Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) relating to the privacy of individually identifiable health information. I agree that a photocopy or facsimile copy of this Authorization shall be valid and effective just as the original. I understand that I have the right to: Inspect or copy the individually identifiable health information to be disclosed. Refuse to sign this authorization and that my treatment is not conditioned upon my signature hereon. Receive a copy of this Authorization upon request. Signature of Patient or Personal Representative Dated Name of Patient or Personal Representative Description of Personal Representative s Authority to Sign for Patient (if applicable)

9 Frequently Asked Questions Q: When should I file a claim? A: Immediately after an injury occurs regardless of the merits of the injury. Fill out the forms attached to this packet, and return to us as soon as possible. Any investigation we complete will depend on having these forms as soon as possible. Q: Where do I get the claims forms I need for my employees to fill out and if all forms have been used? A: Please contact your agent. They can request another packet for you. Q: Are all injuries at work covered? A: Injuries that arise out of and are in the course and scope of an employees work are covered by Workers Compensation. The injury must be causally related to the employment, however, if an employee states he/she was injured at work, always fill out the documents and let your carrier determine the compensability of the claim. Q: What if an employee is injured at a company social or recreational function? A: If the employee s presence is required at the function, an injury could be covered. If the employee attends on a purely personal basis, then coverage would probably be excluded. These issues are very factspecific and require much investigation. Q: Are workers covered for travel going to and from their place of employment? A: Workers could be covered if the travel arises out of their employment and is in the course and scope of the employment. If the travel is purely personal, it will not be covered, however if they are driving a company car it will depend on the course of travel. Q: Are injuries that appear over time, or occupational diseases, covered? A: Very possible. These are usually repetitive motion injuries such as carpal tunnel syndrome or overuse syndrome. Medical verification is needed to connect the work performed to the condition complained of. Q: What can I do if I think an employee s workers compensation claim is not valid? A: You should submit that information to the workers compensation claims administrator/claims representative. Inform them of ALL the facts you know, any witnesses you are aware of, and the people they can talk to. Follow up any phone or verbal report with a letter.