For any other Claim or Risk related questions please see the contact table below. REQUEST / REPORTING

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1 The enclosed information includes workers compensation claim reporting instructions and forms. Please carefully review this information to ensure timely reporting of work related injuries/illnesses and to control worksite exposures. The following information is enclosed: Step-By-Step Claim Reporting Instructions Employer s Report of Work-Related Injury/Illness Form Employee s Statement of Acknowledgement Form Employer Authorization for Initial Treatment Workers Compensation Pharmacy Form The above information will assist you with proper claims reporting and OSHA compliance. When reporting worker related injuries or illness please: Complete both pages of the Employer s Report of Work-Related Injury/Illness form and.. Complete the Employee s Statement of Acknowledgement Form and both forms to wcclaims@ or fax both forms to (866) within 24 hours of your knowledge of a work related injury or illness. If you have any questions regarding the Claims Reporting Guide and forms, please feel free to contact the Claims Examiner at or For any other Claim or Risk related questions please see the contact table below. REQUEST / REPORTING WC Claim Questions/Injury Reporting wcclaims@ Safety & Loss Control/OSHA Questions babdallah@ Certificates of Insurance/Proof of Insurance certificaterequest@ Loss Run Request smartinez@

2 Workers Compensation Claims Reporting Step-by-Step Instructions 1. Complete both pages the AlphaStaff Employer s Report of Work-Related Injury/Illness ( EROWI ) form. 2. Review the Employee s Statement of Acknowledgement form with the injured employee. This form advises the employee of his/her responsibilities under workers compensation. This form must be signed and dated by the employee and an employer representative (e.g. supervisor or manager). Please submit one copy of the signed form to AlphaStaff, along with the Employer s Report of Work-Related Injury/Illness; provide a copy to the claimant; and keep the original signed form in the employee s personnel file. 3. or fax the EROWI and the Employee s Statement of Acknowledgement form to AlphaStaff s Claims Department within twenty-four (24) hours of the incident. wcclaims@ Fax: If the employee requires/request medical treatment, complete the Employer s Authorization For Initial Treatment form and give it to the employee to present to the clinic receptionist upon arrival. 5. Give the employee a Chain of Custody Form, to present to the clinic receptionist upon arrival, so a post accident drug screen can be performed. If you do not have Chain of Custody forms the clinic can use their standard Chain of Custody form. 6. Send the injured employee to one of the medical facilities listed on your medical panel or to the nearest urgent care clinic. 7. If the injury is a life threatening (e.g. loss of consciousness, deep laceration, head injury, fall from a ladder, down a staircase, possible loss of life or limb) please call 911. THE FORMS REFERRED TO ABOVE CAN BE FOUND AT / ALPHASTAFF FORMS LIBRARY

3 EMPLOYER S REPORT OF WORK-RELATED INJURY/ILLNESS To Be Completed By The Injured Employee s Supervisor or Authorized Personnel FAX TO ALPHASTAFF AT (866) OR TO wcclaims@ WITHIN 24 HOURS Today s Date: A: CLIENT COMPANY INFORMATION Client Company Name Client Company Address Client ID # (Loc Code) Client Company Phone # ( ) B: EMPLOYEE INFORMATION Employee Name: Social Security Number: Sex: Male Female Date of Birth: (MM/DD/YYYY) Marital Status: Married Single Divorced Separated Home Address (including City, State, Zip): Telephone Number: ( ) Occupation: Date Hired: Hours Work Per Day: Hours Work Per Week: Days Of Week Employee Works: S M T W Th F S Wages Per Hour $: Salary Employee: Yes Weekly Wage $: No C: INJURY/ILLNESS DETAILS Date of Incident: (MM/DD/YYYY) Time of Incident: AM PM Cannot be determined. Date employee notified you of injury/illness(mm/dd/yyyy): Time employee began work on date of incident: AM PM Did employee return to work? Yes No. If Yes Date Returned (MM/DD/YYYY): If No Last Day Worked (MM/DD/YYYY): Location of Incident (e.g. 1 Main St., Miami, FL, in the file room): Description of Incident (Provide detailed facts): Injury / Illness (e.g. pain/laceration/sprain): Part of Body Affected (indentify right/left): What object or substance directly harmed the employee? (e.g. concrete floor, knife, debris): Name(s) of anyone who witnessed the incident: Was Employee Advised To Seek Medical Care? Yes No. If No Why: Did Employee Refuse To Seek Medical Care? Yes No. If Yes Why: D: TREATMENT INFORMATION (Physician/Hospital/Clinic) Provider Name: Provider Address: Provider Phone #: ( ) Did Provider Administer Drug Test? Yes No Was employee hospitalized as an in-patient? Yes No If employee died, date of death: (MM/DD/YYYY): Page 1 of 2 Complete Both Pages

4 Client Company: EE Name: Date of Injury/Illness: E: ACCIDENT CAUSATION Environmental Factors: Improper lighting Ventilation Wet floor/surface Weather/Hot Cold Rain Other Equipment / Machine: Equipment Broke Equipment not provided Equipment not suitable for job or activity Equipment broke during use Equipment was broken prior to use Guards failed Guards were enabled Other Human Factors: Employee trained for the task Yes No. Is training documented Yes No. Employee failed to follow procedures Yes No. Didn t understand procedure Employee followed established procedures. Employee followed procedures, but procedures were wrong There are no procedures for this job to follow. Employee failed to wear provided safety equipment Yes No. If Yes Too big Too small Other Employee was not provided safety equipment Yes No Supervisor knew or saw that employee was not following proper procedures but failed to take corrective action: Yes No If Yes Why? F: CORRECTIVE ACTION Accident was reviewed with employee by supervisor Yes No Work orders have been submitted to repair broken equipment Yes No Procedures were reviewed and employee understands procedures Yes Procedure created or modified and taught to employees Yes No Employee given a verbal or written warning Yes No Supervisor given verbal or written warning Yes No Safety Committee reviewed accident and corrective actions Yes No No G: SUPERVISOR INFORMATION Name of Supervisor or Authorized Personnel: Position/Title: (Who Completed This Form) Phone #: ( ) Work Do you question this injury/illness: Yes No If Yes please explain: Any other comments: 800 Corporate Drive Suite 600 Fort Lauderdale, FL Page 2 of 2

5 EMPLOYEE S STATEMENT OF ACKNOWLEDGEMENT Relative to my claim for workers compensation benefits, I acknowledge the following: It is my responsibility to provide my employer (i.e. supervisor, manager, Human Resources Representative) with a copy of the Medical Treatment/Status Reporting form after each medical appointment. This form is also referred to as a Work Status Report/Note or Fit for Duty Status Report. I must clarify my work status during the appointment or before I leave the physician s office. It is my responsibility to know the date and time of all follow up physician and physical therapy appointments before leaving the physician or therapist office. I must keep all physician and physical therapy appointments. I must follow my physician s treatment plan. I must submit all bills relative to my claim, to my workers compensation adjuster immediately upon receipt. I must complete and return all forms to the insurance carrier when asked. This includes the mandatory fraud statement. You must review, sign and return the mandatory fraud statement to the insurance carrier. By signing this document, you are confirming your understanding of this important information. Your benefits may be suspended if you refuse to sign and return this document to the insurance carrier. I must return to work when I am released to return to work by my physician and when my employer offers me a position within my physical limitations/restrictions. Your lost wage benefits may be suspended if you do not return to work when advised too. I must report all wages/income, from all sources of employment, to the insurance carrier if I have more than one employer. I must report earnings/income to the insurance carrier such as social security income, unemployment compensation, including workers compensation benefits from a different insurance carrier. I must keep my workers compensation adjuster regularly informed on the status of my progress or if I have any needs such as medical authorization or additional physical therapy. Note: If you are represented by an attorney, the adjuster may not be able to speak with you directly. I must notify my workers compensation adjuster of any change of address or telephone number. I can call the authorized treating physician s office if I need to see the doctor before my next appointment date. If an appointment is not available and you need to see a doctor immediately, contact your workers compensation adjuster. EMPLOYEE NAME (PRINT) EMPLOYEE SIGNATURE DATE EMPLOYER REPRESENTATIVE NAME (PRINT) EMPLOYER REPRESENTATIVE SIGNATURE DATE ORIGINAL FOR EMPLOYER RECORDS COPY TO EMPLOYEE COPY TO ALPHASTAFF, INC

6 EMPLOYER AUTHORIZATION FOR INITIAL TREATMENT DATE: INCOMING PATIENT EMPLOYEE NAME: SSN: PHONE: INJURY: (Body Part) DATE OF INJURY: COMPANY NAME: AlphaStaff, Inc. CLIENT COMPANY NAME: CLIENT COMPANY ADDRESS: PHONE: AUTHORIZED BY: TITLE: Information below for Medical Facility use only: 1. Initial evaluation and treatment of the workers compensation injury is hereby authorized for the above employee, and should be billed to the following Workers Compensation carrier: AmTrust North America/Technology Insurance Company States: AL, HI, WESTERN REGION P.O. Box89453 trustgroup.com Fax (216) States: CT, ME, NH, RI, VT NORTHEAST REGION P.O. Box Fax (518) States: DC, DE, MD, MIDATLANTIC REGION P.O. Box Fax: (678) States: IL, IN, IA, KS, KY, MO, TX, CO, NE, ND, WA, WY MIDWEST REGION P.O. Box Fax (678) States: AL, AR, GA, MS, NC, SC, TN, VA, WV, FL SOUTHEAST REGION P.O. Box Fax (561) A 5 Panel Post-Accident Drug Screen MUST be done. If the employee does not bring a Chain-of-Custody form, please use your form. PLEASE MAIL, , OR FAX THE DRUG SCREEN RESULTS AND BILL TO ALPHASTAFF, INC. BILLING ADDRESS IS BELOW FAX: / WCCLAIMS@ALPHASTAFF.COM 3. Subsequent medical treatment must be pre-authorized by the assigned WC Adjuster at AmTrust/Technology Insurance Company. If you have any questions regarding the Claims Reporting Guide and forms, please feel free to contact the Claims Examiner at or Thank you for your services.

7 AmTrust Pharmacy Program Administered by Carlisle Medical Workers Compensation Prescription Drug Program Employer please complete the following Employee: Date of Injury: Policy #: Employer: You ll print this info How Does This Program Work? Your workers compensation carrier has initiated a prescription drug program through Carlisle Medical. Approved medications prescribed by your workers compensation physician can be filled at over 69,000 participating pharmacies or Carlisle Medical Home Delivery Pharmacy at no cost to you. This program does not impact medications which are not related to your workers compensation claim. Who is Covered? This program covers only you, the injured worker. What is Covered? This Workers Compensation Program allows you to have prescriptions filled that are authorized by your physician for treatment of your specific on-the-job injury. This program also provides you with DME items and supplies (see back of this sheet for details) which are authorized for your workers compensation injury. Contact us if you need assistance obtaining DME supplies. How Do I Use This Program? 1. Call Carlisle Medical to activate your prescription card. Please be sure your card below has the correct and completed information before presenting it to the pharmacy (You may need to fill in the missing information). 2. Take your prescription to the nearest RESTAT participating pharmacy (see below for partial listing) or call for home delivery (see back for details). 3. Present this card to the pharmacy every time you fill a prescription for your work related injury. Customer Service representatives can be reached by calling our toll-free number below to assist with any questions you may have. To receive your medications for your Workers Compensation injury, Please Call before going to your pharmacy. Participating Chain Store Pharmacies: Workers Compensation Prescription Card, Please detach. Contact Numbers: Carlisle Medical Inc.: Customer Service Available Mon - Fri 7:00 a.m. - 10:00 p.m. CST CVS Target Kroger Walmart Publix Walgreens Prescription Card Activation Injured Worker Prescription Card Rite Aid Winn-Dixie Home Delivery Pharmacy SAM s Club Subscriber Name Rick Nelson Doe, Medication Authorization or Rejections Member ID Pharmacist Program Questions Group Number ,000 pharmacies in our national network. W805 You ll print DME Assistance Person Code 000 this info visit us online at RX BIN Number Restat: In addition to the chain pharmacies listed above, many independent pharmacies are among the For information on those participating in your area, please call Carlisle Medical at or Provider Eligibility/Authorization Pharmacy Technical Support Technical Support Available 24/7 Terms and Conditions: This card is for identification only, is non-transferable and remains the property of RESTAT. Please carry it with you at all times. Prescription benefits obtained through the use of this card are governed by the condition of the agreement between RESTAT and the insuring organization. The unauthorized or fraudulent use of this card to obtain prescription drugs is punishable by law. This card is VOID when your eligibility terminates.