ASSIGNMENT 15 1 Review Questions
|
|
|
- Philippa McCormick
- 5 years ago
- Views:
Transcription
1 ASSIGNMENT 15 1 Review Questions Part I Fill in the Blank 1. a. federal compensation laws b. state compensation laws 2. accident 3. occupational illness or disease (Optional answer: industrial or workers compensation illness) 4. a. Workmen's Compensation Law of the District of Columbia b. Federal Coal Mine Health and Safety Act c. Federal Employees' Compensation Act (FECA) d. Longshoremen's and Harbor Workers' Compensation Act (LHWCA) 5. Compulsory laws 6. Elective laws 7. a. monopolistic state or provincial fund b. qualification employers qualified as self- insurers c. territorial fund d. competitive state fund e. private insurance company 8. Employers 9. Answers will vary; see Table 15.1 in the Handbook 10. subsequent or second-injury fund (SIF) 11. a. domestic or casual employees b. laborers c. babysitters d. charity workers e. gardeners f. newspaper vendors or distributors 12. Answers will vary; see Table 15.2 in the Handbook 13. Answers will vary; see Table 15.3 in the Handbook 14. a. Medical treatment b. Temporary disability indemnity c. Permanent disability indemnity d. Death benefits for survivors e. Rehabilitation benefits 15. Medical doctor, osteopath, dentist, or chiropractor 16. a. Nondisability (ND) Claim: Person is injured or ill, is treated, and goes back to work. No disability from his or her job. b. Temporary disability (TD) claim: Person is injured or ill and cannot work at his or her job and is off work for a period of time. c. Permanent disability (PD) claim: Person is injured or ill and cannot work, and the problem results in permanent injury or illness. 17. a percentage of the employee's earnings at the time of the injury 18. work hardening 19. The state's industrial accident commission or workers' compensation board 20. Yes; Workers' Compensation Appeals Board (WCAB) or the Industrial Accident Commission 1
2 21. the insurance carrier 22. Third party subrogation means to substitute one person for another. In workers compensation cases, it means a transfer of claims and rights from the original creditor to the third-party liability carrier. 23. Employer's Report of Occupational Injury or Illness Form; medical service order Part II Multiple Choice 24. a. Occupational Safety and Health Administration (OSHA) Act of b. litigation 26. d. deposition 27. c. lien 28. d. all of the above Part III True/False 29. T 30. F 31. F 32. T 33. T 34. T 2
3 Assignment 15 2 COMPLETE A DOCTOR S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS FORM FOR A WORKERS COMPENSATION CASE 3
4 Assignment 15 3 COMPLETE A CLAIM FORM FOR A WORKERS COMPENSATION CASE Glen M. Hiranuma: Because the chart note states that the patient will return to work on 6/6/xx, he is unable to work through 6/5/xx and that date should be entered in the TO portion of Block 16. A workers compensation report was prepared by the physician and should be billed to the carrier (99080). ICD-9-CM Diagnostic codes, Block 24E: Up to four diagnostic codes may be entered, separated by a comma; all three of the following diagnoses apply to the services billed: 1. Concussion with brief loss of consciousness of 30 minutes or less (15 min) Concussion with loss of consciousness of 30 min or less 2. Sprain and strain, shoulder and upper arm; unspecified site Unspecified sprain of left shoulder girdle 3. Superficial injury of hip, thigh, leg, and ankle; abrasion without mention of infection Abrasion of left hip Abrasion left lower leg ICD-9-CM Code ICD-10-CM Code S06.0x1A S43.92xA S70.212A S80.812A In some states, workers compensation carriers may require a code to indicate the external cause of injury; fall on or from ladder (E881.0) [ICD-10-CM code: W11.xxxA] Additional Coding 1. Site Description of Service Code a. College Hospital Radiology Left hip x-rays (complete) b. College Hospital Radiology Left femur x-rays (two views) c. College Hospital Radiology Cervical spine x-rays (three views) d. College Hospital Radiology Computed tomography; brain (without contrast material) Note: HCPCS Level II modifier LT may be added to the hip and femur x-ray codes to indicate left side. 4
5 5 Chapter 15
6 6 Chapter 15
Workers Compensation. Workers Compensation
Federal and State Administration Qualifications for coverage Classifications of cases Physician reimbursement Billing and claims processing 2 1 Federal and State Laws Employers required to provide workers
JLT SPORT PERSONAL INJURY CLAIM FORM
JLT SPORT PERSONAL INJURY CLAIM FORM AUSTRALIAN FOOTBALL NATIONAL RISK PROTECTION PROGRAMME IMPORTANT INFORMATION WHO SHOULD COMPLETE THIS CLAIM FORM? You should complete this form if: You are an Insured
Commercial Insurance
covers medical expenses of individuals and groups Types of benefits and policies vary Group vs. Individual coverage Regulated by individual states 2 1 Fee-for-Service Types of Coverage High-Risk pools
Form DFS-F5-DWC-9 B. Completion Instructions. Submitted by Licensed Health Care Providers
Form DFS-F5-DWC-9 B Completion Instructions Submitted by Licensed Health Care Providers A. Header Information Health Care Providers shall enter Insurer/Carrier name, address and zip code in the blank area
ORDER OF THE LIEUTENANT GOVERNOR IN COUNCIL
PROVINCE OF BRITISH COLUMBIA ORDER OF THE LIEUTENANT GOVERNOR IN COUNCIL Order in Council No. 595, Approved and Ordered November 9, 2018 Executive Council Chambers, Victoria On the recommendation of the
PROFESSIONAL ATHLETES APPLICATION
Send completed application and exam to: Petersen International Underwriters 23929 Valencia Boulevard Suite 215, Valencia, CA 91355 Email: piu@piu.org Fax: (661) 254-0604 Telephone (800) 345-8816 Proposed
JLT Sport Personal Injury Claim Form
Who should use this claim form? You should complete this form if: Insured - You are a participant of an Team insured within the AFL National Risk Protection Programme; and Injured - You sustained an accidental
Federal Employee s Compensation Act (FECA) & OWCP Overview. SPD Park Rangers Conference February 4, 2010
Federal Employee s Compensation Act (FECA) & OWCP Overview SPD Park Rangers Conference February 4, 2010 By: Aaron Larsen SPD Injury Compensation Program Administrator (ICPA) FECA Overview Fd Federal lemployee
WORKERS COMPENSATION CITUS ET CERTUS. Ms. Kappler 435 MSS/DPCS-A
WORKERS COMPENSATION Ms. Kappler 435 MSS/DPCS-A References Definition of FECA Responsibilities under FECA Requirements of Coverage Electronic Data Interchange (EDI) System Questions OVERVIEW REFERENCES
PROFESSIONAL ATHLETES APPLICATION
SHORT FORM Name in Full: FI RST Residence Address: MIDDLE LAST STREET AND NUMBER CITY Personal information: Occupation Details: STATE DATE OF BIRTH ( ZIP HEIGHT DAYTIME PHONE NUMBER WEIGHT SPORT LEAGUE
Completing the CMS-1500 Claim Form
Completing the CMS-1500 Claim Form Below are instructions for filling out a CMS-1500 Claim Form (version 08/05) when submitting a claim to CareFlorida. Each field on the form is described, and all required
PROFESSIONAL ATHLETES APPLICATION
Send completed application and exam to: Petersen International Underwriters 23929 Valencia Boulevard Suite 215, Valencia, CA 91355 Email: piu@piu.org Fax: (661) 254-0604 Telephone (800) 345-8816 Proposed
JLT SPORT PERSONAL INJURY CLAIM FORM
JLT SPORT PERSONAL INJURY CLAIM FORM AUSTRALIAN FOOTBALL NATIONAL RISK PROTECTION PROGRAMME IMPORTANT INFORMATION WHO SHOULD COMPLETE THIS CLAIM FORM? You should complete this form if: You are an Insured
HIGHLIGHTS OF THE NEW PERSONAL INJURY PROTECTION ( PIP ) STATUTE SIGNED INTO LAW ON MAY 04, 2012
HIGHLIGHTS OF THE NEW PERSONAL INJURY PROTECTION ( PIP ) STATUTE SIGNED INTO LAW ON MAY 04, 2012 By Travis L. Stock, Esq. May 14, 2012 On May 04, 2012, Governor Rick Scott signed legislation that purportedly
Voluntary Disability Benefits
Voluntary Disability Benefits Enclosed you will find a disability packet that will provide information to assist you in filing for disability benefits through The Claremont Colleges Voluntary Disability
EMPLOYEE WORKERS COMPENSATION HANDBOOK 2018
EMPLOYEE WORKERS COMPENSATION HANDBOOK 2018 The City of Stockton is self-insured for Workers' Compensation benefits. The City pays benefits directly to injured employees, rather than purchasing an insurance
FECA BENEFITS FECA BENEFITS cont.
FECA OVERVIEW Federal Employee s Compensation Act (FECA) passed in 1916 Amended in 1974 to include COP and choice of physician Exclusive remedy to compensate federal employees who are injured or become
OCF 18 - TREATMENT PLAN USER MANUAL
OCF 18 - TREATMENT PLAN USER MANUAL MARCH 2006 Document Change History Date Description of Change Reason 20050214 Revised Signature of Health Practitioner & Applicant Signature, Repositioned Signature
JLT Sport Personal Injury Claim Form
Who should use this claim form? You should complete this form if: Insured - You are a player, umpire, official or volunteer (Insured Person) of a League/Club (the Insured) covered within the ; and Injured
accident insurance with Expanded Benefits
BE WELL. BE SMART. BE PROTECTED. Allstate at Work accident insurance with Expanded Benefits on- or off-the-job including a disability income benefit plus riders An accident can wreak havoc on your savings
JLT SPORT PERSONAL INJURY CLAIM FORM
JLT SPORT PERSONAL INJURY CLAIM FORM CYCLING AUSTRALIA NATIONAL RISK PROTECTION PROGRAM WHO SHOULD COMPLETE THIS CLAIM FORM? You should complete this form if: You are an Insured person Cycling Australia
JLT Sport Personal Injury Claim Form
Who should use this claim form? You should complete this form if: Insured - You are a player, umpire, official or volunteer (Insured Person) of a League/Club (the Insured) covered within the ; and Injured
JLT SPORT PERSONAL INJURY CLAIM FORM
JLT SPORT PERSONAL INJURY CLAIM FORM AUSTRALIAN FOOTBALL NATIONAL RISK PROTECTION PROGRAMME AFL 9 S WHO SHOULD USE THIS CLAIM FORM? You should complete this form if: Insured: You are a participant of an
Form DFS-F5-DWC-9 B. Completion Instructions
Completion Instructions Submitted by Ambulatory Surgical Centers A. Header Information Health Care Providers shall enter Insurer/Carrier name, address and zip code in the blank area on top-right side of
RULES OF DEPARTMENT OF COMMERCE AND INSURANCE DIVISION OF INSURANCE AND DIVISION OF TENNCARE
RULES OF DEPARTMENT OF COMMERCE AND INSURANCE DIVISION OF INSURANCE AND DIVISION OF TENNCARE CHAPTER 0780-1-73 UNIFORM CLAIMS PROCESS FOR TENNCARE PARTICIPATING TABLE OF CONTENTS 0780-1-73-.01 Authority
JLT Sport Personal Injury Claim Form
Northern NSW Football Risk Protection Programme Who should use this claim form? You should complete this form if: Insured - You are a player, umpire, official or volunteer (Insured Person) of a League/Club
Claim Form Billing Instructions CMS-1500 (08-05) Claim Form
Claim Form Billing Instructions CMS-1500 (08-05) Claim Form Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 1 of 10 Presbyterian Health Plan / Presbyterian Insurance
Personal Accident Claim Form
Personal Accident Claim Form Football NSW Insurance Programme Please read this page before completing the claim form Dear Member, Thank you for your claim form request. This letter contains important information
OCF 23 THE PRE-APPROVED FRAMEWORK TREATMENT CONFIRMATION FORM USER MANUAL
OCF 23 THE PRE-APPROVED FRAMEWORK TREATMENT CONFIRMATION FORM USER MANUAL March 2006 Document Change History Date Description of Change Reason 20050214 Revised Applicant Signature, Signature of the Initiating
OVERVIEW OF WISCONSIN WORKER S COMPENSATION SYSTEM
OVERVIEW OF WISCONSIN WORKER S COMPENSATION SYSTEM Julie J. Darnieder Adjunct Professor Law Marquette Law School julie.darnieder@marquette.edu NATURE OF THE SYSTEM Created by Wisconsin Legislature in 1911
Alberta Basketball Association
Alberta Basketball Association Special Risk Accident Insurance Coverage Summary and Definitions Prepared By: Alan Hollingsworth Partner & Vice President Darren Brown Account Associate HUB International
VOLUNTARY BENEFITS AT THE WORKPLACE Accident Insurance
VOLUNTARY BENEFITS AT THE WORKPLACE Accident Insurance Accident Insurance Personal Coverage Plan for Your Selected Voluntary Accident Insurance Plan Who will be covered under your plan? Employee Only Employee
September 2007 Physician Assistants Guide to Oregon On-the-Job Injuries
September 2007 Physician Assistants Guide to Oregon On-the-Job Injuries Workers Compensation Division Physician Assistants Guide to Oregon On-the-job Injuries Quick Reference for Chart Notes Chart notes
January 2012 Health Care Providers Guide to Oregon On-the-Job Injuries
January 2012 Health Care Providers Guide to Oregon On-the-Job Injuries Workers Compensation Health Care Providers Guide to Oregon On-the-Job Injuries Quick Reference for Chart Notes Chart notes should
STUDENT ACCIDENT INSURANCE for
STUDENT ACCIDENT INSURANCE for 2017 POLICY BROCHURE 17128 CONESTOGA COLLEGE INSTITUTE OF TECHNOLOGY AND ADVANCED LEARNING DEAR STUDENT: Conestoga College Institute of Technology and Advanced Learning is
STUDENT ACCIDENT INSURANCE PLAN
STUDENT ACCIDENT INSURANCE PLAN Designed for Students of: (the Policyholder ) 2016-2017 Policy Number US 562772 Underwritten by: United States Fire Insurance Company SJC 16/17 TABLE OF CONTENTS Introduction...4
Naturopathic Physicians Guide to Oregon On-the-Job Injuries
January 2014 Naturopathic Physicians Guide to Oregon On-the-Job Injuries Workers Compensation Naturopathic Physicians Guide to Oregon On-the-Job Injuries Quick Reference for Chart Notes Chart notes should
GROUP PERSONAL INJURY INSURANCE
CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED A.B.N. 69 003 710 647 A.F.S. Licence No: 239778 Level 1, 225 St Georges Terrace, Perth WA 6000 PO Box Z5471 St Georges Terrace, Perth WA 6831 Telephone: 61-8-6211
EMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING
EMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING Please read the entire contents of the packet and follow directions below. 1. Call 1-800-445-6965 to report your work-related claim as soon as possible. 2. Advise
ACCIDENT MEDICAL CLAIM FORM
ACCIDENT MEDICAL CLAIM FORM Chubb Life Insurance Company of Canada 199 Bay Street - Suite 2500 P.O. Box 139, Commerce Court Postal Station Toronto, Ontario M5L 1E2 O +1.416.594.2627 or +1.877.772.7797
STUDENT ACCIDENT INSURANCE PLAN
STUDENT ACCIDENT INSURANCE PLAN Designed for Undergraduate Students of: (the Policyholder ) Rockland Campus 1 South Boulevard Nyack, NY 10960 2016-2017 Policy Number US 562773 Underwritten by: United States
DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION
DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION FORM DFS-F5-DWC-9-A SHALL COMPLETE THE DWC-9 ACCORDING TO. 1. TYPE OF CLAIM T 1a. INSURED S I.D. NUMBER Enter the Social Security Number
Comparative Review of Workers Compensation Systems in Select Jurisdictions
of Workers Compensation Systems in Select Jurisdictions JURISDICTION: MICHIGAN ENVIRONMENT Population Size 9.4 million in 1994, 8th largest state. Labor Force 4.9 million in 1997 Demographic and Economic
DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION
DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION FORM DFS-F5-DWC-9-A SHALL COMPLETE THE DWC-9 ACCORDING TO. NAME STATUS COMMENTS SUBJECT TO 1. TYPE OF CLAIM T 1a. INSURED S I.D. NUMBER
Voluntary Benefits. So Important. Your Guide to Understanding Voluntary Disability Income Protection
Voluntary Benefits Your Guide to Understanding Voluntary Disability Income Protection What would happen if you couldn t work? How would your life change if you became ill or injured and couldn t bring
Workers Compensation
Workers Compensation All work-related injuries or illnesses must be reported. If the injury is an emergency, arrange for appropriate medical treatment. The employee has the right to select his or her own
What you do every day may lead to an accident. TRAVEL WORK
What you do every day may lead to an accident. SPORTS TRAVEL WORK VACATION Accident Insurance Helps cover costs associated with injury treatments Accident coverage from Allstate Benefits pays cash benefits
EMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING
EMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING Please read the entire contents of the packet and follow directions below. 1. Call 1-800-445-6965 to report your work-related claim as soon as possible. 2. Advise
NCAA CATASTROPHIC INJURY INSURANCE PROGRAM FREQUENTLY ASKED QUESTIONS
NCAA CATASTROPHIC INJURY INSURANCE PROGRAM FREQUENTLY ASKED QUESTIONS APPLICABLE TO 8/1/17 TO 7/31/2020 POLICY PERIOD This document is a summary of the NCAA Catastrophic Injury Insurance Program. The insurance
By Russell Uliase FEDERAL WORKERS COMPENSATION AN OVERVIEW
By FEDERAL WORKERS COMPENSATION AN OVERVIEW PART 1 If you are employed by the federal government, or work for a contractor or subcontractor of the federal government, what are your rights to compensation
Table of Contents WR
Table of Contents Argent Mission Statement/Core Values Profile (Claims/Loss Control) Claims Reporting Tips/How to Write Injury Descriptions Report of Injury and/or Disease or Illness WC Cost Containment
Common Traffic Impairment (CTI) Guideline
Common Traffic Impairment (CTI) Guideline Part A Introduction This Guideline is issued pursuant to s. 268.3 of the Insurance Act for the purposes of the Statutory Accident Benefits Schedule - Effective
St. Norbert College. Employer Paid Long Term Disability Insurance. NCLTD1_Value Employer Paid Long Term Disability Insurance
NCLTD1_Value Employer Paid Long Term Disability Insurance This this text box here. A post process uses the text above to do a "Find/Replace" of variable text and the header. Template: NCLTD_BHS Employer
Top Ten Questions to Ask a Potential Workers Compensation Claimant
Top Ten Questions to Ask a Potential Workers Compensation Claimant 1. Are you an employee? Jessica Cleereman Applicability of the workers compensation act depends on the existence of an employer-employee
Group Disability Income Insurance Protection for CSEA Members
Group Disability Income Insurance Protection for CSEA Members 1-877-VIP-CSEA (847-2732) Valuable Insurance Programs Sponsored by Administered by Important Benefits for CSEA members Why You Need Disability
NAPA Auto Parts Voluntary Long Term Disability Insurance Plan Highlights
NAPA Auto Parts Voluntary Long Term Disability Insurance Plan Highlights Who is eligible? What is my monthly benefit amount? You are eligible for Voluntary Long Term Disability (VLTD) coverage if you are
License Coach Health Section Live Cram Course Handout
License Coach Health Section Live Cram Course Handout 174) Health Insurance Slide 175) Health insurance policies that provide specialized limited coverage, such as AD&D and dread disease. 176) In health
January 2014 Nurse Practitioners Guide to Oregon On-the-Job Injuries
January 2014 Nurse Practitioners Guide to Oregon On-the-Job Injuries Workers Compensation Nurse Practitioners Guide to Oregon On-the-Job Injuries Quick Reference for Chart Notes Chart notes should be used
ATTENTION! FAILURE TO UNDERSTAND YOUR RESPONSIBILITIES UNDER THIS POLICY MAY RESULT IN YOUR COMPANY BEING SUBJECT TO STATE FINES!
MIDWEST FAMILY GROUP MIDWEST FAMILY MUTUAL INSURANCE COMPANY MIDWEST FAMILY ADVANTAGE INSURANCE COMPANY Telephone 7639517000 Fax 7639517092 4401 Westown Parkway Suite 305, West Des Moines, IA 50266 Mailing
GROUP PERSONAL INJURY INSURANCE
CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED A.B.N. 69 003 710 647 A.F.S. Licence No: 239778 Citigroup Centre, Level 29, 2 Park Street, Sydney 2000 Telephone: 61-2-9273 0100 Facsimile: 61-2-9273 0101 DX:
Alberta Accident Benefits Initial Claims Process
Overview Alberta Accident Benefits Initial Claims Process If you have been injured in an automobile accident in Alberta, you are entitled to accident benefits coverage regardless of whether you were at
Short-Term Disability
American Fidelity Assurance Company s Short-Term Disability Income Insurance Plan Designed Specifically For: Shelby County, TN Schools Plan Highlights s are paid directly to you, not to a doctor or your
WORKERS COMPENSATION REFORMS OFFICIAL MEDICAL FEE SCHEDULE PHYSICIAN SERVICES SUMMARY CHANGES TO THE OFFICIAL MEDICAL FEE SCHEDULE PHYSICIAN SERVICES
SUMMARY CHANGES TO THE SB 863, enacted in 2012, required the Division of Workers Compensation to transition the Official Medical Fee Schedule for physician services to a Medicare RBRVS system over four
Town of Grand Chute. Employer Paid Short Term Disability Insurance. NCSTD1_Value Employer Paid Short Term Disability Insurance
NCSTD1_Value Employer Paid Short Term Disability Insurance This this text box here. A post process uses the text above to do a "Find/Replace" of variable text and the header. Tempalte: NCSTD_BHS Employer
Long Term Disability Income Continuance Plan
Long Term Disability Income Continuance Plan Long Term Disability Income Continuance Plan The Long Term Disability Income (LTDI) Continuance Plan is designed to provide income replacement if you are unable
221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:
221 Madison Ave Morristown, New Jersey 07960 (973) 538 4444 Fax (973) 538 0420 PATIENT INFORMATION Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal
RESEARCH UPDATE. Analysis of California Workers Compensation Reforms. Part 2: Temporary Disability Outcomes Accident Years Claims Experience
January 2008 RESEARCH UPDATE Analysis of California Workers Compensation Reforms Part 2: Temporary Disability Outcomes Accident Years 2002 2006 Claims Experience by Alex Swedlow, MHSA and John Ireland,
Worksite Benefits. 38% of working Americans say they could not pay their bills for more than three months if their employment income was lost.
Worksite Benefits CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst
PROFESSIONAL SPORTSPERSON'S ACCIDENT & ILLNESS INSURANCE PROPOSAL / MEDICAL APPLICATION FORM
INSURED AT LLOYD'S OF LONDON PROFESSIONAL SPORTSPERSON'S ACCIDENT & ILLNESS INSURANCE PROPOSAL / MEDICAL APPLICATION FORM AGENT CAUNCE O'HARA & CO LTD CITY WHARF NEW BAILEY STREET MANCHESTER M3 5ER TEL:
2015 APPLICATION FOR MEMBERSHIP
2015 APPLICATION FOR MEMBERSHIP The Oregon Crusaders thanks you for your interest in being a part of the Oregon Crusaders Drum and Bugle Corps. The following information should be completed and turned
Chandler Chiropractic 333 N. Dobson Rd., #16, Chandler AZ
Chandler Chiropractic 333 N. Dobson Rd., #16, Chandler AZ 85224 480.899.9855 Name Address: City State Zip Home # Cell # Email SSN Date of Birth Age Weight Height Male Female Single Married Divorced # of
DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION
DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION FORM DFS-F5-DWC-9-B. 1. TYPE OF CLAIM T 1a. INSURED S ID NUMBER Enter the Social Security Number or the Division-Assigned Number of the
Voluntary Long Term Disability (LTD) Benefit Summary
Policyholder: Washburn University Voluntary Long Term Disability (LTD) Benefit Summary Effective Date: 01/01/2018 This chart provides you a brief summary of the key benefits of the long-term disability
Blue Cross & Blue Shield of Rhode Island CMS-1500 (02/12) Form Completion Informational Guide
Blue Cross & Blue Shield of Rhode Island CMS-1500 (02/12) Form Completion Informational Guide All professional provider services filed to Blue Cross & Blue Shield of Rhode Island (BCBSRI) must be filed
Mental Health/Substance Use Treatment Claim Form
Mental Health/Substance Use Treatment Claim Form DIRECTIONS FOR COMPLETION If you are in treatment with a non-participating Beacon Health Options, Inc. (Beacon) provider and your provider has indicated
Request for Designated Doctor Examination Type (or print in black ink) each item on this form
Texas Department of Insurance Division of Workers Compensation 7551 Metro Center Drive, Suite 100 MS-603 Austin, TX 78744-1645 (512) 804-4380 phone (512) 804-4121 fax Complete, if known: DWC Claim # Carrier
Benefits Handbook Date July 1, Optional Long Term Disability Marsh & McLennan Companies
Date July 1, 2018 Marsh & McLennan Companies SPD and Plan Document This section provides a summary of the Optional Long Term Disability Plan (the Plan ) as of January 1, 2018. This section, together with
May 11, 2008 RAILROAD INSURANCE COVERAGE UPDATE STEVE YOUNG
May 11, 2008 RAILROAD INSURANCE COVERAGE UPDATE STEVE YOUNG 1. TO HAVE COVERAGE: a. New employee working under UTU contract must work 4 months before coverage begins b. All other new employees need only
DELAWARE AMERICAN LIFE INSURANCE COMPANY ONE ALICO PLAZA WILMINGTON, DELAWARE (302) (Herein called the Insurance Company)
DELAWARE AMERICAN LIFE INSURANCE COMPANY ONE ALICO PLAZA WILMINGTON, DELAWARE 19801 (302) 661-8674 (Herein called the Insurance Company) CERTIFICATE OF INSURANCE for certain Employees of: University Corporation
Southern Arkansas University Athletic Medical Insurance Information June 2017
Athletic Medical Insurance Information June 2017 Dear Parent/Guardian: I would like to take this opportunity to share with you s (SAU) Athletic Department policies regarding medical insurance and payment
National Uniform Claim Committee
National Uniform Claim Committee 1500 Health Insurance Claim Form Reference Instruction Manual for 08/05 Version Disclaimer and Notices 2005 American Medical Association This document is published in cooperation
SPORTING ACCIDENT CLAIM FORM Eastern Football League
Dear Member, SPORTING ACCIDENT CLAIM FORM Eastern Football League Please read this page first before completing the Claim Form Sportscover Australia Pty Ltd Thank you for your Claim Form request. This
Seafarers Injury & Illness Cover
Seafarers Injury & Illness Cover Australia s leading income protection scheme Injury insurance designed for Australian Workers Up to $275,000 death benefit from an at-work injury serious trauma, broken
February 1, Basic Long Term Disability MMC
February 1, 2008 MMC This plan provides you with income in case you can t work for an extended period of time because of an injury or illness. Effective January 1, 2007, benefits under MMC s Basic and
Personal Accident Claim Form
Please read this page before completing the claim form Personal Accident Claim Form Equestrian Australia National Insurance Programme Thank you for your claim form request. This letter contains important
Instructions for Injury Insurance Claim
Instructions for Injury Insurance Claim 1. Section 1 Certificate Information: Is to be completed by the claimant or the Insured Person if the claim is for a minor. 2. Section 2 Claimant s Statement: Is
National Uniform Claim Committee
National Uniform Claim Committee 1500 Health Insurance Claim Form Reference Instruction Manual for 08/05 Version Disclaimer and Notices 2005 American Medical Association This document is published in cooperation
Short-Term Disability
AMERICAN FIDELITY ASSURANCE COMPANY S Short-Term Disability Income Insurance Plan Designed Specifically For: KENTUCKY DISABILITY - SPECIAL Plan Highlights Benefits are paid directly to you, not to a doctor
Bowdoin College. Salary Continuation Plan for Faculty. Revised 10/24/13
Bowdoin College Salary Continuation Plan for Faculty Revised 10/24/13 Benefits under the Short Term Disability Salary Continuation Plan described in the following pages are provided and funded by the Employer.
Who Administers the Workers Compensation Program and Related Responsibilities?
What is Workers Compensation? Who Administers the Workers Compensation Program and Related Responsibilities? Who is Eligible for Workers Compensation? What Coverage is Provided? What is a Compensable Injury?
Associate in Risk Management ARM 54 -Chapter 6 Assessing Liability Loss Exposures. Understanding the RM Process. #1 Workers Compensation 5/3/2012
Associate in Risk Management ARM 54 -Chapter 6 Assessing Liability Loss Exposures Presented by: Lynne Lovell RHU CLU ChFC CIC CRM ARM CPCU AFSB ASLI AINS MLIS CRIS Understanding the RM Process Educational
Total and Permanent Disablement. claim form. Privacy. Life insured details. Illness or injury details. Policy Number. Claim Reference Number
claim form This form is to be completed by the life insured and the policy owner. Please have your treating doctor complete the Physician s Report on pages 6-8 of this form. To avoid delays, check that
Workers Compensation Claim State Environmental Guide - Massachusetts
Workers Compensation Claim State Environmental Guide - Massachusetts MASSACHUSETTS www.mass.gov/dia Indemnity issues Temporary Total Benefits (Post 12/23/91 Injuries) Section ( ) 34 Temporary Partial Benefits
Your Choice Voluntary Long Term Disability Coverage Highlights Texas Northside Independent School District
Your Choice Voluntary Long Term Disability Coverage Highlights Texas Voluntary Long Term Disability Insurance Standard Insurance Company has developed this document to provide you with information about
Voluntary Disability Insurance Overview Short-term & Long-term Disability. Prepared for the employees of: Millennia Companies
Voluntary Disability Insurance Overview Short-term & Long-term Disability Prepared for the employees of: Millennia Companies Voluntary Short-term Disability Insurance Coverage paid by you Eligibility If
INDUSTRIAL COMMISSION OF ARIZONA
INDUSTRIAL COMMISSION OF ARIZONA WORKERS COMPENSATION INFORMATION FOR THE INJURED WORKER Phoenix Office: Industrial Commission of Arizona 800 W. Washington Street Phoenix, Arizona 85007-2922 Claims Phone:
Accident/Illness Claim
Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections. Policy. Claim. Insured Details Insured Claimant Surname
accident insurance with Expanded Benefits
BE WELL. BE SMART. BE PROTECTED. Allstate at Work accident insurance with Expanded Benefits on- or off-the-job including a disability income benefit plus riders An accident can wreak havoc on your savings
Form A57625RCA 2 A57625RCA Aflac All Rights Reserved
American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters 1932 Wynnton Road Columbus, Georgia 31999 1.800.99.AFLAC (1.800.992.3522) This is a supplement to
Student Care. Claim Form. How to Get Quick Action on Your Claim. Check List For Schools & Colleges. Check List For Students/Parents STOP
Student Care Claim Form Claim Number (office use only) How to Get Quick Action on Your Claim Catholic Church Insurance Limited will act on your claim as soon as we receive this form. You can help us to