Representing Financial Strength & Integrity. Claims Kit Maine. Contents: BHHC Claims Kit Introductory Letter 10/29/2013

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Representing Financial Strength & Integrity Claims Kit Maine Contents: BHHC Claims Kit Introductory Letter 10/29/2013 BHHC Instructions for ME Form WCB-90 10/08/2013 ME Form WCB-90 Workers

1 Representing Financial Strength & Integrity Claims Kit Maine Contents: BHHC Claims Kit Introductory Letter 10/29/2013 BHHC Instructions for ME Form WCB-90 10/08/2013 ME Form WCB-90 Workers Compensation Board Notice to Employees 01/2013 ME Form WCB-1 Employer s First Report of Occupational Injury or Disease 01/01/2013 BHHC General Employee Accident Report 10/03/2013 BHHC General Supervisor Accident Report 10/03/2013 BHHC General Witness Accident Report 10/03/2013 ME Form WCB-220 Limited Certificate Authorizing Written Release of Medical- Health Care Information 01/01/2013 ME Form WCB-2 Wage Statement 01/01/2013 ME Form WCB-2B Fringe Benefits Worksheet 01/01/2013 BHHC Workers Compensation Fraud Poster (English & Spanish) 10/09/2013

Dear Policyholder: P.O. Box 881236, San Francisco, CA 94105 Phone: (888) 495-8949 bhhc.com Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC).

2 Dear Policyholder: P.O. Box , San Francisco, CA Phone: (888) bhhc.com 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, , 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: Phone: (800) Fax: (800) newclaim@bhhc.com Online: 1. Go to our website: 2. Highlight Workers Comp in the menu 3. Highlight Claims Center 4. Click Report a Claim State law 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) 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

3 Workers Compensation Posting Requirements REQUIREMENTS FOR FORM WCB-90 - WORKERS' COMPENSATION BOARD NOTICE TO EMPLOYEES Post in one or more conspicuous places at all business locations and work sites Print on 11 x 17 paper (39-A Maine Revised Statutes 406)

4 FOR DATES OF INJURY ON AND AFTER JANUARY 1, 2013 WORKERS COMPENSATION FRENCH ITALIAN PORTUGUESE VIETNAMESE ARABIC SPANISH ENGLISH Statewide TTY: Maine Relay 711 La ley del estado de Maine requiere que su empresario proporcione el seguro de compensaciones para el trabajador a todos los trabajadores. El seguro de compensaciones para el trabajador proporciona beneficios a los trabajadores accidentados en el trabajo. En caso de sufrir accidente o daño laboral, NOTIFÍQUELO INMEDIATAMENTE A SU EMPRESARIO. Podría perder el derecho a recibir compensación a menos que su empresario sea notificado de este accidente o daño en el plazo de 30 días. Así mismo esta reclamación debe hacer referencia a unaccidente o daño que no haya ocurrido hace más de dos años. Los defensores del trabajador están disponibles para proporcionar ayuda a los trabajadores accidentados en el Consejo de Administración de Compensaciones para el Trabajador (Workers Compensation Board). El hecho de no clasificar a los empleados como contratistas independientes, con el propósito de evitar el seguro por compensación al trabajador, cobertura para desempleados, ú otros impuestos pagados y retenidos por el empleador; está en contra de la ley del empleador. Para mayor información acerca de las leyes pertenecientes a la contratación de contratistas independientes, visite el Worker Misclassification Task Force en la página web de En caso de tener cualquier pregunta sobre sus derechos, favor de dirigirse a una de las oficinas regionales de compensaciones para el trabajador. PERSIAN Visit our website at: D après les lois de l Etat du Maine, votre employeur est tenu de souscrire à une assurance indemnisant ses employés victimes d un accident du travail. Si vous êtes victime d un accident du travail, PREVENEZ VOTRE EMPLOYEUR IMMEDIATEMENT. Passé un délai de 30 jours, vous risquez de perdre vos droits à l indemnisation. Au-delà de deux ans, votre déclaration n est plus recevable. Pour aider les victimes d un accident du travail, le Workers Compensation Board met des conseillers juridiques à leur disposition. La loi interdit aux employeurs de classifier fallacieusement leurs salariés comme étant des contractants privés aux fins d`échapper a l`assurance compensatrice-employé, aux Aviso a los Trabajadores: SOMALI CARIBOU 43 Hatch Drive, Suite 110 Caribou, ME A l intention desemployes: POLISH PORTLAND 62 Elm Street Portland, ME RUSSIAN BANGOR 106 Hogan Road, Suite 1 Bangor, ME indemnités de chômage, ou aux autres charges et retenues dues par employeur. Pour plus de détails sur la législation relative a l`utilisation des services privés, visitez le site internet de Worker Misclassification Task Force (Unité anti-fraude en matière de classification des salariés) : Si vous n êtes pas sûr de vos droits, veuillez contacter l un des bureaux régionaux. CHINESE LEWISTON 36 Mollison Way Lewiston, ME State law requires your employer to provide workers compensation insurance for its employees. Workers compensation insurance provides benefits to employees who are injured at work. If you are injured at work, NOTIFY YOUR EMPLOYER AT ONCE. You may lose your right to receive benefits unless your employer is notified within 30 days of your injury. Your claim is also subject to a two year statute of limitations. Worker advocates are available at the Workers Compensation Board to help injured workers. It is against the law for employers to misclassify employees as independent contractors for the purposes of avoiding workers compensation insurance, unemployment coverage, or other employer paid taxes and withholdings. For more information on laws pertaining to the hiring of independent contractors, visit the Worker Misclassification Task Force website at If you have any questions about your rights, please contact one of the regional offices. JAPANESE AUGUSTA 24 Stone Street, Suite 102 Augusta, ME Notice to Employees: KOREAN WORKERS COMPENSATION BOARD REGIONAL OFFICES Turjunaanno waa la helayaa Marka aad caawinaad inoogu soo yeeraneysid, fadhlan luqaddaada af Ingiriisi inoogu sheeg turjubaan ayaa lguugu yeeri doonaaye. Taleefoonkana ha dhigin. To the employer: This notice must be posted in a conspicuous place upon your premises accessible to employees. 39-A MRSA 406. The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services or activities. This poster is available in alternative format. For further assistance, contact the Maine Workers Compensation Board, ADA Coordinator, telephone: (888) or TTY (877) WCB-90 (1/13)

5 EMPLOYER S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE : : REASON FOR REPORT (check all that apply) EMPLOYER (check one) INSURER THIRD PARTY ADMINISTRATOR (TPA) SELF-ADMINISTERED EMPLOYER EMPLOYEE CLAIM INFORMATION PREPARER INFORMATION THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: OR TTY Maine Relay 711. WCB-1 (eff. 1/1/13)

6 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:

7 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 Unused/unavailable PPE (gloves, hardhat, goggles, etc.) Unused/unavailable sharps container Unguarded or improperly guarded equipment Electrical exposure Obstructed view Lack of training Defective tools or equipment Wet/slippery floor Poor housekeeping Interaction with co-worker Interaction with patient or resident Interaction with customer Chemical exposure Motor vehicle accident 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:

8 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.

9 LIMITED CERTIFICATE AUTHORIZING WRITTEN RELEASE OF MEDICAL / HEALTH CARE INFORMATION STATE OF MAINE WORKERS'COMPENSATION BOARD EMPLOYEE: ADDRESS: DATE OF INJURY: SOCIAL SECURITY NUMBER: BRIEF DESCRIPTION OF BODY PART(S) INJURED: EMPLOYER: INSURER: ATTORNEY: ADDRESS: ADDRESS: ADDRESS: I hereby authorize the above employer, insurer, or their attorney to obtain from any hospital, physician, osteopath, chiropractor, or other health care provider, after payment to the provider of a reasonable fee, any written information only which is or has been prepared in connection with my examination or treatment regardless of date which relates to my (i.e. body part and/or condition) only. This certificate of authorization remains valid and must be honored for as long as I continue to make any claim for compensation, any compensation payment scheme remains in effect, or I receive compensation. This certificate of authorization does NOT permit the release of any information regarding psychological, substance abuse, sexually transmitted disease treatment, testing, or counseling and does NOT authorize oral communication with or by any health care provider. EMPLOYEE SIGNATURE DATE NOTICE TO THE EMPLOYEE YOU HAVE 20 DAYS FROM RECEIPT OF THIS CERTIFICATE TO SIGN AND RETURN IT TO THE EMPLOYER OR INSURER. FAILURE TO SIGN AND RETURN THIS CERTIFICATE MAY RESULT IN A SUSPENSION OF ACTIVITY ON YOUR CLAIM FOR COMPENSATION, OR IF YOU ARE CURRENTLY RECEIVING COMPENSATION, YOUR PAYMENTS OF COMPENSATION MAY BE SUSPENDED UNTIL YOU SIGN AND RETURN THIS CERTIFICATE. THIS IS THE AUTHORIZED FORM FOR THE RELEASE OF MEDICAL AND RELATED INFORMATION UNDER THE MAINE WORKERS' COMPENSATION ACT AND IS INTENDED TO SUPPLEMENT THE RIGHTS TO SECURE MEDICAL INFORMATION SET FORTH BY TITLE 39-A OF THE MAINE REVISED STATUTES ANNOTATED AND CHAPTER 12, SECTION 18 OF THE BOARD'S RULES AND REGULATIONS. THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: OR TTY Maine Relay 711. WCB-220 (eff. 1/1/13)

10 WAGE STATEMENT STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (LAST 4 DIGITS): 7. WCB FILE NUMBER: xxx -xx- 2. EMPLOYER NAME: 8. EMPLOYEE LAST NAME: 9. FIRST NAME: 10. M.I.: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. ADDRESS-NUMBER AND STREET: 4. INSURER NAME: 12. CITY: 13. STATE: 14. ZIP: 15. HOME PHONE: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 17. DESCRIPTION OF INJURY: 18. DOES EMPLOYEE WORK CONCURRENTLY FOR ANOTHER EMPLOYER? IF YES, GIVE NAME(S): NOTE: THE EMPLOYER SHALL SUBMIT A WAGE STATEMENT FOR EACH ADDITIONAL EMPLOYER. YES NO 19. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP WHILE ON WORKERS COMPENSATION? NOTE: THE EMPLOYER SHALL RECALCULATE THE AVERAGE WEEKLY WAGE IF/WHEN FRINGE BENEFITS CEASE (SEE RULE 1.5(2)) WK 1 WEEK ENDING GROSS EARNINGS WK 19 WEEK ENDING GROSS EARNINGS WK WEEK ENDING COMMENTS: YES NO GROSS EARNINGS 24. PREPARER NAME (TYPE OR PRINT): ADDRESS: 25. TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 26. DATE MAILED: / / MM DD YYYY The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers Compensation Board. Telephone: or TTY Maine Relay 711. WCB-2 (eff. 1/1/13)

11 FRINGE BENEFITS WORKSHEET STATE OF MAINE WORKERS COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): XXX-XX- 7. WCB FILE NUMBER: 2. EMPLOYER NAME: 8. EMPLOYEE LAST NAME: 9. FIRST NAME: 10. M.I.: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. EMPLOYEE ADDRESS-NUMBER AND STREET: 4. INSURER NAME: 12. CITY: 13. STATE: 14. ZIP: 15. HOME PHONE: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 17. DESCRIPTION OF INJURY: PROVIDE THE COST OF THE FRINGE BENEFIT PAID BY THE EMPLOYER AS OF THE EMPLOYEE S DATE OF INJURY IF THE EMPLOYEE WAS RECEIVING THE BENEFIT ON HIS/HER DATE OF INJURY (SEE RULE CHAPTER 1(5)(1)). NOTE: THE AMOUNTS REPORTED ARE SUBJECT TO VERIFICATION BY THE EMPLOYEE AND HIS/HER REPRESENTATIVE AND DOCUMENTATION MUST BE PROVIDED UPON REQUEST. 18. Fringe Benefit Provided Continues while Employee is out of work Date Benefits End Weekly Cost of Benefits to Employer Health Benefits (inc. insurance) Yes No Yes No $ Dental Insurance Yes No Yes No $ Disability Insurance (inc. short and long term) Yes No Yes No $ 401K Yes No Yes No $ Life Insurance Yes No Yes No $ Education/Training Yes No Yes No $ Pension Yes No Yes No $ Other (please list): Yes No Yes No $ Other (please list): Yes No Yes No $ 19. PREPARER NAME (TYPE OR PRINT): ADDRESS: 20. TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 21. DATE MAILED: / / MM DD YYYY The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers Compensation Board. Telephone: (888) or TTY Maine Relay 711. WCB-2B (eff. 1/1/13)

12 BERKSHIRE HATHAWAY HOMESTATE COMPANIES OFFERS: REWARD WORKERS COMPENSATION CLAIMS FRAUD $1,000 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* Most states make it a FELONY to make or cause to be made a knowingly false or fraudulent material statement in order to obtain Workers Compensation benefits. Berkshire Hathaway Homestate Companies 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 these 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. You, and all of us, reap the rewards of reducing Workers Compensation Fraud. TOLL FREE: JAIL 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 *Maximum reward of $1,000 per conviction. In the event more than one individual submits information regarding the same fraudulent claim, Berkshire Hathaway will equally divide the reward among those providing information used in obtaining the conviction. Berkshire Hathaway 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 interpretation of this policy shall be resolved by Berkshire Hathaway Homestate Companies at their sole discretion. Program subject to change or termination without prior notice.

13 LA COMPAÑIA DE SEGUROS BERKSHIRE HATHAWAY OFRECE: RECOMPENSA DEMANDAS FRAUDULENTAS DE COMPENSACION DE TRABAJADORES $1,000 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 se 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. Usted y todos nosotros no beneficiamos cuando reducimos los casos fraudulentos de Compensación al Trabajador. LLAMADA GRATIS: JAIL 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 *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.

Representing Financial Strength & Integrity. Claims Kit Idaho. Contents: BHHC Claims Kit Introductory Letter 10/29/2013

Representing Financial Strength & Integrity Claims Kit Idaho Contents: BHHC Claims Kit Introductory Letter 10/29/2013 BHHC Instructions for ID Poster 10/08/2013 BHHC ID Form - Workers' Compensation Poster