Claims Reporting Quick Reference Guide (Policy Yr: 6/1/14-5/31/15)

Transcription

1 Claims Reporting Quick Reference Guide (Policy Yr: 6/1/14-5/31/15) SUPERVISION INVESTIGATION RPT B-1 ANY VIDEO SEE CONTACT INFORMATION. FORM. TTP (You must provide the policy number when reporting to this number) Form R-2 Revised 6/1/2014 HAVE EMPLOYEE COMPLETE EMPLOYEE S REPORT OF INJURY FORM C-1. (For CA see form DWC-1) STATEMENT FORM C-2. REPORT THE CLAIM TO SEE CONTACT. WA7-65D NEVADA CLAIMS OFFICE: 7881 W. Charleston Blvd. - Suite 190 Las Vegas, NV Phone: (702) Fax: (603) Subrogation regarding injured workers are handled by Liberty Mutual FORM STATEMENT A-3 SEND ABOVE TO AS Marsh Street FORM STATEMENT A-3 NCS sicreportaloss@scottsdaleins.com Or Mail To: For Policy Yr

2 Claims Reporting Quick Reference Guide (Policy yr: 6/1/13-5/31/14) SUPERVISION INVESTIGATION RPT B-1 HAVE EMPLOYEE COMPLETE EMPLOYEE S REPORT OF INJURY FORM C-1. (For CA see form DWC-1) STATEMENT FORM C-2. REPORT THE CLAIM TO EITHER TELEPHONICALLY OR VIA . SEE CONTACT. FORM STATEMENT A-3 FORM STATEMENT A-3 SMARTDRIVE SEE CONTACT INFORMATION. FORM. TTP Form R-2 Revised 6/1/2013 WA7-65D NEVADA CLAIMS OFFICE: 7881 W. Charleston Blvd. - Suite 190 Las Vegas, NV Phone: (702) Fax: (603) Subrogation regarding injured workers are handled by Liberty Mutual SEND ABOVE TO AS Marsh St., 2nd Floor BCS TOM COLE - Unit Manager For Policy Yr

3 SERIOUS / CRITICAL ACCIDENT AND CLAIMS HANDLING PROCEDURES ACCIDENT OCCURS KEOLIS MGMT TEAM GOES IMMEDIATELY TO ACCIDENT SCENE KEOLIS MANAGEMENT DETERMINES IF SERIOUS SEE BELOW IF SERIOUS 1. ENSURE ALL INURED PERSONS ARE ATTENDED TO 2. NOTIFY FIRST RESPONDERS 3. NOTIFY CUSTOMER 4. RESTORE SERVICE AS SOON AS POSSIBLE SECURE THE ACCIDENT SCENE COOPERATE WITH FIRST RESPONDERS DON T MAKE STAEMENTS AT THE SCENE TO UNKNOWN INDIVIDUALS TAKE PHOTOGRAPHS INTERVIEW WITNESSES KEEP MANAGEMENT APPRAISED OF DEVELOPMENTS SECURE SMART DRIVE VIDEO CLIPS COMPLETE & SUBMIT APPLICABLE FORMS VEHICLE ACCIDENT REPORT FORM A-1 SUPERVISORS INVESTIGATION RERPORT B-1 PASSENGER SEATING DIAGRAM A-2 WITNESS STATEMENT FORM A-3 PHOTOGRAPHS VIDEO CLIPS In the event you are not sure as to whether or not to report the accident immediately, call the VP of Claims Administration or the VP - Safety & Risk Management. MANAGEMENT TEAM CONTINUES THOROUGH ACCIDENT INVESTIGATION GENERAL MANAGER IMMEDIATELY CALLS HOTLINE TO REPORT THE CLAIM IMMEDITAELY CALLS ONE OF THE PRIMARY CORPORATE CONTACTS LISTED BELOW. NO VOICE MESSAGES ARE ALLOWED - YOU MUST SPEAK WITH ONE OF THE INDIVIDUALS LISTED IN THE PRIMARY CONTACT BOX BELOW REGARDLESS OF TIME OF DAY. A SERIOUS/ CRICIAL ACCIDENT IS DEFINED AS AT LEAST, BUT NOT LIMITED TO, THE FOLLOWING: Fatality (including accidental death on a bus or company property, regardless of fault) Serious burns Quadriplegia or Paraplegia Amputation Brain damage actual or alleged Serve injury with apparent permanent disability Severe cosmetic disfigurement Blindness or loss of hearing Severe fractures or multiple fractures Psychiatric problems due to trauma, actual or alleged Serious vascular abnormalities due to trauma Any accident involving injuries to more than three persons Any pedestrian accident Assault or molestation incidents Severe bleeding Vehicle roll-over Any accidents that result in an individual being "care flighted" from the scene. & ALCOHOL TESTING DECISOIN FORM A-4 & MAINTAIN IN ACCIDENT FILE. PRIMARY CONTACTS FOR REPORTING SERIOUS ACCIDENTS # CONTACT NAME OFFICE # CELL # 1 VP of Claims Administration Doug Lawson SVP - Safety & Risk Management Drew Jones VP - Safety & Risk Management Reggie Reese The Region SVP of operations is also to be notified of all serious accidents in this category as well as the Regional Safety Manager.

4 Claims Reporting Quick Reference Guide HAVE EMPLOYEE COMPLETE EMPLOYEE S REPORT OF INJURY FORM C-1. (For CA see form DWC-1) FORM FORM STATEMENT FORM C-2. SMARTDRIVE SEE CONTACT INFORMATION. FORM Form R-2 REPORT THE CLAIM TO LIBERTY MUTUAL EITHER TELEPHONICALLY OR VIA . SEE CONTACT. WA7-65D Subrogation regarding injured workers are handled by Liberty Mutual STATEMENT A-3 SEND ABOVE TO AS7-65L Marsh St., 2nd Floor STATEMENT A-3 BCS TOM COLE - Unit Manager For Policy Yr Form R-1

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