AMERIND RISK TRIBAL WORKERS' COMPENSATION (TWC) PROGRAM EMPLOYEE INJURY REPORT TO BE FILLED OUT BY EMPLOYER

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1 AMERIND RISK TRIBAL WORKERS' COMPENSATION (TWC) PROGRAM EMPLOYEE INJURY REPORT TO BE FILLED OUT BY EMPLOYER Submit Report to: CLAIM ADMINISTRATOR BERKLEY RISK ADMINISTRATORS COMPANY, LLC PO BOX MINNEAPOLIS, MN Tel. (866) Fax (612) Complete and return this report to the address shown at left within 24 hours of notice of injury. EMPLOYER INFORMATION Policy Number Affiliate Name and Address Policy Period to Nature of Business (Tribal Government, Casino, Etc) Contact Person Contact Phone No Contact Fax No Name of Person Completing Report Title of Person Completing Form Signature of Person Completing Form Date Completed EMPLOYEE INFORMATION Last Name First M.I. Social Security Number Sex Birth Date Home Address (Number & Street) City State Zip Code Phone No. Employee s Job Title When Injured Employee s Assigned Department DESCRIPTION OF ACCIDENT Date of Injury Time of Injury Last Day of Work After Injury Date of Return to Work Date Employer Notified of Injury Address or Location of Accident City State Zip Code On Employer Premises? Was Injury Fatal? Nature of Injury (Scratch, Cut, Etc.) Part of Body Injured Emergency Room, Hospital or Medical Facility Treated by (Name, Address & Phone) Attending Physician (Name) How Did Accident Happen? What Was Employee Doing When Accident Occurred? (State All Details, Use Other Side if Needed) If Validity of Claim Is Doubted, State Reason EMPLOYEE S WAGE DATA Was Worker in Date of Last Hire Hours Per Your Employ Day Employee From To When Injured Worked Employee s Wage $ Per Hour Day Week Month Personal Time Off during the 26 calendar weeks preceding injury. Number of Days Per Week: Gross Wages of Employee During 26 Weeks Preceding Injury; or if Employee Worked Less Than 26 Weeks, Gross Wages From Date of Hire through Day Prior to Injury From To Employee Usually Works $ This form does not guarantee payment of benefits AM 9530 (10/12)

2 PO Box 59143, Mpls., MN S Ninth St, Ste 1300, Mpls., MN Phone (866) Fax (612) This folder contains important documents and instructions for filing claims for your employees. Please read everything carefully now so you will know what to do when an injury occurs. If you have any questions, please contact your AMERIND Representative or Berkley Risk Administrators Company, LLC. CRITICAL INFORMATION Any serious (life threatening) injury or injury causing death should be reported to us by phone immediately. Dial (866) In all other situations the AMERIND Risk Tribal Workers Compensation (TWC) Program requires you, the employer, to report all injuries and illnesses, which your employees claim, are related to work. You must report their claim using an EMPLOYEE INJURY REPORT form within 24 hours of receiving notice of an injury and submit the form to Berkley Risk Administrators Company, LLC. The TWC Program also requires prompt payment of any employee injury benefits that may be due. Payment for lost wages must be made within 14 days of receiving notice to or having knowledge of a work-related injury. To help you do that, you will find instructions for completing the Employee Injury Report form on the following page. If you need additional copies of any of the enclosed forms, please contact your AMERIND Representative or Berkley Risk Administrators Company, LLC. PREVENT WORK INJURIES For your benefit and assistance, AMERIND Risk Management Corp. offers safety services that can be tailored to your needs to help prevent work-related injuries. Their Loss Control Representatives are available for consultation regarding safety in the workplace and for safety surveys of your facilities. They can also assist you in the development of your own program of accident prevention and loss control. These services are provided at no additional charge to you. Call (800) to schedule a visit or for more information on safety and loss control topics. Equal Opportunity Employer AM 2530 (12/13)

3 AMERIND Risk Tribal Workers Compensation (TWC) Program INSTRUCTIONS FOR EMPLOYERS WHAT TO REPORT The Risk Tribal Workers Compensation (TWC) Program requires that you report any and all injuries and illnesses that your employees believe are work-related. Berkley Risk Administrators Company, LLC will then determine if any workers compensation benefits are payable to the injured employee. Remember, filing an Employee Injury Report with us does not mean that you are admitting any liability. It means only that you are reporting a claimed injury or condition that your employee thinks is related to work activities. WHO REPORTS AN INJURY The injured employee is required to report an injury to you, the employer, within forty-eight (48) hours of its occurrence. You, the employer, are then required to report that claimed injury to us on an Employee Injury Report form. It is not the injured employee's responsibility to report the injury to us. Do not ask the injured employee to complete the form. WHEN TO REPORT AN INJURY If an employee is killed or suffers a life-threatening injury (amputation of limb, massive internal injuries, etc.) you should report by phone to Berkley Risk Administrators Company within 24 hours of the occurrence. You must also send a completed Employee Injury Report form to us. You must report any other work-related injury or illness within 24 hours of your first knowledge of its occurrence. If the employee s supervisor or manager knows about the injury, then you, the employer, have knowledge of it even if you are unaware of the injury. The injury must be reported on an Employee Injury Report form. Because of possible delays by the Postal Service, we recommend that you complete and mail the original Employee Injury Report on the same day you are notified of the injury. Do not wait for the employee to return to work or for medical bills or other information. HOW TO REPORT AN INJURY When an accident occurs, have the employee's supervisor complete the Supervisor's Report of Accident (SRA). This form will assist in your internal investigation of the accident and what caused it. Then you, the employer, should complete the Employee Injury Report form using information from the SRA, personnel records, and elsewhere. If there are any unusual circumstances or you need to provide more information, you should attach a letter to the report. Fax the Employee Injury Report and Supervisors Report of Accident (SRA) to Mike Sternal at Berkley Risk Administrators Co., LLC at (612) Keep a copy of each for your records. REMINDERS AND ADVICE If an employee begins to lose time from work after you've mailed the Employee Injury Report, call us immediately to let us know. Then we can pay any benefits due in a timely manner. Call us as soon as an employee returns to work after a work-related injury. We can then discontinue time-loss benefits and avoid the possibility of overpaying your employee. Promptly send us all injury-related medical bills you or your employee receives. Medical providers often bill only one party, so if you receive a bill, it probably means that we have not. Before we pay a bill, we review it to ensure that it s related to the work injury and we request medical records for it. The TWC Program allows us 45 days from the date we receive those records to pay a bill so it may sometimes be several months from the date of treatment before we re able to pay. Do not pay medical bills for your employees' work-related injuries. First, by paying a bill, you may be accepting liability for an injury that is not really work-related. Second, because of the Medical Fee Schedule, we can often pay less than what the medical provider charges, which saves you money. Do not deliberately obstruct or attempt to prevent an employee from seeking TWC Program benefits. You should post the name and address of your Claims Administrator (Berkley Risk Administrators Company, LLC) in a conspicuous place. You may use the "Employees' Rights" poster for that purpose. If an employee claims a work-related injury, report it to us along with all relevant information. Let us investigate and determine if any employee injury benefits are due. Don't ignore your injured employees. Communicate with them regularly and let them know you are concerned about them. It is especially important, if they are losing time from work, that you keep them mentally "connected" to their job. If at all possible, provide light duty or part-time work to help return them to health and productivity as soon as possible. This is not only good for your employees; it also helps to reduce your claim costs. Be accessible and provide us with the information we need when we request it. This will allow us to be more effective in managing your claims and controlling your TWC Program costs.

4 AMERIND Risk Tribal Workers' Compensation (TWC) Program SUPERVISOR'S REPORT OF ACCIDENT (PLEASE READ AND FOLLOW INSTRUCTIONS ON BACK) EVERY ACCIDENT SHOULD BE INVESTIGATED AND THE CAUSES CORRECTED SO THAT MORE ACCIDENTS WILL NOT OCCUR. DO NOT OVERLOOK THE SO-CALLED "UNIMPORTANT" CASES, BECAUSE, EXCEPT FOR "CHANCE" THEY COULD ALSO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED. NAME OF EMPLOYEE EMPLOYER DEPT. DATE OF ACCIDENT TIME DID EMPLOYEE LOSE TIME FROM WORK? YES NO HOURS LOST ON DATE OF ACCIDENT HAS EMPLOYEE RETURNED TO WORK? YES NO JOB TITLE SERVICE WITH THE EMPLOYER YEARS IN PRESENT JOB GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK "YES" OR "NO" 1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS?... YES NO 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS?... NO YES 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE)... YES NO 4. DID POOR HOUSEKEEPING CONTRIBUTE TO INJURY?... NO YES 5. DID HORSEPLAY CAUSE THE INJURY?... NO YES 6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS?... NO YES 7. SHOULD A GUARD BE PROVIDED?... NO YES 8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY?... NO YES 9. WAS IT CAUSED BY AN UNSAFE ACT?... NO YES 10. DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY?... YES NO ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED, WHO WAS INVOLVED, NATURE OF INJURY, PART OF BODY AFFECTED.) WITNESSES' NAMES UNSAFE ACTS. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?) UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY, EQUIPMENT, BUILDING OR PREMISES WAS INVOLVED?) ACTIONS TAKEN. (WHAT DID YOU DO TO CORRECT THE CONDITIONS WHICH CAUSED THIS INJURY?) REMEDIES. (WHAT SHOULD YOUR ORGANIZATION DO TO PREVENT OTHER INJURIES LIKE THIS?) MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL? YES NO IF YES, COMPLETE THE FOLLOWING NAME OF DOCTOR OR HOSPITAL ADDRESS DATE OF INITIAL VISIT TELEPHONE NUMBER AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER THE TWC PROGRAM? YES NO REASONS WHY REPORT SUBMITTED BY DATE AM 2520 (8/11)

5 COMPLETION INSTRUCTIONS FOR SUPERVISORS' REPORT OF ACCIDENT (SRA) The primary purpose of the SRA is to investigate the accident. It is also used to report the accident to the central office where the Employee Injury Report is then completed by administrative personnel. The SRA should be filled out as soon as possible after the accident. If the SRA is incomplete or delayed, corrective action may also be delayed. A delay in taking corrective action will probably result in the occurrence of a similar accident. The initial information asked for at the top of the SRA concerning the injured person's name, occupation, age, job history and l oss of time from work is selfexplanatory, but very necessary for eventual completion of the Employee Injury Report. The following is a line-by-line set of instructions for completing of the SRA by the Supervisor of the injured employee. Concrete examples of important parts of the form are given for your use. This report should not be completed by the injured employee. QUESTIONS 1. Was proper instruction given to the employee on how to do the job safely? Supervisors should instruct their employees on how to do the job efficiently and safely. 2. Referred to in question #1. 3. The supervisor should have told the employee what personal protective equipment is necessary to do the job. Did the employee wear the personal protective equipment when this job was being done? 4. Was the work area clean and well organized? i.e., scraps on the floor, blocked aisles, wet floor, spilled food, etc. 5. Was there inadequate supervision? Did horseplay or practical jokes contribute to the accident? 6. Was the injured person using equipment that was unsafe and in need of repair? i.e., broken ladder, bad electric cord on drill, etc. 7. Would a guard prevent another accident from happening? i.e., guard around the belts and pulleys, railing properly in place, guard on saw, etc. 8. Did this person have any bodily defects which might have helped cause the accident? i.e., poor vision, previous back injury, etc. 9. Most injuries are caused in part by unsafe acts. An Unsafe Act is something that the injured person or another person did, that he or she should not have done, which led to the accident. Below is a list of the most common unsafe acts and contributing factors: 1. Operating without authority 2. Failure to warn or secure 3. Operating at unsafe speed 4. Making safety devices inoperative 5. Using equipment, tools, materials or vehicles unsafely 6. Using defective equipment, materials, tools or vehicles 7. Failure to use personal protective equipment 8. Failure to use equipment provided (except personal protective equipment) 9. Unsafe loading, placing and mixing 10. Unsafe lifting and carrying (including insecure grip) 11. Taking an unsafe position 12. Adjusting, clearing jams, cleaning machinery in motion 13. Distracting, teasing 14. Poor housekeeping practices 15. Disregard of instructions 16. Lack of knowledge or skill 17. Act of other than injured 18. Others The accident should have been reported immediately to the supervisor; was it? Accident 1. Describe what the injured was doing at the time of the accident. 2. What happened? 3. Who was involved? 4. What injuries resulted? Example: John was drilling a hole in the ceiling and chips of plaster fell into his eye. (This answers questions 1 and 2. ) John got chips of plaster in his eye, resulting in a scratch to his eye. John was wearing his prescription glasses. (This answers questions 3 and 4.) Note the names of witnesses, if any. Unsafe Act Refer to question 9 above and examples of Unsafe Acts. Example: John was not wearing proper personal protective equipment. Unsafe Conditions 1. Defective tools, equipment, substances 5. Improper ventilation 2. Unsafe design or construction 6. Improper dress 3. Hazardous arrangement 7. Poor housekeeping 4. Improper illumination 8. Congested area 9. Other Action Taken Example: John has been re-instructed to wear proper personal protective equipment such as goggles or face shield when drilling overhead. Remedy Example: Standard safety policy should be adopted that requires use of personal protective equipment. This policy should be strictly enforced by the supervisors. Medical Care: Include all medical information that is known at this time. Do not delay the completion of this form for more complete information. As supervisor, do you feel that this injury should be covered under the TWC program? As a general rule, if the employee is injured while at work, that injury is covered under the TWC program. However, if you as supervisor, have reason to suspect that the injury did not occur at work, please tell us. This is only an opinion and by itself will not deny benefits.

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