ARIZONA EMPLOYER. We are pleased to have the opportunity to serve you.

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1 ARIZONA EMPLOYER Dear American Liberty Insurance Policyholder: Thank you for placing your workers compensation coverage with American Liberty Insurance. We greatly appreciate your business and look forward to assisting your company in the future. Your new policy and claims kit are enclosed. Please review and retain for future reference. As you review this information, please feel free to contact your insurance professional or us directly with any questions you may have. American Liberty s management team is committed to providing you with cost effective coverage and personalized service to meet your workers compensation insurance needs. We are pleased to have the opportunity to serve you.

2 Within this packet you will find: Three (3) Posting Notices to be displayed in a public area visible to all employees Claim Reporting Envelope containing: Actions to take immediately after any work-related injury occurs Arizona Employers Report of Industrial Injury form Medical Provider List for the injured employee Authorization to Release Protected Health Information form Arizona Medical Treatment Provider List form Welcome to American Liberty Insurance Company in conjunction with our Claims Administrator (TPA), S & C Claims Services, Inc N. University Ave #100 Provo, Utah Toll Free: (866) Hour Reporting Hotline: (800) ALIC Arizona Claims Kit

3 How to use this kit: STEP #1: Display Posting Notices in areas accessible to employees Employee Safety and Health Protection Poster Notice of Arizona Workers Compensation Law Notice of Work Exposure to Bodily Fluids STEP #2: Report job-related injury as it happens: Seek medical treatment for injured worker Report work-related injury either online, fax, phone or by mail. STEP #3: Provide the injured worker with the following: Medical Provider List Authorization to Release Protected Health Information form Arizona Medical Treatment Provider List form ALIC Arizona Claims Kit

4 ACTIONS for immediately after an injury occurs: MEDICAL TREATMENT Immediately refer injured worker to closest directed care medical clinics or emergency room! REPORT YOUR WORK-RELATED INJURY Fill out EMPLOYER S REPORT OF INDUSTRIAL INJURY (Form included) and use ONE of the following methods for reporting: INTERNET: Log on to our website to fill out the form: click on File a Claim (preferred method quickest and most accurate) FAX form to: PHONE: Toll free (during normal business hours only) ALIC Arizona Claims Kit

5 For the Injured Worker: MEDICAL PROVIDERS LIST: For the injured worker to help find treatment in the closest clinic that participate in our program. AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION: For the injured worker to sign and send in to Blue Star Claims Management. ARIZONA MEDICAL TREATMENT PROVIDER LIST FORM: For the injury worker to fill out and send to Blue Star Claims Management. ALIC Arizona Claims Kit

6 Notice to Employers WC Fraud: Tell-tale Signs Experience shows that when there are two or more of the below signs present in a workers' compensation claim, there is a greater chance the workers compensation claim may be fraudulent. Being present are not "absolutes" but are simply possible indicators. Many legitimate claims are filed on Mondays and some accidents have no witnesses. If you are suspicious of a potential fraud claim and you are a policyholder of American Liberty Insurance Company, please send an wc_fraud@american-liberty.net. T hey Are Hard to Reach You/we have difficulty contacting claimant at home when they are allegedly disabled. evolving Service Providers and Other Changes - The claimant has a history of frequently R changing physicians, changing addresses & numerous past employment changes. sing the Service Providers U Use of the same doctors and lawyers by group of claimants. uspicious Service Providers - The employee's medical providers and/or legal consultants S have a past history of handling suspicious claims. reatment is Refused - The claimant refuses a diagnostic procedure to confirm the nature or T extent of a work related injury. A L I ccident With No Witnesses - The accident has no witnesses and the employee's own description does not logically support the cause of the alleged work related injury. ate Reporting of Injury or Claim - The employee delays reporting the claim without a reasonable explanation. njury 'Monday Morning' - The alleged work related injury occurs first thing on Monday morning or occurs late on a Friday afternoon but is not reported until Monday. onflicting Descriptions - The employee's description of the work related injury conflicts C with the medical history reflected on the First Report of Injury. ALIC Claims Kit

7 American Liberty Insurance Company C/O S&C Claims, Inc N. University Ave #100 Provo, Ut NOTE TO EMPLOYER: 1. Mail one copy to the Industrial Commission within 10 days. 2. Mail one copy to your insurance carrier within 10 days. 3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of * The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission s forms, prescribed under the Commission s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. Form ICA (Rev. 7/01) THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

8 Concentra Locations in Arizona Phoenix area 5340 W. Buckeye Road, Suite S. Val Vista Road, suite 106 Phoenix, AZ Mesa, AZ Telephone: (602) Telephone:(480) Fax:(602) Fax:(480) After hours: (602) After hours:(480) Urgent Care 8:00 am - 5:00 pm (Mon.-Fri.) Urgent Care 8:00 am - 5:00 pm (Mon. - Fri.) Occupational Medicine 8:00 am - 5:00 pm (Mon.-Fri.) Occupational Medicine 8:00 am - 5:00 pm (Mon. - Fri.) 1818 E. Sky Harbor Circle North, Bldg N. 83rd Avenue, Bldg. H Suite 150 Suite 148 Phoenix, AZ Peoria, AZ Telephone:(602) Telephone:(623) Fax: (602) Fax:(623) After Hours: (602) After hours:(623) hours, 7 days a week Urgent Care 7:00 am - 6:00 pm (Mon.-Fri.) Occupational Medicine 7:00 am-6:00 pm (Mon.-Fri.) Tucson area 3532 W. Thomas Road, Suite 5 Phoenix, AZ W. Ruthrauff Road, Suite 111 Telephone: (602) Tucson, AZ Fax: (602) Telephone:(520) After Hours (602) Fax:( 520) After hours (520) Urgent Care 8:00 am - 6:00 pm (Mon.-Fri.) 8:00 am -12:00 pm (Sat.) Occupational Medicine 8:00 am - 6:00 pm (Mon.-Fri) 8:00 am -12:00 pm (Sat.) Urgent Care 8:00 am - 5:00 pm (Mon.- Fri) Occupational Medicine 8:00 am -5:00 pm (Mon. - Fri) 1710 W. Southern Avenue 4600 So. Park Avenue, Suite 5 Mesa, AZ Tucson, AZ Telephone (480) Telephone: (520) Fax:(480) Fax:(520) After hours (480) After Hours (520) Urgent Care 8:00 am -6:00 pm (Mon. - Fri.) 8:00 am -12:00 pm (Sat.) Urgent Care 7:00 am -8:00 pm (Mon.- Fri.) 8:00 am - 4:00 pm (Sat. & Sun.) Occupational Medicine 8:00 am -6:00 pm (Mon. - Fri.) 8:00 am -12:00 pm (Sat.) Occupational Medicine 7:00 am -8:00 pm (Mon.- Fri.) 8:00 am - 4:00 (Sat.& Sun.) N. Northsight Blvd. Suite E. Broadway Blvd. Scottsdale, AZ Tucson, AZ Telephone (480) Telephone:(520) Fax (480) Fax:(520) After hours (602) After Hours ( 520) Urgent Care 8:00 am -5:00 pm (Mon.-Fri.) Urgent Care 8:00 am - 5:00 pm (Mon.-Fri.) Occupational Medicine 8:00 am -5:00 pm (Mon.-Fri.) Occupational Medicine 8:00 am - 5:00 pm (Mon.- Fri.) 950 W. Southern Avenue Flagstaff area Tempe, AZ Telephone (480) Fax:(480) W. Fine Ave. After hours (602) Flagstaff, AZ Telephone (928) Urgent Care 8:00 am - 5:00 pm (Mon. - Fri.) Fax:(928) Occupational Medicine 8:00 am -5:00 pm (Mon.- Fri.) After hours:(928) Urgent Care 8:00 am - 8:00 pm (Mon.-Fri) 8:00 am - 4:00 pm (Sat. & Sun.) Occupational Medicine 8:00 am -8:00 pm (Mon.- Fri.) 8:00 am -4:00 pm (Sat.& Sun.) N. Black Canyon Highway Phoenix, AZ Telephone:(602) Fax:( 602) After hours:( 602) Urgent Care 7:00 am -7:00 pm (Mon.-Fri) Occupational Medicine 7:00 am -7:00 pm (Mon.-Fri.) ALIC Arizona Claims Kit

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11 American Liberty Insurance Company, Inc. C/O S&C Claims Inc. AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEALTH INFORMATION (HIPAA COMPLIANT) To: This authorization permits you to release a copy of any and all records in your possession regarding any medical treatment and/or hospitalization of: Name of Claimant Date of Birth Social Security Number Date(s) of Injury/Occupational Disease I AUTHORIZE you to disclose any information and records regarding the above named individual in your possession. This includes but is not limited to, your medical findings, diagnosis, treatment, treatment summaries, psychological or psychiatric evaluations, prognosis, clinic notes, diagnostic reports or radiology films, physical therapy records, pharmacy records, or any other health information in your records. I understand that based on the information released it may include information related to any substance abuse. I UNDERSTAND that the information furnished may be used to evaluate and verify my claim for benefits for a work related injury or occupational disease. The information obtained is relevant to a workers compensation claim(s) and may be used by persons or organizations performing a service related to, or adjudicating the claim(s). THIS AUTHORIZATION will expire 90 days following a resolution of the workers compensation claim(s) but may be revoked by signator in writing to the requesting party. Revocation of this authorization will not be valid if the requesting party has taken action in reliance upon such authorization. Please note that the information disclosed or used pursuant to this authorization may be subject to re-disclosure and would, therefore, no longer be protected under the terms of the HIPAA privacy rule. A PHOTOSTATIC COPY of this authorization shall be deemed to have the same authority as the original. I hereby certify that I have read the provisions in this authorization. I understand and agree to its terms, and authorize disclosure of the information described above. _ Claimant Date Requesting Party: Sandra Jones Toll Free Phone Number: Fax: Address: S& C Claims Inc N. University Ave #100 Provo, Utah 84604

12 American Liberty Insurance Company, Inc C/O S&C Claims, Inc N. University Ave #100 Provo, Utah MEDICAL TREATMENT PROVIDER LIST Claimant Name Address Telephone Number Social Security Number Date of Injury Employer Notification to the Workers Compensation Claimant We are asking that you please fill out this form to help expedite the Workers Compensation claim filed. Please list all the medical providers for industrial injury first. Please list any other medical providers who have treated you for any medical problems within the past years (up to 15 years). Zip Zip Telephone Number Telephone Number Zip Telephone Number Zip Telephone Number Zip Telephone Number Please attach additional pages, if necessary. Zip Telephone Number Zip Telephone Number Zip Telephone Number Name of Party Requesting the Medical Records: S&C Claims, Inc. Sandra Jones Address: 3601 N. University Ave #100 Provo, Ut Telephone Number: Relationship to the Claimant: Adjuster Failure to return this form to the requester may result in a delay or denial of your claim. ALIC Arizona Claims Kit