Welcome to Tower Group Companies` Workers Compensation

Transcripción

Dear Policyholder:
Welcome to Tower Group Companies’ Workers Compensation Insurance Program. Although we hope that
your company never has to experience an injury to an employee, we want you to have all the information
you might need in the event one does.
Enclosed is our Workers Compensation Injury Reporting Kit that contains the California State mandated
forms, and a step-by step process to follow in case of an injury to an employee.
When a claim occurs, please contact the Tower First Report Unit in Irvine, California. Contact information
for the First Report Unit is listed on the “Reporting Work Related Accidents” form included in this packet.
Once reported, a claims representative will contact you to get additional information about the injured
employee and to answer any questions that you might have regarding the California workers compensation
process.
We thank you for your business, and look forward to being of service to you.
Very truly yours,
Tower Group Companies
CL-08-045 TGC (08/10)
Reporting Work Related Accidents
The timely reporting of work related accidents is critical in helping to reduce the overall costs
associated with these claims. Please remember to notify us immediately if one of your
employees is injured at work or becomes ill due to conditions on the job. By doing so we can
work together to help control claim costs. It is very important to include contact numbers for
both the employee and the employer when submitting an Employer’s Report of Occupational
Injury of Illness Form (Form 5020). We recommend that you list both the landline and cell
phone numbers.
Reporting a work related accident can be done by fax, email, phone, or mail. Simply complete
the attached Employer’s Report of Occupational Injury of Illness form and forward to us in any
manner noted below.
By Fax:
To report a claim by Fax:
Fax the completed Employer’s Report of Occupational Injury of Illness form for our First Report
fax line at 1-888-535-3407.
By Email:
To report a claim by email- Please email the completed Employer’s Report of Occupational Injury
of Illness form to [email protected]
By Phone:
To report a claim by phone – Call – 1-888-856-5522
By Mail:
To report a claim by mail – Please forward the completed Employer’s Report of Occupational
Injury of Illness form to:
Claims Department
P.O. Box 17059
Irvine, CA, 92623
If at any time you have questions about the reporting process or how to complete the Employer’s
Report of Occupational injury or Illness form, please feel free to contact our claims department at
1-888-856-5522.
Workers Compensation Injury Reporting Kit
(These materials are to be used to report an on-job-injury of illness.)
Injuries must be reported within 24 hours!
1. Employee Claim Form (DWC-1)
The Employer provides this form to the injured employee within 24 hours of knowledge
of injury.
a.
b.
c.
d.
Employee completely reads and fills in #’s 1-8
Employee retains a copy and returns the form to the employer
The employer completes #’s 9-18 (*Note # 14 is Tower Group Companies)
The employer provides a dated copy of the completed form to the employee,
sends a copy to Tower Group Companies and keeps a copy on file.
2. Employer provides injured employee with the following additional items in the
appropriate language
a. Name of treating physician or authorized industrial clinic
b. Informational pamphlet
c. Name, telephone number and P.O. Box our First Report Unit in Irvine,
California.
3. Employer’s Report of Occupational Injury or Illness (Form 5020)
a. Employer fills out lines #’s 1-39
b. At the bottom of form 5020, print the name and title of the person who if
filling the Report of Occupational Injury or Illness.
c. Employer dates and signs Form 5020 in the space provided at the bottom of
the form, sends the completed form to Tower Group Companies and keeps a
copy on file.
4. Medical Care
In an emergency, please contact 911. Otherwise, refer the employee to your industrial
clinic.
5. Report of Occupational Injury of Illness Form (5020)
Within 24 hours of your knowledge of injury or illness, report the claim to the Tower First
Report unit by calling 1-888-856-5522. You will need to be prepared to provide them
with the information necessary to complete the California Employer’s Report of
Occupational Injury of Illness (Form 5020). A sample is enclosed for your reference.
***Remember, a copy of item #1 and #3 MUST be sent to Tower Group Companies***
Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibilty
Formulario de Reclamo de Compeiisación de Trabajadores (DWC 1) y Notlfieación de Posible Elegibildad
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If you are injured or become ill, either physically or mentally. because of
your job, including injuries resulting from a workplace crime, you may be
entitled to workers' compensation benefits. Attached is the fonn for filing
su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de
trabajo, es posible que Ud. tenga derecho a beneticios de compensaeión de
a workers' compensation claim with your employer. You should read all
trabajadores. Se adjunta el formulario para presentar un reclamo de
of the information below. Keep this sheet and all othcr papers for your
compensación de trabajadores COll su ernpleador. UII. debe leer toda la
Si Ud. se lesiona 0 se enferma, ya sea fisieamente 0 mental
mente, debido a
records. You may be eligible for some or all of the benefits listed
información a continuación. Guarde esta hoja y todos los del1ás
required you will be notified by
the claims administrator, who is responsible for handling your claim,
about your eligibility for benefits.
documentos para sus archivos. Es posible que usted reúna los requisitos
depending on the nature of
your claim. If
To fie a claim, complete the "Employee" section of the fomi, keep one
para todos los beneficios, 0 parte de éstos, que se enurneran, dependiendo
de la indole de su reclamo. Si se requiere, el administrador de reclamos,
quien es responsable pOl' el manejo de su reclamo, Ie notificará sobre su
elegibilidad para beneficios.
copy and give the rest to your employer. Your employer will then
complete the "Employer" section, give you a dated copy, keep one copy
and send one to the claims administrator. Bencfits can't start until the
claims administrator knows of the injury, so complete the form as soon as
possible.
Para prescntar un reclaiio, Ilene la sección del foriiiulario designada para el
"Empleado," guarde una copia, y déle el restn a su empleador. Entonces,
su empleador completará la sección designada para el "Empleador," Ie dará
a Ud. una copia fechada, guardará una copia, y enviará una al
administrador de reclamos. Los benefieios no pueden comenzar hasta, que
Medical Care: Your claims administrator will pay all rcasonable and
necessary medical care for your work injuiy or illness. Medical benefits
el administrador de reclamos se entere de la lesión, asi que complete el
formulario 10 antes posible.
may include treatment by a doctor, hospital services, physical therapy, lab
tests, x-rays, and medicines. Your claims administrator will pay the costs
directly so you should never see a bilL. There is a limit on some medical
Atención Médica: Su administrador de reclamos pagará toda ia atención
médica razonable y necesaria, para su !esión 0 enfennedad relacionada con
services.
el trabajo. Es posible que los beneficios médieos incluyan ci tratamiento
pOl' parte de un médico, los scrvicios de hospital, la tcrapia fisica, los
The Priman Treating Phvsician cPTPI is the doctor with the overall
análisis de laboratorio y las medicinas. Su administrador de reclamos
responsibility for treatmcnt of your injury or illness. Generally your
pagará directamentc los costos, de manera que usted nunca verá un eobro.
employer selects the PTP you will see for the first 30 days, however, in
specified conditions, you may be treated by your predesignated doctor or
mcdical group. If a doctor says you still need treatment after 30 days, you
may be able to switch to the doctor of
your choice. Different rules apply if
Hay un Iímite para ciertos servicios médicos.
you are covered by an Ileo or
EI Mcdico Primario que Ie Atiende-Pri11flrr TI'ellifll! PIll sicioii PTP es
d médico con la responsabilidad total para tratar su lesión 0 enfermedad.
Gcneralmcnte, su ernpleaclor selecciona al P7ï' que Ud. verá durante los
primeros 30 dias. Sin embargo, en condiciones especificas, es posible que
usted pueda ser tratado pOi' su médico 0 grupo médico previaiiente
designado. Si el doctor dice que usted aún necesita tratamiento después de
a MPN. Contact your employer for more inforniation. If your employer
30 dias, es posible que Ud. pueda cambial' al médico de su prefèrencia. Hay
has not put up a poster describing your rights to workcrs' compensation,
you may choose your own doctor immediately.
reglas differentes que se aplican cuando su empleador usa una
your employer is using a Health Care Organization (HCO) or a Medical
Provider Network (MPN). A MPN is a selected network of health care
providers to provide treatment to workers injured on the job. You should
receive infoimation from your employer if
Within one working day after you file a claim form, your employer shall
authorize the provision of all treatment, consistent with the applicable
treating guidelines, for the alleged injury and shall continue to be liable
for up to $~ 0,000 in treatment until the claim is accepted or rejected.
Disclosure of Medical Records: After you make a claim for workers'
compensation benefits, your medical records will not have the same level
of privacy that you usually cxpect. If you don't agree to voluntarily
release medical records, a work.ors' compensation judge may decide what
Organización de Cuidado Médico (HCO) 0 una Red de Proveedores
Mcclicos (MPN). Una MPN es una red de proveedores de asistencia médica
seleccionados para dar tratamiento a los trabajadores lesionaclos en cl
trabajo. Usted dcbe recibir infonnaeión de su empleador si su tratamiento
es cubieiio pOl' una HCO 0 una MPN. Hable con su empleador para más
infolliación. Si su einpleador no ha colocado un caiiel describiendo sus
derechos para la compensaeión de trabajadores, Ud. puede seleecionar a su
propio incdico inmediatamente.
Dentm de un día despucs de que Ud. Presente un formulario de reclaino, su
do tratamiento iiédieo de acuerdo eon las pautas de
empleador autorizará to
records will be released. If you request privacy, the judge may "scal"
trataiiiento aplicables a la presunta lesión y será responsable pOl' $ I 0,000
(keep private) certain medical records.
en tratamiento hasta que el reclamo sea aceptado 0 rechazado.
Payment for Teßlllolan Disabilty (Lost Wa~: If you can't work
Divulgación de Exiiedieiites Mcdicos: Después de que Ud. presente un
reclamo para beneficios de compensaeión de trabajadores, sus expedientes
médicos no tendrán el misino nivel cle piivacidad que usted noimalrnente
espera. Si Ud. no está dc aeuerdo en divulgar voluntarial1ente los
while you are recovering from ajob injury or illness, for most il\iuries you
will receive temporary disability payments for a limited pciiod of time.
These payments may change or stop when your doctor says you are able
to rdum to work. These benefits arc tax-free. Temporary disability
payments are two-thirds of your average weekly pay, within minimums
and maximums set by state law. Paynients arc not made for thc first three
days you are otT the job unless you are hospitalized overnight or cannot
expedientes médicos, un juez cle comp(;nsación de trabajadores
posiblel1ente deeida qu6 expedientes se revelarán. Si Ud. solicita
privacidad, es posible que el juez "selle" (inantenga privados) ciertos
expedientes inédicos.
work for more than 14 days.
Pa:.o por Incapacidad Temporal (Sneldos Perdidos): Si Ud. nl) puede
Return to Work: To help you to return to work as soon as possible, you
trabajar, rnientras se está recuperando de una lesión 0 enfennedad
should actively communicate with your treating doctor, claims
relacionada con el trabajo. Ud. recibirú pagos pOl' incapacidad temporal
administrator, and employer about the kinds of work you can do while
recovering. They may coordinate efforts to return you to modified duty or
other work that is medically appropriate. This modified or other duty may
para la mayoria de las lesions pOI' un period limitaclo. Es posible que estos
pagos cambien 0 paren, wando su inédi~o diga que Ud. está en condiciones
de regresar a trabajar. Estos beneficios son libres de inipuestos. Los pagos
Rev.
6110
Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibilty
Formultll'io tie Reclamo tie Compeiistlcióll tie Trabajadol'es (DWC 1) Y Notifcacióii tie Posible Elegibildall
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be temporary or may be extended depending on the nature of your injury
pOl' ineapacidad temporal son dos tercios de su rago semanal promedio,
or illness.
con eantidades Ilínimas y Iláximas establecidas pOl' las Icyes estatales.
Pai ment for Permanent Disabilii: If a doctor says your injury or
a men
illness results in a permanent disability, you may receive additional
más de 14 días.
Los pagos no se haccn durante los primeros Ires dias en que lJd. no trabaje,
os que Ud. sea hospitalizado una noche 0 no pueda trabajar durante
payments. The amount will depend on the type of injury, your age,
occupation, and date of
injury.
Regreso al Tmbajo: Para ayudarle a regresar a trabajar 10 antes pçisible,
lJd. debe cornunicarse de manera aetiva con el médieo que Ie atienda, el
Supplemental Job DiSllljlcement Benefit iSJDB!: If you were injured
administrador de reclamos y el empleador, con respeeto a las clases de
after 1/1/04 and you have a permanent disability that prevents you from
trabajo que lJd. puede hacer rnientras se recupera. Es posible que ellos
returning to work within 60 days after your temporary disability ends, and
your employer does not offer modified or alternative work, you may
qualify for a nontransferable voucher payable to a school for retraining
and/or skil enhancement. If you qualify, thc claims administrator will
pay the costs up to the maximum set by state law based on your
coordinen esfuerzos para regresarle a un trabajo modificado, 0 a otro
percentage of perrnanent disabi Ii ty.
Pa"o pOI. Ineaiiacidad Permanente: Si el doctor dice que su lesión 0
trabajo, que sea apropiado desde el punto de vista médico. Este trabajo
modificado u otro trabajo podna ser temporal 0 podria extenderse
dependiendo de la índole de su lesión 0 enfennedad.
enfermedad resulta en una ineapacidad pernianente, es posible que lJd.
Death Benefits: If the injury or illness causes death, paymcnts may be
made to relatives or household members who were financially dependent
reeiba pagos adicionales. La cariidad dependerá de la clase de lesión, su
edad, su ocupación y la fecha de la lesión.
on the deceased worker.
Beneficio SIi"lementario 1101' Dcs(llazamicnto de Ti'abalo: Si lJd. Se
It is iIe::al for ,'our emiilover to punish or tíre you for having a job
lesionó después del 111/04 y tiene una incaracidad peniianente que Ie
injury or illness, for fiing a claim, or testifying in another person's
impide regrcsar al trabajo dentro de 60 dlas después de que los pagos pOl'
workers' compensation case (Labor Code 132a). If proven, you may
ineapacidad temporal terminen, y su empleador no ofrcce un trabajo
receive lost wages, job reinstatement, increased benetíts, and costs and
modificado 0 alternativo, es posiblc que usted reúna los requisitos para
expenscs up to limits set by the state.
reeibir un vale no-transferible pagadero a una escuda para recibir un nuevo
entrenamiento y/o inejorar su habilrdad. Si Ud. reúiie los requisitios, el
You have the right to disagree with decisions affecting your claim. ifyou
have a disagreement, contact your claims administrator first to sec if you
can resolve it. If you are not receiving benefits, you may be able to get
administrador de reclainos pagará los gastos hasta un máximo establecido
pOl' las leyes estatales basado en su porcentaje de incapacidad pennanente.
State Disability Insurance (SOI) benefits. Call State Employment
Bcnctìcios por Miierte: Si la lesión 0 enferinedad causa la muerte, es
Development Depar1ment at (800) 480-3287.
po,ible que los pagos se hagan a los parientes 0 a las personas que viven en
el hogar y que dependían econ6niicameiite del trabajador difunto.
You can obtain free infonnation from an information and assistance
offcer of the State Division of Workers' Compensation (DWC), or you
can hear recorded information and a list of local oftces by calling (800)
736-7401. You may also go to the DWC website at www.dwe.ea.gov.
Es ilcgal que sll cmpleador Ie castigue 0 despidii, pOl' sufrir una lesión 0
erilènnedad en el trabajo, pOl' presentar un reclaino 0 pOl' testificar cn cl
caso de compensaeión de trabajadores de otra persona. (El Codigo I.aboral
seceión 132a.) De ser rrobado, usted puede recibir pagos por pérdida de
Yon can eonsiilt with an attorney. Most attorneys otTer one frte
sueldos, reposicióii del trabajo, aumento de beneficios y gastos hasta los
consultation. If
you dccide to hire an attorney, his or her fcc will be taken
líniites establecidos pOi' ei estado.
out of some of your benefits. For names of workers' compensation
attorieys, eall tht: State Bar of Calítornia at (415) 538-2120 or go to their
Ud. tiene derecho a no cstar de aeuerdo con las decisiones que afecten su
web site at www.californiiispecialist.org.
reclamo. Si Ud. tiene un desacuerdo, priinero comuníquese con su
aclministrador dt: reclainos para vel' si usted puede resolverlo. Si usted no
está recibiendo beiiefieios, es posible que Ud. pueda obtener beiieficios del
Seguro Estatal de Incapacidad (SOL). Llame al Departamento Estatal del
Desarrollo del Einpleo (EDD) al (800) 480-3287.
Ud. puede obtener infoimación gratis, de un oficial de infonnación y
asistencia, de la Divisióii Estatal de Coripensación de Trabajadores
(Division oj Workers' Compensation -- DWC) 0 puede escuchar
información grabada, asi como una lista de oficinas locales lIamando al
(800) 736-7401. Ud. tambiéri ruede consultar con la pagina Web de la
DWC en www.dwc.ca.gov.
Vd. (liicdc eonsultar con un abo:,ado. La mayoría de los abogados
ofrecen una consulta gratis. Si Ud. decidc contra
tar a un abogado, los
honorarios serán toinados de algunos de sus beneficios. Para obtener
nombres de abogados dc compensación de trabajadores, lIame a la
Asoeiaci6n Estatal de Abogados de Califoiiia (State Bar) al (415) 5382120, ó consulte con la pagina Web en www.calitorniaspccialist.org.
Hev 6/tO
Estado de California
State of California
Department of Industrial Relations
DIVISION OF WORKERS' COMPENSATION
Departamento de Relacioiies liidustriales
DlVlSlON DE COMPENSAC/ÓN AL TRi\BJlADOR
PETITION DEL EMPLEADO PARA DE eOMPENSACIÓN DEL
TRABAJADOR (DWe I)
WORKERS' COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the "Employee" section and give the form to
your employer. Keep a copy and mark it "Employee's Temporary
Receipt" until you receive the signed and dated copy from your employer. You may call the Division of Workers' Compensation and
hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included as the cover sheet of this form.
You should also have received a pamphlet from your employer de-
scribing workers' compensation benefits and the procedures to obtain
Empfeado: Complete la sección "Empleado" y eiitregue la forma a su
empleador. Qiiédese con la copia designada "Recibo Temporal del
Empfeado" l10sm que Vd. reciba la copiafirmada y fechada de su empleador.
Vd. puede llamar a la Division de Compensación al Trabajadoral (800) 736-
7401 para oil' informución gravada. En la hoja ciibierta de esta
forma esla la explicatión de los beneficios de compensación al tmbajador.
Vd. también debería haber recibido de su empleador unfolleiu describiendo los
ado y los procedimieiiios para
them.
benjïcios de compelisaCIó/i al tmbajador lesion
"ny person who makes or causes to he made any knowingly false
or fraudulent material statement or materiiil representation for
the purpose of obtaining or denying workers' compensa1on benefits or payineni~ is guilty of a felony.
Toda aquella persona que a propósito haga 0 calise que se produr.ca
obtenerlos.
Employee--omplete this section and see note above
i.
ciialquler declaraciiín 0 representación material faL~a 0 fraudulenta eim el
fin de obtener 0 negar beneficios 0 pagos de ciimpensación a lraba.ladores
lesionados es culpable de un crimen ma~'or "relonia".
Empleado-complete esta sección y note fa notacióii arriba.
Name. Nombre.
__ Today's Date. Fecha de Hoy.
2. Home Address. Direccióii Residencial.
Zip. Código Postal.
State. Estado.
3. City. Ciudad.
4.
Date of Injury. F echa de la lesión (accidente).
5.
Address and description of where injury happened. DirecCIônllugar dônde occiirió 1'1 accidentI'.
Time of Injury. Hom en que ocurrió..__a.m.
p.m.
6. Describe injury and part of body affected. Descriha la lesión y parte del cueljJO afectada.
7. Social Security Number. Número de Seguro Social del Empleado.
8. Signature of employee. Firmlt del empleado.
Employer--omplete this section and see note below. Empfeiidor-complete estii sección y 1/ote (ll1/otació1/ abiijo.
9.
Name of employer. Nombre del empleador.
10. Address. Dirección.
I i. Date employer first knew of injury. Fecha eii que el empleador supo pOi' primera vez de la lesión 0 accidente.
12. Date claim form was provided to employee. Fecha en que se Ie entregô al empleado la peticiôn.
13. Date employer received claim form. Fedia en que el empleado devo!i'ió la peticiôn al empleador. _.___.________
14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros 0 agencia adminslradora de seguros.
15. Insurance Policy Number. EI niírnero de la l'óliza de Seguro.
16. Signature of employer representative. Firma del representante del empleador.
17. Title. Titulo.
18. Telephone. Teléfono.
Employer: You are required to daic tbis form and provide copies to
your insurer or claims administrator and to the employee, dependent
or representative who filed the elaim within one working dav of
receipt of the form from the employee.
Empleador: Se requiere que Ud.feche estaforma y que provéa copias a su compalÏa de seguros. administrador de reclamos, 0 dependienielrepresentanie de reclanws y al empleado que hayan presemado esta peticiôn demro del plaza de un día
hábil desde elmomento de haher sido recibida lafomia del empleado.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABn~ITY
EL FIRMAR ESTA FORMA NO SlGNIFlCi\ ADMTSTON DE RESPONSABlLlDAD
o Employer copylCopia dd Emp/mdor
6/10 Rev.
o Eniployte copy! Copia del Emplt'ado
o Claims Admini:-trator/.4dmil1is/mdOl de Reclaiios 0 Temporary Receipt/Ri.'cibo del Emplcado
OSHA CASE NO.
I ~,.tc ei t.a i exni_ ..s. comp.cto n ",~"c".llype i possjblo¡ r.',¡¡ ""0 copias 0:
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
FATALITY 0
Any person who makes or causes to be made .ny
knowingly false 01' fraudulent material staement or
material representation for the purpose of obtaining or
denying workers compensation benefis or payments Is
gul~y of a f.lony.
California law requires employers to report within five days of knowledge every occupational injury or illness whicl results in lost time beyond the
date of the incident OR requires medicallreatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or
illness. the employer must fie within five days of knowledge an amended report indicaling death. In addition, every serious injury, illness. or death
must be reported immediately by telephone or telegraph 10 the nearest office of the California Division of Occupational Safety and Heallh.
ia. Polloy Numb.r
1. FIRM NAME
Please do not use
this column
211. Phone Number
E 2. MAIUNG ADDRESS: (Numb.r, Str..t, City, Zip)
CASE NUMBER
M
P
L 3. LOCATION W din.rent rom Mailing Addr.ss (Fiui6.r, Str..i, City and lip!
3a. LocatIon Cõde
OWNERSHIP
o
-6. State unemployment Insuranco aeclno
~ 4. NATURE OF BUSINESS; e.g.. P.ainting cQltraelrl wholes:;lagrcxer, sawmil, hotel, etc.
R
5. TYPEOFEMPLOY"R:
D D DOD D
Pnv:i Stole County ily Sohool Di'lr~1 Oler Go"~ Spei/;:
INDUSTRY
(mm/dd/yy) ~ AM PM
7, DATE OF INJRY I ONST OF ILLNESS 8. TIME INJURYA~,ILLNESS oeCUpMRRED 9. TIfI EMPLOYEE BEGAN WORK 11o.IF EMPLOYEE DIED, DATE OF DEATH (mmlddlyy)
OCCUPATION
11: ~~~e.lE TOWORKFM ÄhiíãY öN'l 12 DATE LAST
WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) _~~~~~ 1
14..I._F S. .TlLl OFDF WORK, CHECK THIS BOX:
FUll DA YAFT~ OF INJURY? .
DYes UNO
SEX
16. PAID FUll DAYS WAGES FOR DATE OF 15. SALARY BEING CONTINUED? 17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 118. DATE EMPLOYEE WAS PROViDED CLAIM FORM
~~~~ig:Ki:~?T 0 Yes ONO DYes DNa INJURynllNESS (mmldd/yy) FORM (mm/ddJy)
AGE
I9.SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS ~ .v.ii.ble, e.g.. sëooñddeiree burns on right arm, tendonitis on leltelbow, lead poisoning
I
~ 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, Crt, Zip)
20a. COUNTY
DAILY HOURS
21. ON EI,'PLOYER'S PREMISES7
DYes DNa
U
R
Y 22. DEPARTMENT
WHERE EVENT OR EXPOSURE OCCURREO, e.g. Shipping department, maohineshop.
DYes DNO
DAYS PER WEEK
l' 3. OtherWorkcrs Injured or II in this event?
Z;:'EciuiPMENT;MATÉRIALS AND CHEMICALS THE EMPLOYEE WAS USING WHËÑEVÊr.T OR EXPÓŠURE,:iCCÜRREOÐ,Ãëetylen., weíding lorch, farm tractor, soaffold
o
R
WEEKLY HOURS
26. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, '.g.. Welding seams of metal forms, loading boxes onto truok.
I
L
L iG. HOW INJURynLLNEsS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIREêiü PRõö-ûèËö THE iNJURYlilNESS;e.g.. Work.r stepped iìi to inspet work
N and sUppe on serap m;;terial. As he fell, he brushed against fresh weld, and burne rIght hand. USE SEPARATE SHEET IF NECESSARY
WEEKLY WAGE
E
COUNTY
S
S
27. Nam~ 8~d add..;;; of physician (numbel"~ sin~et. cii~\... :iip)
NATURE OF INJURY
J 279. Phone Nuinber
IZll.llospitølind as an inpatient o"erni2ht'~ D No Dyes Ify£'s then,iiame and address ofhospiial (numbe.., street, cit)'~ zip)
Ti8a. lho-;e Niwibl--.-----PART OF BODY
29. Emplo)t' Crcatl'd In em('r¡ciii:y room? ~
IIIYcs ONn
ATIENTION This form contains information relating to employee health and must be used In a manner that protects the confidentiality of employees to the extent possible --URCE
while the information is being used for occupational safety and health purposes. See CCR Tille 814300.29 (b)(6)-10) & 14300.35(bX2)(E)2.
Note: Shtidcd boxes indicnte confidenCial employee informaCion as listed in CCR Title 8 14300.35(b)(2)(E)2..
30. EMPLOYEE NAME
32. IlATEOf BIRTH (mmJddlY))
31. SOCIAL SECURITY NUMBER
EVENT
33.. PIlO!'E NUMBER
E 33. 1I0ME ,\DORESS (Sumber. Sireel, Ciiy,Zip)
SECONDARY SOURCE
M
P
L 34. SEX
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
36. DATE 01' IIRE (mm/ddiyyl
o D Male D Female
Yt=- - ----~ E 37. EMPLOYEE USUALLY WORKS
E _ hours per
day,
37.. EMPLOYMENT STATUS
total weekty hours
days per week,
38. GROSS WAGES/SALARY
Completed By (type or print)
. Confidenti;ll i"fonn~tion may be disclosed only to the em
Dreguiafi fult-tlme
Dpar1.tlme
Dtemporary
Dse.sonai
37b. UNDER WHAtCLASS CODE OF YOUR
POUCY WHERE WAGES ASSIGNED
-ËXTENT OF INJURY
3'. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?
per
Signature & Title
DYes ONe
Dale (mm/ddlyyl
pi yee, fonner employee, or their personal represenbtive (CCR Title 8 14300.36), to othcrs for the purpose 0' processing ii workers' compensatIon or other insurance
claim; and under certain circumstnces to ii public health or law enforcement agency or to a consultant hired by the employer (CCR True 8 14300.30). CCR TiUe 8 14300.40 requires provtsion upon request to certin state and
federal workplace safety agencIes.
FORM 5020 (Rev7l June 2002
FILING OF THIS FORM IS NOT AN ADMISSION OF liABILITY
WORKERS COMPENSATION
MANAGED CARE PROGRAMS
Tower Group Companies strives to deliver the highest quality and value of workers compensation products and
services to our customers. We are committed to providing excellent customer service and products which will
meet our customers’ needs in managing their workers compensation claims.
Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry
Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with
a focus of timely return to work for your injured worker.
A summary of each program is outlined below.
Medical Bill Review Services – The Medical Bill Review Services Program provides an opportunity to reduce
your medical costs. The program helps to obtain the maximum savings available on every bill by processing
each bill through an extensive database of state fee schedules, usual and customary charge reviews,
diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts.
Additional savings are obtained by hospital bill auditing and out of network negotiation programs.
Network Providers - Coventry Workers Comp Services provides one of the largest national workers
compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and
Aetna networks; as well as other top regional PPO’s. The combination of these network providers offers
coverage in every jurisdiction in the country resulting in superior network savings and increased medical
provider availability. These networks are comprised of medical providers specializing in occupational medicine
and services focusing on quality of care and expedited return to work for the injured employee. Coventry
credentials each provider within the network to provide quality medical service and who is dedicated to
returning the injured employee to work.
In some states, such as California and Texas state regulations allow ‘specialty networks’ which provide you as
an employer more control over your workers compensation medical and disability costs. The physicians within
these networks are educated in evidence based treatment protocols assisting the injured employee in reaching
early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits
include reduction in over utilization of medical services and excessive treatment costs with the focus in early
return to work, thereby reducing your workers compensation indemnity payments.
One of the first steps in providing quality medical care to your injured employee is to understand how to
access network providers, and generate workplace provider panel cards or provider listings.
There are two convenient ways to locate a network provider or develop provider network listings:
1. Telephonically: Simply call Coventry at 1-800-243-2336 x 4680. Provide the Coventry representative your
employer information, the specific provider specialty you need and your geographic area (city, state and zip
code). The Coventry representative will provide verbally provide you with a list of providers meeting your
requirements or an electronic provider directory can be forward to you via e-mail.
2. Internet Access:

For the standard national workers compensation network go to www.talispoint.com/cvty/twrgrp
and select the Coventry Integrated Network to search for providers in your geographic network.
You will be able to generate provider directories as well as determine whether a specialty physician
is a member of the Network.

If you participate in the California MPN Specialty Network go to www.talispoint.com/cvty/twrgrp and
select any of the search screens. From the Networks drop down box please select First Health
Select CA MPN.

For large panel card production or if you require additional information regarding web access please
contact Tower Group Medical Management division at 312-277-1600.
Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to
help manage the care of your injured employees, including medical case management, catastrophic case
management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and
independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs.
Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the
injured employee’s medical care. These professionals ensure that your employee receives the most
appropriate and timely care. Facilitating effective communication between medical providers and claims
adjusters also provides a quicker resolution of your claims.
Tower’s dedicated team of adjusters will facilitate the integration of these products and services to assist in
reducing injured employee’s lost time and medical costs. Your Tower Group designated adjuster will be
responsible for managing all aspects of the injured employee’s claim and facilitating open lines of
communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact
your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these
programs.
Re: Important Information about your Workers’ Compensation Prescriptions
This letter is provided to inform you that your employer’s workers’ compensation, Tower Group
Companies, has selected PMSI as its workers’ compensation pharmacy partner.With PMSI, you can
choose to pick-up your medications for your work-related injury at a nearby pharmacy through a
program known as Tmesys®, or have them delivered to your home through the mail.
Within the next few weeks, you will receive a new workers’ compensation pharmacy card in the mail.
You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your
next refill or new prescription for your work-related injury.
If you do not receive your new pharmacy card within two weeks, please call Tmesys at 1.866.599.5426
and we will be happy to assist you or send another card. If you are interested in finding out about how
to receive your prescriptions through the mail, please call 1.800.304.1764.
To help you transition to the new pharmacy program, we have
provided answers to some frequently asked questions:
¿Necesitas ayuda en
español? Llame al
1.866.599.5426
Q: How do I know if my pharmacy participates with the new program?
A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the
Pharmacy Center on our website, www.pmsionline.com/pharmacy-center. Click on “Pharmacy
Locator” and select how you would like to search for a nearby pharmacy. You may also call the
helpdesk at 1.866.599.5426 to find a network pharmacy near you.
Q: How does this affect my workers’ compensation claim?
A: Using PMSI’s program for your workers’ compensation medications will enable you to continue to
receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy,
as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you
can have your prescriptions delivered to your home through our convenient mail order program.
Q: Who do I call with questions about the program?
A: PMSI has representatives available to help you with any questions that you may have about the
pharmacy program. Please call our help desk at 1.866.599.5426 to speak to a representative. If you
have any questions about your workers’ compensation claim, we will help you reach your claims
adjuster for assistance.
We look forward to serving you and meeting your workers’ compensation medication needs.
Sincerely,
PMSI
First Fill
Temporary Pharmacy Card
Making it easy to get your workers’ compensation prescriptions filled.
Employer:
Immediately upon receiving notice of injury, fill in the
information below and give it to your employee.
Injured Employee:
Questions?
Call 1.866.599.5426
1. If you need a prescription filled for a work-related injury
or illness, go to a local pharmacy that participates in the
Tmesys Pharmacy Benefit Network (PBN).
2. Give this page to the pharmacist.
3. The pharmacist will fill your prescription at no cost.
Attention Pharmacists: Call 800.964.2531 to establish First
Fill benefit eligibility and obtain the ID# for online adjudication
of approved benefits for the injured worker.
Prescription Card
CARRIER / TPA
¿Necesitas ayuda en
español? Llame al
1.866.599.5426
EMPLOYER
Tmesys is the designated PBM for this patient.
INJURED WORKER NAME
SOCIAL SECURITY NUMBER
Tmesys Pharmacy
Help Desk 800.964.2531
DATE OF INJURY
Notice to Cardholder: This card should be presented to your pharmacy to receive
medication for your work-related injury. It is only valid within 30 days of your date of injury.
For information regarding the program or to find nearby pharmacies call 866.599.5426.
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(To create a card for your wallet, cut along outer line and fold in half.)
Pharmacist:
1. Call the Tmesys Pharmacy Help Desk at 800.964.2531.
2. Provide the information listed above.
3. The Help Desk will provide an ID number for adjudication.
Finding a Network Pharmacy
Use one of these easy methods to find a network pharmacy:
■ Visit your local Walgreens or Rite Aid Pharmacy
■ Call us: 866.599.5426
■ Use our pharmacy locator online: www.tmesys.com.
© 2011 PMSI, Inc. All rights reserved. C1257-1011-02-DOCCA
.
.
Optional Provider Logo
Size .563” x 1.251”
Optional Employer Logo
Size .563” x 1.251”
First Fill Temporary Pharmacy Card
Temporary Pharmacy Card
Making
it easy Relleno
to get your workers’
filled.
En Primer
Tarjetacompensation
Temporalprescriptions
de Farmacia
Hacerlo fácil de llenar sus recetas de la compensación del trabajador.
Employer:
Immediately upon receiving notice of injury, fill in the
Employer:
information
below
and
give it tonotice
your employee.
Immediately
upon
receiving
of injury, fill in the information below
and give it to your employee.
Empleado Lesionado:
1. Si
usted necesita una receta para un accidente de trabajo
Injured
Employee:
¿Preguntas? Llame al
o
enfermedad
ocupacional,
ir
a
una
farmacia
que
participa
1. If you need a prescription filled for a work-related injury or illness, 1.866.599.5426
go to a local
enpharmacy
la red de beneficio
de farmacia
Tmesys
(PBN). Benefit Network (PBN).
that participates
in thede
Tmesys
Pharmacy
2. 2.Dar
estathis
página
Need help in English?
Give
pagealtofarmacéutico.
the pharmacist.
3. 3.El The
farmacéutico
surtir
sin costo alguno.
Call 1.866.599.5426
pharmacist
will su
fill receta
your prescription
at no cost.
Provider Logo
Size: .394“ x .875”
Employer Logo
Size: .394“ x .875”
Remove if not using
Prescription Card
CARRIER / TPA
PORTADORA
EMPLOYER
EMPLEADOR
Carrier
Employer
INJURED WORKER
NOMBRE
DEL TRABAJADOR
NAME
LESIONADO
SOCIAL SECURITY
NUMERO
DE SEGURO
NUMBER
SOCIAL
Attention PharmaPharmacists: Call 800.964.2531 to establish First
cists:
Call eligibility
800.964.2531
to establish
First
Fill benefit
eligibility
Fill benefit
and obtain
the ID# for
online
adjudication
and
of approved
obtain the
benefits
ID# forfor
online
the injured
adjudication
worker.
of approved benefits for the injured worker.
Tmesys Pharmacy
Help Desk 800.964.2531
DATE OF
FECHA
DEINJURY
LA LESIÓN
Aviso a to
losCardholder:
titular de la tarjeta:
tarjeta
ser presentada
a su farmacia
para recibir
Notice
This cardEsta
should
bedebe
presented
to your pharmacy
to receive
medicamentofor
para
tratar
su lesión relacionada
el valid
trabajo.Sólo
es válido
dentro
los of
30injury.
días de
medication
your
work-related
injury. It iscon
only
within 30
days of
yourde
date
su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias
For information regarding the program or to find nearby pharmacies call 866.599.5426.
cercanas llame 866.599.5426.
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(Para crear una tarjeta
para su
billetera,
lo largo
dealong
la linea
exterior
doblar
porinlahalf.)
mitad.)
(To create
a card
for corte
your awallet,
cut
outer
liney and
fold
Pharmacist:
Pharmacist:
1. Call the Tmesys Pharmacy Help Desk at 800.964.2531.
1. 2.Call
the Tmesys
Pharmacylisted
Helpabove.
Desk at 800.964.2531.
Provide
the information
2. 3.Provide
the information
listed an
above.
The Help
Desk will provide
ID number for adjudication.
3. The Help Desk will provide an ID number for adjudication.
Encontrar una farmacia de la red
Finding
Network
Pharmacy
Utiliceauno
de estos
métodos fáciles para encontrar una farmacia de la red:
Use one of these easy methods to find a network pharmacy:
■ Visite a su local de Walgreens y Rite Aid Pharmacy
■ Visit your local Walgreens or Rite Aid Pharmacy
■ Nos llame al: 866.599.5426
■ Call us: 866.599.5426
■ Utilice nuestro localizador de farmacias en linea:
■ www.pmsionline.com/pharmacy-center.
Use our pharmacy locator online: www.pmsionline.com/pharmacy-center.
© 2011 PMSI, Inc. All rights reserved. C1257-0511-01-DOCCA
© 2011 PMSI, Inc. Todos los derechos reservados. C1257-1011-03-DOCCA .
.
.
.
Workers’ Compensation Notification
Pharmacy Benefit Network
Your employer and your workers’ compensation claims administrator
have selected PMSI as their workers’ compensation pharmacy
benefit network (PBN) or “plan”, to provide medications for your workrelated injury through PMSI’s pharmacy network, Tmesys.
This plan provides that drugs (and other services)
prescribed for treating your work injury can be
obtained only from companies or providers
specified in your plan.
If you have any questions about how to obtain
prescribed medications, call 866.599.5426.
Plan Limitations
■
You must present your
workers’ compensation
pharmacy card to a
participating plan/network
pharmacy in order to receive
medications.
■
Only medications used to treat
your work-related injury are
covered.
■
Some medications may not be
on the authorized list, in which
case the pharmacy will contact
PMSI to try to obtain approval
while you are at the pharmacy.
■
■
If a pharmacy that is part of the
participating plan network
charges you for medications,
you are not subject to plan
limitations.
Your prescribed medication
may be subject to Utilization
Review at the request of your
claims administrator.
LOCATING A
PLAN PHARMACY
More than 5,000 Locations in CA
Go to PMSI’s website at
www.pmsionline.com
Click on Pharmacy Center
Click on Pharmacy Locator
Select the search method
you prefer
Call 866.599.5426 to speak
to a customer care specialist
How to Obtain Medicines
1. Your employer will provide you
information and notification on the
plan and how to obtain medications
upon implementation or when you
were hired.
2. Upon receiving a notice of first injury,
your employer will provide you with
additional notification of plan
requirements and a Tmesys First Fill
Card.
3. Give the card to the pharmacist at a
participating plan/network pharmacy
with your prescription.
4.The pharmacist will fill your
prescription. You should not receive a
bill for these medications.
5. A permanent workers’ compensation
pharmacy card will be mailed to you.
6. Use the permanent card each time
you have a prescription filled for your
work-related injury.
We look forward to serving you. If you have any questions about
how to obtain prescribed medications, call 866.599.5426 or visit
our Pharmacy Center on www.pmsionline.com.
© 2011 PMSI, Inc. All rights reserved. C1252A-1011-04
PLAN LIMITATIONS
■ You must present your workers’ compensation
pharmacy card to a participating plan/network
pharmacy in order to receive medications.
Workers’ Compensation
Notification
Pharmacy Benefit
Network
Your employer and your workers’
compensation claims administrator
have selected PMSI as their workers’
compensation pharmacy benefit network
(PBN) or “plan”, to provide medications for
your work-related injury through PMSI’s
pharmacy network, Tmesys.
This plan provides that drugs
(and other services) prescribed for
treating your work injury can be
obtained only from companies or
providers specified in your plan.
If you have any questions about how
to obtain prescribed medications, call
the following toll free number
866.599.5426.
■ Only medications used to treat your work-related
injury are covered.
■ Some medications may not be on the authorized list,
plan network charges you for medications,
you are not subject to plan limitations.
■ Your prescribed medication may be subject
to Utilization Review at the request of your
claims administrator.
in which case the pharmacy will contact PMSI to try
to obtain approval while you are at the pharmacy.
HOW TO OBTAIN MEDICINES
Please read the following information carefully as it contains instructions on the required use
of a participating plan/network pharmacy to receive your medications.
New Injuries
Existing Injuries
1. Upon receiving notice of injury, your employer
will provide you with a First Fill Card to be used
at a participating plan/network pharmacy.
Medications for your work-related injury
will continue to be provided (subject to
limitations) under the new plan/network
effective immediately.
1. You will receive a permanent workers’
compensation pharmacy card in the mail.
2. If you are receiving your work-injury related
medications from a non-plan provider, your
prescriptions must be transferred to a
plan/network pharmacy before your next fill.
Simply go to a plan/network pharmacy with
your pharmacy card and request that they
transfer your prescription(s) to their
pharmacy.
3. If you are already using a plan/network
pharmacy, take this card in the next time
you need a re-fill or have a new prescription
related to your work injury.
4. The card will identify you to the pharmacist
for our workers’ compensation program.
5. The pharmacist will fill your prescription.
By using a participating plan/network
pharmacy, you should not receive a bill
for your medications.
2. Give the card to the pharmacist with your
prescription.
3. The pharmacist will fill your prescription.
By using a participating plan/network pharmacy,
you should not receive a bill for your medications.
4. A permanent workers’ compensation pharmacy
card will be mailed to you.
5. Use the permanent card each time you have a
prescription filled for your work-related injury.
LOCATING A PLAN PHARMACY
More Than 5,000 Locations In CA
 Go to PMSI’s website at
www.pmsionline.com
 Click on Pharmacy Center
 Click on Pharmacy Locator
 Choose your preferred search
method and follow the instructions
We look forward to
serving you. If you have
any questions about
how to obtain prescribed
medications, call
 Call 866.599.5426 to speak to a
customer care specialist
866.599.5426.
© 2011 PMSI, Inc. All rights reserved. C1253A-1011-02
■ If a pharmacy that is part of the participating
PLAN DE LIMITACIONES
■ Usted debe esentar su tarjeta de trabajadores
Notificación de
Compensación de
Beneficios de Farmacia
de redes
Su empleador y sus trabajadores
administrador de reclamaciones de
indemnización ha seleccionado PMSI
como de sus trabajadores de la red de
compensación de beneficios de farmacia
(PBN) o ”plan“, para proporcionar
medicamentos para su lesión relacionada
con el trabajo a través de la red de
farmacias PMSI, Tmesys.
Este plan prevé que las drogas
(y otros servicios) prescrita para el
tratamiento de su lesión en el
trabajo sólo se puede obtener de las
empresas y proveedores de
servicios especificados en su plan.
Si usted tiene alguna pregunta
acerca de cómo obtener los
medicamentos recetados, llame al
siguiente número sin cargo
866.599.5426.
de farmacia una indemnización a un plan de
participantes / farmacia de la red para recibir los
medicamentos.
■ Sólo los medicamentos utilizados para tratar su
lesión relacionada con el trabajo están cubiertos.
■ Algunos medicamentos pueden no estar en la lista
autorizada, en cuyo caso lafarmacia se pondrá en
contacto PMSI para tratar de obtener la
■ Si una farmacia que es parte de la red del
plan participantes que los gastos de
medicamentos, no están sujetos a las
limitaciones del plan.
■ Su medicación prescrita puede ser objeto
de revisión de la utilización, a petición de su
administrador de reclamaciones.
CÓMO OBTENER MEDICAMENTOS
Por favor, lea atentamente la siguiente información, ya que contiene instrucciones sobre el uso
requerido de un plan de participación farmacia de la red / a recibir sus medicamentos.
Nueva Lesiones
Las lesiones existentes
1. Al recibir aviso de la lesión, su empleador le
proporcionará una tarjeta de Primero de relleno
a utilizar en un plan de participantes / farmacia
de la red.
Los medicamentos para su lesión relacionada
con el trabajo seguirá siendo siempre (sujeto a
limitaciones) en el marco del nuevo plan o la red
con efecto inmediato.
2. Darle la tarjeta a la farmacia con su receta.
1. Usted recibirá una tarjeta permanentes de
trabajadores de farmacia de compensación
en el correo.
3. El farmacéutico se surtir su receta. Mediante el
uso de un plan de participantes / farmacia de la
red, usted no debe recibir una factura por sus
medicamentos.
4. Tarjeta permanentes de trabajadores de farmacia
será enviado por el correo. `
5. Usa la tarjeta permanente cada vez que tenga
una receta médica para su lesión relacionada con
el trabajo.
LOCALIZACIÓN DE UN PLAN DE FARMACIA
Más de 5,000 hoteles en CA
 Lr a la página web de PMSI en
www.pmsionline.com
 Haga clic en “Pharmacy Center”
 Haga clic en “Pharmacy Locator”
 Elija una opción de búsqueda
 Llame al 866.599.5426 para hablar con
un especialista en atención al cliente
aprobación, mientras usted está en la
farmacia.
Esperamos poder
servirle. Si usted tiene
alguna pregunta acerca
de cómo obtener los
medicamentos
recetados, llame al
866.599.5426.
2. Si usted está recibiendo sus medicamentos
de lesiones relacionadas con el trabajo de
un proveedor fuera del plan, sus recetas
deben ser transferidos a un plan / farmacia
de la red antes de su llenado siguiente. Sólo
tienes que ir a una farmacia plan de red o
con su tarjeta de la farmacia y pedir que la
transferencia de su receta (s) a la farmacia.
3. Si usted está utilizando ya un plan / farmacia
de la red, tener esta tarjeta en la próxima
vez que necesite un nuevo relleno o
presentar una nueva receta relacionada con
su lesión de trabajo.
4. El tarjeta le identifica con el farmacéutico de
nuestro programa de compensación de
trabajadores.
5. El farmacéutico se surtir su receta. Mediante
el uso de un plan de participantes farmacia
de la red, usted no debe recibir una factura
por sus medicamentos.
Dear P
olicyholder, Thank you for choosing Tower Group Companies for your Workers Compensation coverage. We are committed to ensuring your injured worker receives quality health and medical care. Our mission is to provide you outstanding claim service while lowering costs and helping employees return to work faster. One of the ways we aim to keep your claim costs low is through the utilization of the California Medical Provider Network (CA MPN). By electing to participate and properly implementing a MPN program you will enjoy the benefits of quality medical care for your injured employees at favorable costs. What is an MPN? In April 2004, in response to California’s widely-‐acknowledged workers compensation costs, the California Legislature passed Senate Bill 899. This bill included several provisions designated to control workers compensation costs. Among the provisions Labor Code 4616 providing for the implementation of medical provider networks, or MPNs. A Medical Provider Network – or MPN – is an entity or group of health care providers set up by an insurer or self-‐insured employer and approved by Division of Workers Compensation’s (DWC) Administrative Director to treat workers injured on the job. Participating in the MPN provides employers numerous advantages: Lifetime medical control. Your employees must treat within the network for the life of the claim, unless an employee pre-‐designates his/her primary treating physician. If an employer chooses not to participate in the MPN, the employer only has 30-‐day medical control. Employees can then seek medical treatment by a provider of their choice. Medical cost savings. The MPN provides contracted control of medical fees and expectations for medical treatment outcomes. The contracted fees are lower than the State’s Official Medical Fee Schedule. Implementing the MPN, you will experience an increase in network usage and a reduction in overall medical payout. California medical network contracts on average reduce medical claim payout by 9.5%. Quality medical providers. Tower Group uses Coventry Workers Compensation Services as our medical network partner. Coventry has an extensive credentialing process, which helps to ensure quality medical providers. Not every physician is accepted in the MPN. Furthermore, with an MPN in place, there is improved provider accountability through the network’s quality assurance and provider relations departments. All complaints are tracked and monitored for severity and frequency. Appropriate treatment. If the employer has an MPN in place, employees who pre-‐designate their primary treating physician can only pre-‐designate their personal medical doctor (MD) or doctor of osteopath (DO). If the employer does not implement the MPN, employees can also pre-‐designate their personal chiropractor or acupuncturist. To enjoy the full benefits of utilizing a MPN, complete the enclosed Employer MPN Acknowledgement and return for processing. Once received, an implementation packet will be sent to you. For additional questions and/or educational materials, call (877) 782-‐3291 to speak to the MPN Liaison. Thank you again for choosing Tower Group! Employer Only
Form1
Employer California Workers Compensation Medical Provider Network (MPN) Acknowledgment Form I acknowledge that participation in a California workers compensation MPN is voluntary and the choice of the employer. ________________________________ Company Name I have received and reviewed information from Tower Group Companies regarding their workers compensation Medical Provider Network. ____ I elect to participate in the California workers compensation MPN offered by Tower Group Companies. ____ I decline to participate in the California workers compensation MPN offered by Tower Group Companies. ________________________________ _______________________________ Signature Employer ________________________________ _______________________________ Printed Name Date Note to Employer: Make your MPN choice and return form via fax to the attention of the CA MPN Liaison: Via Fax: (312) 896-‐9408 Via Mail: Tower Group Companies P.O. Box 06110 Chicago, IL 60606-‐6110
F
UD
COMMIT WORKERS' COMP FRAUD AND YOU'LL
HAVE A LOT OF TIME ON YOUR HANDS
Workers' compensation fraud is
The law also applies to other
now illegal in Calilornia. I\S or
participants in the workers'
January I, 1994 Wiy person who
compensation systems:
files or contributes to the Ii ling ol a
1~11se workers' coinp claim is C011-
mitting a crime punishable by a
prison sentence and/m a pClwlty
fine.
.Attorneys
If an atlolley knowingly makes
fraudulent statements I()r the pur-
pose of obtaining workers' coinp
benclíts ('or his or her client, he or
"'hat is a fraudulent claim'?
I Jere arc some examples of activities for which you can be prosecutcd:
she is guilty ola felony. II'an ältur-'
ney who Ilegotiatcs workers' comp :
claims oilers comliissioliS to aiiy
person tòr the refcrral or solicitation of c1lcnts, he or she can ¡¡ice
.Filng a claim for a non-existing
injury
If you file a claim for an injury
or illness that docs nol exisL you arc
~iiilty of workers' compensation
IhlUd.
suspension or disbarment ,1Id a
prison term.
.Doctors
II' a doctor knowingly prepares .
f~lIse wri Uen reports in ordcr to ob- i
.Filng a claim for a noii-work re-
lain payments, hc or she can losc i
lated in.jury
Iii~ or her iiedieal liceiise. It is a
I l you are injured orr the job, but
pretend it happened at work so you
can collecl workcrs' comp benc1ïts,
crime to assist or conspirc with any
person who cngages in fraudulciit
activity.
you are committing a felony.
Fraud hamis employcrs by contrib-
.Aiding a co-wol'(cr in liing a
false claim
If you make a lalse statemcnt to
support a Icllow employee's claim
for benefits, 1'011 arc parlicipatiiig in
uting to the increasingly high cost
or inslInlicc aiid harms employees
hy undermining the legi1imacy of
all workers' compensation claims
Do your part 10 halt lì'aiid today!
a crime.
"Any person wlto knowingly prcscnls a Iiilse ur Ji.audiilcni claim for tlte payiiieiil of
a loss is guilty of a el'I1IlC, and iiiay be siibiect to imprisoiiment iii the stale prison
for lip 10 5 years, or hy (I line up 10 0; 150,()(¡O, or both."
l~D'IHajit;., ('nilt. _~~Ù'L'.(i(J:. 1871-~
F
UDE
4&
COMETA A TRABAJADORES' FRAUDE DE COMP V USTED
TENDRAN MUCHO TIEMPO EN LAS MANOS
EI lraudc de la conipensaciúii de tra- I,a Icy tanihicii apliea a otros partieibajadorcs cs ahora iJegal en CaliJ()r- pantes en sistemas de la eompen- !
nia. AI ci I de enero de 19l)4 cualljuier saciòn de Ius trahajadorcs:
persona que arcliiva u contribuye al
expedientc dc reclaino del eollp de un
Los ahogados
trabajadorcs ralsu coiiete un cr¡mel) Si un ;ibogal!o haec astutaincnlc dcpunible pOl' una coiidcna yin una pen,)
elaraeioiics ,'raudulcl1tas para cl
multa.
propúsito de oblêner heiiefieios dcl
COl1p de trabajadorcs para su dicntc,
I
¿Que
cs un rcclaino fraudulcnto'? cl 0 ella SOil eulpahlcs de Uii eriiieii
i\quí cstan algunos ejeniplos de ac- gi'ave. Si un ahogado qm: negocia las
tividades para quc usted puedc scr c"misiones de of
crt
as de rcclaiios del
proeesado: comp de trahajadores a clialquier perSOIW para ia rcfcrcncia 0 la soliei-
EI cxpcdicntc ull rcclamo para una taciòn de elientcs, cl 0 ella piieden enhcrida dc no-cxistiendo Si usted (l- ear;ir suspeiisiòii (l expulsiòii de f()ro
chi va un reclainu para una hcrida 0 la y uiia estancia carce!aria
enfcrmedad que no existcn, ustcd es
culpable de fhtudc de 1;1 coinpen-
sación de trabajadorcs.
Los medicos
Si L11l iiicdico prcpara astLltaiielite rc-
portes cseritos talsos para obteiicr pa-
EI cxpcdicntc qii(' un rcclaino para gos, cl 0 ella piieden pcrdcr SLi licenun no-traba.jo rclacionó hcrida Si cia nicdica. Es ull crimen de ayiidar 0
usted cs hcrido del trahnjo, peru 10 coiispirar COil ciiaiquier persona que
tïngc sLicediú en el trabajo tan Listed entra en la acti\ ¡dad I¡'audulenta.
puede reunir bcnetieios del camp de
trahajadores, Listed euinete un
EI ii'aude dana a empleadorcs con-
Cllllen grave.
tribiiycndo al costo cada vez mús alto
. de seguro l' daña a emplcados so-
~~uda.. a un colcga ci~ la c1,~slfica- cavando la legitiiiidad de rcc1anios
cion de un l'ed~l,nio, talso Si usted de la eompel1saeiól1 de todos traba-
haec una deelaraeion lalsa para ai.)~~yar jadorcs. i Poiign de su partc para pnrar
ei rcclamo de lUi cmplcaclo pro.ll1l0 ihiude hoy!
para bctlcficios, lIstcd toiia parte
en un crimen
"( 'ua!quicr pcrsiiiia que pli:sciila astiilaiiieiite ull rcclaiiiii lalso 0 lrauclukiito para cl
p:igo de una perdida cs culpahle dc ull criinen, y pucde Sl.r susceptihle al eiicarcclainicnlo eii la prisiúu csialalliasla 5 alioq, 0 poi una imilta basla ~ i 5(),OOO, 0 aiibos",
i u ,)'(.('i'iúii dt' C',.Jdlgo di~ St'í~Ul() /871-2
i
California Workers Compensation Benefits for Injured Workers
As an employee, you may be entitled to workers compensation benefits if you are injured and/or become ill
because of your job. Workers compensation covers most work-related injuries and illnesses. An injury or illness
can be caused by a specific work-related event such as a slip or fall, or by continuous or repeated exposure such
as a wrist injury from continuous typing. This brochure explains your rights and potential benefits under the
California’s Workers Compensation system.
 Workers Compensation Defined
o What is an injury?
As an employee, if you get hurt on the job your employer is required by law to provide you with
workers compensation benefits. An injury can take various forms, the most common being a
specific physical injury.
Examples of an injury include (but are not limited to):
 hurting your back as a result of a fall
 being burned by a fire while working at your job
 cutting your hand while opening a box
 being injured in a car accident while driving for your employer.
o Who is covered by workers compensation?
Any person who meets the definition of an employee, working for an employer at the time of
injury, is covered by workers compensation.
o What types of injuries are covered by workers compensation?
According to California Labor Code section 3208, an injury includes any injury or disease
arising out of employment. This also includes injuries to artificial members, dentures, hearing
aids, eyeglasses, and medical braces of all types.
 Employee reporting obligations-How, to whom, and when?
o How to report injuries
You can report injuries to your employer in the following ways:
 orally, directly to your employer
 over the phone
 via mail
 through the Internet.
1
No matter how you report your injury to your employer, you must do so as soon as you are
aware of the injury! Your employer will need to provide you a State of California Claim
Form (DWC-1) within one business day. It is your responsibility to fill out the top portion of
the DWC-1 and give it back to your employer immediately! Any delay in completing or
submitting the claim form may delay the payment of benefits. If you need a claims form you
may also call your claims administrator, Tower Group Companies, at 888-856-5522.
o To whom should I report my injury?
You can report injuries to any person of authority who is a representative of your employer. This
could include (but is not limited to):
 a human resource representative
 the owner of the business
 your direct supervisors or manager
 a company nurse
 a representative of your employer in their Safety or Risk Management department.
o When should I report an injury?
You must report any and all injuries immediately once you know an injury has occurred. Not
reporting an injury immediately may delay the payment of certain benefits to you.
 What do Workers Compensation benefits include?
o Medical care
This includes doctor visits, chiropractic sessions, physical therapy, lab and diagnostic tests (such
as MRIs, X-rays and CT scans), over-the-counter and prescription medications, pain
management and occupational therapy. Please note that there are limitations on care for some
services; such as caps on the amount of occupational therapy, physical, therapy, and chiropractic
visits.
Reimbursement for medical treatments is subject to review according to approved utilization
review criteria; medical bills are checked for treatment need and relatedness to the workers
compensation injury.
You should never see a bill from any medical provider for your work-related injury. In most
cases medical providers send the bill directly to Tower Group Companies. If you receive a bill,
please submit it to Tower Group Companies or your employer immediately.
o Disability Benefits

Temporary Disability (TD):
2
Temporary Disability Benefits pay you for a portion of your lost wages while you are
recovering from your injury. Most injuries have a two year cap on Temporary Disability
Benefit payments that occurs within five years of the date of injury. In addition, the State
of California has a minimum threshold and a maximum cap on the amount of temporary
disability you receive. Normally, the rate you are paid will equal two thirds (2/3) of your
average weekly wage, subject to these minimum and maximum amounts, as dictated by
the State of California.

Permanent Disability (PD):
You may receive Permanent Disability (PD) payments if you have lasting permanent
disability that affects your future ability to compete in the open labor market and affects
your activities of daily living as defined by your physician and the AMA Guides 5th
edition.
PD payments are also subject to maximum and minimum rates, with overall value
defined by the State of California. Your physician will assign you a base value known as
a Whole Person Impairment (WPI). For dates of injury prior to 01/01/2013, the WPI will
be adjusted for your Future Earnings Capacity (FEC), occupation and age at the time of
injury. This will determine the final PD rating. Your Claims Examiner will rate the
medical report from your physician to determine a Permanent Disability amount. All final
settlements of Permanent Disability are reviewed and approved by the State of California
Workers Compensation Appeals Board (WCAB).

Death Benefits:
If the work-related injury/illness causes death, your qualified dependents may receive
death benefits based on two thirds (2/3) of your average weekly wage. They are subject
to state minimum and maximum amounts in effect on the date of injury and death.
There is also a burial allowance that is payable if the death is work-related.
o Supplemental Job Displacement Benefits
If your injury occurred after January 1, 2004, you may be eligible for a supplemental job
displacement voucher if your employer cannot take you back to regular or modified employment.
The amount of the supplemental job displacement voucher may be up to $ 6,000.
o Other benefits
State Disability/ Economic Development Department (EDD)
You may be eligible for certain benefits from the State of California. In most cases, however,
you may not collect both workers compensation and EDD benefits at the same time. EDD
benefits may be obtained if there is a timely request made by you when Temporary Disability
benefits are terminated, delayed, or denied.
3
 Medical care services include the following:
o First Aid Treatment
These types of injuries are minor in nature, such as small scratches, cuts, minor burns, splinters,
or other minor industrial injuries. These injuries can be treated by anyone (such as the employer,
an on-site nurse, a physician’s nurse or assistant, or a physician). These injuries do not result in
any lost time and/or permanent disability, and require only a single treatment.
o Emergency Care
This is usually provided in a hospital and/or emergency setting for serious or life-threatening
injuries.
o Ongoing treatment and medical bills
All reasonable and necessary medical bills related to your workers compensation injury are
covered and paid, following bill and/or utilization review.
o Medical Provider Network (MPN)
A Medical Provider Network (MPN) is a selected network of healthcare providers that treats
workers injured on the job. See your employer for more information on your selected MPN.
MPN physicians may include the following:

Pre-Designated Physicians
These need to be selected by you prior to an injury. Your employer can give you forms to
preselect a physician or chiropractor who will render treatment in the case of a workrelated injury. Please note, however, that your physician must agree to all reporting,
billing and treatment guidelines as required by the State of California labor rules and
regulations. Please complete the attached form to pre-designate your treating physician.

Emergency Treatment
This includes emergency rooms, hospitals and paramedic service.

Primary Treating Physician
This is the physician who is primarily responsible for your medical care and reporting to
your claims administrator. The treating physician can refer you to other medical
specialists as needed for your particular injury.

Specialists
4
Your initial MPN physician can recommend a Medical Specialist. Specialists are
available through the MPN 2nd and 3rd opinion process. Your employer has additional
information on how the MPN works, to provide to you.
 What to do if you sustain an injury?
o Report your injury immediately
Report the injury immediately to your supervisor, employer’s representative, human resource
personnel, company owner, person of authority, and/or your immediate supervisor. You may
also report your injury to representatives of your employer in their Safety or Risk Management
department. Do not wait to report your injury. If you wait too long, your benefits may be
delayed, or you may lose your right to benefits. Your employer must provide you a claim form
(called a DWC-1 form) within one working day after learning about your injury. Your employer
must also authorize up to $10,000 in medical treatment, within one working day after you report
your injury.
You can also receive help regarding your claim from an Information & Assistance (I&A) Officer
at the DWC Information and Assistance (I&A) Unit. The I&A Unit provides information and
assistance to injured employees, employers, labor unions, insurance carriers, physicians,
attorneys and other interested parties; concerning rights, benefits and obligations under
California's workers' compensation laws. The unit can assist you in obtaining medical and
disability benefits by communicating with your employer and/or employer’s insurance carrier or
claim administrator. Additionally, if you do not have an attorney, the unit will review any
recommended claim settlement that comes before the WCAB. We have provided a list of
Information and Assistance offices at the end of this document to help you find the Information
and Assistance office nearest you.
o Obtain medical care immediately
If you need first aid treatment such as a Band-Aid or aspirin, contact your employer’s
representative, human resource personnel and/or your immediate supervisor. If you need
emergency care of any kind, call 911 and immediately let someone at your employer know that
you need help.
o See your MPN Primary Treating Physician
Your primary treating physician is the doctor with overall responsibility for treating your injury
or illness, and for reporting your progress to your claims administrator. He or she is responsible
for maintaining the continuity of your care and making referrals to specialists. If your employer
has an approved Medical Provider Network (MPN) in place, he or she may be able to limit your
choices of treating physicians, and require you to accept care from an MPN physician from the
onset.
5
If your employer has an MPN, you can use any applicable physician within the MPN network. If
you do not select a physician within the MPN, your employer has the right to select the physician
who will treat you for the first 30 days. If your employer does not have an approved MPN and
you wish to change doctors in the first 30 days after reporting your claim, your claims
administrator must select a new physician within five days of your request.
If you have provided your employer with the name of your personal physician before your
injury, you may see him or her for treatment even if your employer has an approved MPN. Your
personal physician must be a general practitioner or a board-eligible internist, pediatrician,
obstetrician-gynecologist, family practitioner, or multi-specialty medical group of doctors of
medicine or osteopathy. They must have treated you and maintained your medical history and
records before your work injury, and must also agree to treat you for a work-related injury or
illness. If your employer does not have an approved MPN and you gave your employer the name
of your personal chiropractor or acupuncturist in writing before you were injured, you may
switch to the chiropractor or acupuncturist upon request. If you still need medical care after 30
days, you may be able to switch to a doctor of your own choice.
 Who is my Claims Administrator?
The Claims Administrator is responsible for handling all aspects of your claim. A Claims Examiner will
be assigned to your case who will explain all your benefits and rights under California’s Workers
compensation system. Your Claims Administrator is Tower Group Companies. You may direct all
correspondence to the following address:
P.O Box 17059
Irvine, Ca. 92623
Phone 888-856-5522
 Discrimination
It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim,
or for testifying in another person's workers compensation case. Under California’s Labor Code Section
132A, you have protection against any manner of discrimination due to having filed a workers’
compensation claim. Protections provided by Section 132a include protections against unlawful
discharge, or threats of discharge. You may also have additional rights under the Americans with
Disabilities Act (ADA) or the Fair Employment and Housing Act (FEHA).
For additional information, contact FEHA at 800-884-1684 or the Equal Employment Opportunity
Commission (EEOC) at 800-669-3362. You can obtain free information from a state Division of
Workers Compensation Information & Assistance Officer. You can hear recorded information and a list
of local offices by calling toll-free 800-736-7401, or learn more online at: http://www.dir.ca.gov.
6
You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact
your claims administrator first to see if it can be resolved.
You can obtain free information from an Information and Assistance Officer of the State Division of
Workers Compensation, or you can hear recorded information and a list of local offices by calling 1800-736-7401. We have provided a list of Information and Assistance offices at the end of this
document to help you find the Information and Assistance office nearest you. You may also go to the
DWC web site at: http://www.dir.ca.gov for further information.
You may also consult with an attorney of your choice. Most workers compensation attorneys will offer
you one free consultation. If you decide to hire an attorney, his or her fee may be taken out of some of
your benefits if any are to be paid. For names of workers compensation attorneys, you may call the State
Bar of California at 415-538-2120 or 1-866-442-2529. You may also visit the State Bar of California
website at http://www.calbar.ca.gov.
Any person who makes, or causes to be made, any knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or denying workers compensation benefits or
payments, is guilty of a felony.
7
Beneficios de Compensación del Trabajador de California para Trabajadores
Lesionados
Como empleado, usted puede tener derecho a beneficios de compensación del trabajador si se lesiona y/o se
enferma a causa de su trabajo. La compensación del trabajador cubre la mayoría de accidentes y enfermedades
ocupacionales. Una lesión o enfermedad puede ser causada por un evento específico relacionado con el trabajo
como un resbalón o una caída, o por la exposición continua o repetida, como una lesión en la muñeca por
escribir continuamente en teclado. Este folleto explica sus derechos y beneficios potenciales de acuerdo con el
sistema de compensación del trabajador de California.
 Definición de Compensación del trabajador
o ¿Qué es una lesión?
Como empleado, si usted se lesiona en el trabajo, su empleador está obligado por ley a
proporcionarle beneficios de compensación del trabajador. Una lesión puede adoptar diversas
formas, y la más común es una lesión física específica.
Ejemplos de una lesión incluyen (entre otros):
 lastimarse la espalda como consecuencia de una caída
 resultar quemado por un incendio mientras trabajaba en su trabajo
 cortarse la mano al abrir una caja
 resultar herido en un accidente automovilístico mientras conduce hacia la sede de su
empleador.
o ¿Quién tiene cobertura de la compensación del trabajador?
Cualquier persona que cumpla con la definición de un empleado, que trabaja para un empleador
en el momento de la lesión, tiene cobertura de la compensación del trabajador.
o ¿Qué tipos de lesiones tienen cobertura bajo la compensación del trabajador?
De acuerdo con la sección 3208 del Código Laboral de California, una lesión incluye cualquier
lesión o enfermedad que surja del empleo. Esto también incluye las lesiones de los miembros
artificiales, dentaduras postizas, ayudas auditivas, anteojos y apoyos médicos de todo tipo.
 Obligaciones de informes de los empleados – ¿Cómo, a quién y cuándo?
o Cómo informar lesiones.
Usted puede informar las lesiones a su empleador de la siguiente manera:
 verbalmente, directamente a su empleador
 por teléfono
1


por correo postal
a través de Internet.
No importa cómo usted informa su lesión a su empleador, ¡usted debe hacerlo apenas usted
se entera de la lesión! Su empleador tendrá que entregarle un Formulario de Reclamación del
Estado de California (DWC-1) en un periodo no mayor de un día laborable. Es su
responsabilidad completar la parte superior del formulario DWC-1 y ¡devolverlo a su
empleador inmediatamente! Cualquier retraso en completar o entregar el formulario de
reclamación puede retrasar el pago de beneficios. Si usted necesita un formulario de
reclamación, también puede llamar al administrador de reclamaciones, Tower Group
Companies, al 888-856-5522.
o ¿A quién debo informar mi lesión?
Usted puede informar las lesiones a cualquier persona con autoridad que sea representante de su
empleador. Esto puede incluir (entre otros) a:
 un representante de recursos humanos
 el propietario de la compañía
 sus supervisores directos o gerente
 una enfermera de la empresa
 un representante de su empleador en su departamento de Seguridad o Gestión de Riesgos.
o ¿Cuándo debo informar una lesión?
Usted debe informar todas las lesiones inmediatamente una vez que conozca que se ha
producido una lesión. No informar una lesión inmediatamente puede retrasar el pago de ciertos
beneficios para usted.
 ¿Qué incluyen los beneficios de compensación del trabajador?
o Atención médica
Incluyen consultas médicas, sesiones de quiropráctica, terapia física, exámenes de laboratorio y
pruebas de diagnóstico (por ejemplo resonancias magnéticas, radiografías y tomografías
computarizadas), más medicamentos de venta libre y en venta con receta médica, manejo del
dolor y terapia ocupacional. Tenga en cuenta que existen limitaciones en la atención de algunos
servicios; por ejemplo límites sobre la cantidad de terapia ocupacional, terapia física, y visitas al
quiropráctico.
El reembolso de los tratamientos médicos está sujeto a revisión de acuerdo con los criterios de
revisión de utilización aprobados; se revisa la necesidad de tratamiento de las facturas médicas y
su relación con la lesión que recibe beneficios de compensación del trabajador.
Usted nunca debe tener una factura de cualquier proveedor de atención médica para su lesión
ocupacional. En la mayoría de los casos, los proveedores médicos envían la factura directamente
2
a Tower Group Companies. Si usted recibe una factura, por favor envíela a Tower Group
Companies o a su empleador inmediatamente.
o Beneficios por discapacidad

Discapacidad Temporal (TD, por sus siglas en inglés):
Los Beneficios por Discapacidad Temporal le pagan una parte de su salario perdido
mientras usted se está recuperando de su lesión. La mayoría de las lesiones tienen un
límite máximo de dos años en los pagos de Beneficios por Discapacidad Temporal que
ocurren en un periodo de cinco años luego de la fecha de la lesión. Además, el Estado de
California tiene un umbral mínimo y un tope máximo del monto por discapacidad
temporal que usted recibe. Normalmente, la tarifa que se paga será igual a dos tercios
(2/3) de su salario semanal promedio, sujeto a los importes mínimos y máximos, según lo
establecido por el Estado de California.

Discapacidad Permanente (PD, por sus siglas en inglés):
Usted puede recibir pagos por Discapacidad Permanente (PD) si usted tiene una
discapacidad permanente prolongada que afecta su capacidad futura para competir en el
mercado laboral y afecta sus actividades cotidianas según lo definido por su médico y las
Guías AMA 5ª edición.
Los pagos por Discapacidad Permanente también están sujetos a las tasas máximas y
mínimas, con un valor global definido por el Estado de California. Su médico le asigna
un valor base que se conoce como un Impedimento del Cuerpo Entero (WPI, por sus
siglas en inglés). En casos antes de la fecha 1 de enero del2013 El WPI se ajustará a su
Capacidad de Obtener Ingresos Futuros (FEC, por sus siglas en inglés), ocupación y edad
al momento de la lesión. Esto determinará la calificación final de Discapacidad
Permanente. Su Examinador de Reclamaciones calificará el informe de su médico para
determinar un monto de Discapacidad Permanente. Todos los convenios transaccionales
finales de Discapacidad Permanente son revisados y aprobados por la Junta de
Apelaciones de Compensación del Trabajador (WCAB, por sus siglas en inglés) del
estado de California.

Beneficios por defunción:
Si el accidente/enfermedad ocupacional causa la muerte, sus dependientes calificados
pueden recibir los beneficios por muerte sobre la base de dos tercios (2/3) de su salario
semanal promedio. Esto está sujeto a los importes mínimos y máximos del estado
vigentes en la fecha de la lesión y la muerte.
También existe una asignación para sepelio que se paga si la muerte se relaciona con el
trabajo.
o Beneficios Complementarios por Desplazamiento Laboral
3
Si su lesión ocurrió después del 1 de enero de 2004, usted puede ser elegible para un bono de
desplazamiento laboral complementario si su empleador no puede hacer que usted vuelva a su
empleo común o modificado. El monto del bono de desplazamiento laboral complementario,
puede ser hasta $6000.
o Otros beneficios
Discapacidad Estatal/Departamento de Desarrollo Económico (EDD, por sus siglas en
inglés)
Usted puede ser elegible para recibir ciertos beneficios del Estado de California. Sin embargo, en
la mayoría de los casos, usted no puede recaudar la compensación del trabajador y los beneficios
del EDD al mismo tiempo. Los beneficios de EDD se pueden obtener si hay una solicitud
oportuna hecha por usted cuando cesan, se retrasan o deniegan los beneficios de Discapacidad
Temporal.
 Los servicios de atención médica son los siguientes:
o Tratamiento de primeros auxilios
Este tipo de lesiones son leves por naturaleza, por ejemplo pequeños arañazos, cortes,
quemaduras leves, astillas, u otras lesiones industriales de menor importancia. Estas lesiones
pueden ser tratadas por cualquier persona (por ejemplo, el empleador, una enfermera de la sede,
una enfermera o asistente médico, o un médico). Estas lesiones no dan como resultado la pérdida
de tiempo y/o discapacidad permanente, y sólo requieren un tratamiento único.
o Atención de emergencia
Este tratamiento suele ser proporcionado en un hospital y/o sala de emergencia para lesiones
graves o potencialmente mortales.
o Tratamiento en curso y facturas médicas
Todas las facturas médicas razonables y necesarias relacionadas con su lesión que recibe
compensación del trabajador están cubiertas y pagadas, después de la revisión de utilización.
o Red de Proveedores Médicos (MPN, por sus siglas en inglés)
Una Red de Proveedores Médicos (MPN) es una red selecta de proveedores de atención médica
que trata a los trabajadores lesionados en el trabajo. Acuda a su empleador para obtener más
información sobre su MPN seleccionada.
Los médicos de la MPN pueden incluir a los siguientes:
4

Médicos previamente designados
Estos deben ser seleccionados por usted antes de una lesión. Su empleador le puede
entregar formularios para preseleccionar a un médico o un quiropráctico quien le prestará
tratamiento en el caso de una lesión relacionada con el trabajo. Sin embargo, tenga en
cuenta que su médico debe estar de acuerdo con todas las directrices de presentación de
informes, facturación y tratamiento según lo exigido por las normas y reglamentos
laborales del Estado de California. Por favor, complete el formulario adjunto para
designar previamente a su médico tratante.
Tratamiento de emergencia
Esto incluye las salas de emergencia, hospitales y servicios de paramédicos.

Médico tratante primario
Este es el médico que es el principal responsable de su atención médica y de informar a
su administrador de reclamaciones. El médico tratante puede derivarlo a otros médicos
especialistas, según sea necesario para su lesión en particular.

Especialistas
Su médico inicial de la MPN puede recomendar a un médico especialista. Los
especialistas están disponibles a través del proceso de 2ª y 3ª opinión de la MPN. Su
empleador tiene más información sobre cómo funciona la MPN, que usted debe recibir.
 ¿Qué hacer si usted sufre una lesión?
o Informe su lesión de inmediato
Informe la lesión inmediatamente a su supervisor, representante de su empleador, personal de
recursos humanos, propietario de la compañía, persona con autoridad, y/o su supervisor directo.
Usted también puede informar su lesión a los representantes de su empleador en su departamento
de Seguridad o Gestión de Riesgos. No pierda tiempo para informar su lesión. Si espera
demasiado tiempo, sus beneficios se pueden retrasar, o usted puede perder su derecho a recibir
beneficios. Su empleador tiene que proporcionarle un formulario de reclamaciones (denominado
formulario DWC-1) en un periodo no mayor de un día laborable después de enterarse de su
lesión. Su empleador también debe autorizar un monto máximo de $10,000 en el tratamiento
médico, dentro de un periodo de un día laborable después que usted informe su lesión.
También usted puede recibir ayuda con respecto a su reclamación de un Funcionario de
Información y Asistencia (I&A) en la Unidad de Información y Asistencia (I&A) de DWC. La
Unidad de I&A provee información y asistencia a los empleados lesionados, empleadores,
sindicatos, compañías de seguros, médicos, abogados y otras partes interesadas, sobre los
derechos, beneficios y obligaciones de acuerdo con las leyes de compensación del trabajador de
California. La unidad puede ayudarle a obtener beneficios médicos y de discapacidad por
5
comunicarse con su empleador y/o la compañía de seguros o administrador de reclamaciones de
su empleador. Además, si usted no tiene un abogado, la unidad revisará cualquier convenio
transaccional de reclamación recomendado ante la WCAB. Hemos proporcionado una lista de
las oficinas de Información y Asistencia al final de este documento para ayudarle a encontrar la
Oficina de Información y Asistencia más cercana.
o Obtenga atención médica inmediatamente
Si necesita tratamiento de primeros auxilios, por ejemplo una venda adhesiva para heridas o una
aspirina, póngase en contacto con el representante de su empleador, personal de recursos
humanos y/o su supervisor directo. Si necesita atención de emergencia de cualquier tipo, llame al
911 inmediatamente y comunique a una persona de su empleador que usted necesita ayuda.
o Consulte a su médico tratante primario de la MPN
Su médico tratante primario es el médico que tiene la responsabilidad general del tratamiento de
su lesión o enfermedad, y de informar de su avance a su administrador de reclamaciones. Dicho
médico es responsable de mantener la continuidad de su atención y hacer derivaciones a
especialistas. Si su empleador tiene una Red aprobada de Proveedores Médicos (MPN)
implementada, su empleador puede ser capaz de limitar las opciones de tratamiento médico que
usted tiene, y exigirle que acepte la atención de un médico de la MPN desde el principio.
Si su empleador tiene una MPN, usted puede utilizar a cualquier médico aplicable dentro de la
red MPN. Si usted no selecciona a un médico dentro de la MPN, su empleador tiene el derecho
de seleccionar al médico que le atenderá durante los primeros 30 días. Si su empleador no tiene
una red MPN aprobada y usted desea cambiar de médico en los primeros 30 días después de
informar su reclamación, el administrador de reclamaciones debe seleccionar a un nuevo médico
en un periodo no mayor de cinco días luego de su solicitud.
Si usted ha proporcionado a su empleador el nombre de su médico personal antes de su lesión,
usted puede verlo para recibir tratamiento, incluso si su empleador tiene una red MPN aprobada.
Su médico personal debe ser un médico de cabecera o un internista elegible por la junta, pediatra,
gineco-obstetra, médico de familia, o grupo médico de varias especialidades en medicina u
osteopatía. El médico debe haberle tratado anteriormente y conservado su historial médico y
registros antes de su lesión ocupacional, y también debe estar de acuerdo en tratarle por una
lesión o enfermedad ocupacional. Si su empleador no tiene una red MPN aprobada y usted dio a
su empleador el nombre de su quiropráctico o acupunturista personal por escrito antes de
lesionarse, puede cambiar a dicho quiropráctico o acupunturista a solicitud. Si usted todavía
necesita cuidados médicos después de 30 días, usted puede cambiar al médico de su elección.
6
 ¿Quién es mi Administrador de Reclamaciones?
El Administrador de Reclamaciones es responsable de manejar todos los aspectos de su reclamo. Un
examinador de reclamaciones será asignado a su caso y le explicará todos los beneficios y derechos en
virtud del sistema de compensación del trabajador de California. El administrador de reclamaciones es
Tower Group Companies. Usted puede dirigir correspondencia a la siguiente dirección:
P.O Box 17059
Irvine, Ca. 92623
Teléfono 888-856-5522
 Discriminación
Es ilegal que su empleador lo sancione o despida por tener una lesión o enfermedad, por presentar una
reclamación o por testificar en el caso de compensación del trabajador de otra persona. De acuerdo con
la Sección 132A del Código Laboral de California, usted tiene protección contra cualquier forma de
discriminación por haber presentado una reclamación de compensación del trabajador. Las protecciones
proporcionadas por la Sección 132a incluyen la protección contra el despido ilegal, o amenaza de
despido. Usted también puede tener derechos adicionales de acuerdo con la Ley de Estadounidenses con
Discapacidades (ADA, por sus siglas en inglés) o la Ley de Empleo y Vivienda Justos (FEHA, por sus
siglas en inglés).
Para obtener más información, comuníquese con FEHA llamando al 800-884-1684 o la Comisión de
Oportunidad Equitativa de Empleo (EEOC, por sus siglas en inglés) llamando al 800-669-3362. Usted
puede obtener información gratuita del Funcionario de Información y Asistencia de la División de
Compensación del Trabajador. Usted puede escuchar información grabada y una lista de oficinas
locales, llamando al número gratuito 800-736-7401, u obtener más información en línea en:
http://www.dir.ca.gov.
Usted tiene derecho a estar en desacuerdo con las decisiones que afecten su reclamación. Si usted tiene
un desacuerdo, comuníquese con su administrador de reclamaciones para ver si se puede resolver.
Usted puede obtener información gratuita de un Funcionario de Información y Asistencia de la
División Estatal de Compensación del Trabajador, o puede escuchar información grabada y una lista de
oficinas locales llamando al 1-800-736-7401. Hemos proporcionado una lista de las oficinas de
Información y Asistencia al final de este documento para ayudarle a encontrar la Oficina de Información
y Asistencia más cercana. También puede visitar el sitio Web de la DWC: http://www.dir.ca.gov para
más información.
También puede consultar a un abogado de su elección. La mayoría de los abogados de compensación del
trabajador le ofrecen una consulta gratuita. Si usted decide contratar a un abogado, sus honorarios se
pueden descontar de algunos de sus beneficios si se pagan dichos beneficios. Para obtener nombres de
abogados de compensación del trabajador, puede llamar al Colegio de Abogados de California al
7
415-538-2120 o 1-866-442-2529. También puede visitar el sitio Web del Colegio de Abogados de
California http://www.calbar.ca.gov.
Cualquier persona que haga, o provoque que se haga, una declaración o representación material falsa o
fraudulenta con el propósito de obtener o denegar beneficios o pagos de compensación del trabajador, es
culpable de un delito grave.
8
EMPLOYEE PRE-DESIGNATION FORM
Your employer or their insurer has chosen a Medical Provider Network (MPN) administered by Tower
Group Companies, to provide quality and timely medical care for work-related injuries and illnesses. As
a participating employee in the Medical Provider Network, you may seek emergency treatment for a
work-related injury or illness from the nearest emergency facility. For non-emergency treatment, your
employer will direct you to an occupational medicine or urgent care facility for your first appointment,
after which you have the right to choose an MPN physician to provide your care. Your personal
physician may already be an MPN provider.
You may also have the right to designate your personal physician as your treating physician, if you are
injured on the job. To do this you must inform your employer in writing before you are injured. Your
pre-designated physician must be your personal medical doctor, who has treated you prior to your injury,
who has your medical records, and who agrees to treat you for any work injuries that may occur. Any
treatment provided by a pre-designated physician is still subject to prior authorization and reasonably
necessary utilization review as required by the California law (Labor Code § 4600(d)). Any specialty
care or ancillary services ordered by your pre-designated physician must be provided by a MPN provider.
If you want to designate your own physician, you should do so in the space below. You do not need to
complete this form to participate in your employer or insurer sponsored Medical Provider Network.
By signing, you affirm that the information provided is true and correct to the best of your knowledge,
and you affirm your understanding that your employer, insurer, or their authorized agent may verify the
validity of your pre-designation.
Employee Number:
Last Name:
First Name:
Street:
City:
State: CA
Zip Code:
Name of Employer:
Employee Signature:
Date of Signature:
Physician Name:
Street:
City:
Phone:
Employee Pre-Designation Form
State: CA
Zip Code:
FORMULARIO DE DESIGNACIÓN PREVIA DEL EMPLEADO
Su empleador o su aseguradora han optado por una Red de Proveedores Médicos (MPN), administrada por Tower
Group Companies, para ofrecer atención médica oportuna y de calidad para lesiones y enfermedades ocupacionales.
Como empleado participante en la Red de Proveedores Médicos, usted puede buscar tratamiento de emergencia para
una lesión o enfermedad ocupacional en el centro de emergencias más cercano. Para el tratamiento que no sea de
emergencia, su empleador le dirigirá a un centro de medicina ocupacional o de atención de urgencias para su
primera cita, después de la cual usted tiene derecho de elegir a un médico de la MPN para brindarle atención. Es
posible que su médico personal ya sea un proveedor de la MPN.
Usted también puede tener derecho de designar a su médico personal como su médico tratante si usted se lesiona en
el trabajo. Para hacer esto, usted debe informar a su empleador por escrito antes de lesionarse. Su médico
designado previamente debe ser su médico personal que lo ha tratado antes de su lesión, que tiene su historia clínica,
y que está de acuerdo en tratar las lesiones ocupacionales que puedan ocurrir. Todo tratamiento proporcionado por
un médico previamente designado aún está sujeta a autorización previa y revisión de utilización razonablemente
necesaria según lo establecido por la ley de California (Código Laboral § 4600(d)). Toda atención especializada o
servicios complementarios ordenados por su médico designado previamente deben ser proporcionados por un
proveedor de la MPN.
Si usted desea designar a su propio médico, debe hacerlo en el espacio abajo. No es necesario completar este
formulario para participar en la Red de Proveedores Médicos patrocinada por su empleador o asegurador.
El médico no está obligado a firmar este formulario; sin embargo, si el médico o empleado designado del médico o
grupo médico no firma, se exigirá otra documentación del acuerdo del médico para ser designado previamente de
conformidad con el Título 8 del Código de Normativas de California, sección 9780.1(a)(3).
Al firmar, usted afirma que la información proporcionada es verdadera y correcta a su leal entender, y afirma que
tiene entendido que su empleador, aseguradora o su agente autorizado puede verificar la validez de su designación
previa.
Número del empleado:
Apellido:
Primer nombre:
Dirección:
Ciudad:
Estado: CA
Código postal:
Nombre del empleador:
Firma del empleado:
Fecha de la firma:
Nombre del médico:
Dirección:
Ciudad:
Estado: CA
Código postal:
Teléfono:
Médico: Estoy de acuerdo con esta designación previa:
Firma:____________________________________________________Fecha:__________
(Médico o Empleado Designado por el Médico o Grupo Médico)
Formulario de Designación Previa del Empleado
Information and Assistance Officer Phone Numbers and Locations Anaheim
1065 N. PacifiCenter Drive,
Suite 170
Anaheim 92806-2141
(714) 414-1801
Oakland
1515 Clay Street,
6th floor
Oakland, CA 94612-1519
(510) 622-2861
San Diego
7575 Metropolitan Drive,
Suite 202
San Diego, CA 92108-4424
(619) 767-2082
Bakersfield
1800 30th Street,
Suite 100
Bakersfield, CA 93301-1929
(661) 395-2514
Oxnard
1901 N. Rice Ave., Ste. 200
Oxnard, CA 93030-7912
(805) 485-3528
San Francisco
455 Golden Gate Avenue,
2nd floor
San Francisco, CA 94102-7014
(415) 703-5020
Eureka
100 "H" Street,
Room 202
Eureka, CA 95501-0481
(707) 441-5723
Pomona
732 Corporate Center Drive
Pomona, CA 91768-2653
(909) 623-8568
San Jose
100 Paseo de San Antonio,
Room 241
San Jose, CA 95113-1402
(408) 277-1292
Fresno
2550 Mariposa Mall,
Room 2035
Fresno, CA 93721-2219
(559) 445-5355
Redding
2115 Civic Center Drive
Suite 15
Redding, CA 96001-2740
(530) 225-2047
San Luis Obispo
4740 Allene Way,
Suite 100
San Luis Obispo, CA 93401-8736
(805) 596-4159
Goleta
6755 Hollister Avenue,
Room 100
Goleta, CA 93117-5551
(805) 968-4158
Riverside
3737 Main Street,
Suite 300
Riverside, CA 92501-3337
(951) 782-4347
Santa Ana
605 W Santa Ana Blvd, Bldg 28
Suite 451
Santa Ana, CA 92701-4070
(714) 558-4597
Long Beach
300 Oceangate Street,
Suite 200
Long Beach, CA 90802-4304
(562)590-5001
Sacramento
160 Promenade Circle,
Suite 300
Sacramento, CA 95834-2962
(916) 928-3158
Santa Rosa
50 "D" Street,
Suite 420
Santa Rosa, CA 95404-4771
(707) 576-2452
Los Angeles
320 W. 4th Street,
9th floor
Los Angeles, CA 90013-1954
(213) 576-7389
Salinas
1880 North Main Street,
Suite 100
Salinas, CA 93906-2037
(831) 443-3058
Stockton
31 East Channel Street,
Room 344
Stockton, CA 95202-2314
(209) 948-7980
Marina del Rey
4720 Lincoln Blvd
2nd floor
Marina del Rey, CA 90292-6902
(310) 482-3858
San Bernardino
464 W. Fourth Street,
Suite 239
San Bernardino, CA 92401-1411
(909) 383-4522
Van Nuys
6150 Van Nuys Blvd.,
Suite 105
Van Nuys, CA 91401-3370
(818) 901-5367
Localidades y Números de Teléfono del Funcionario de Información y Ayuda Anaheim
1065 N. PacifiCenter Drive,
Suite 170
Anaheim 92806-2141
(714) 414-1801
Oakland
1515 Clay Street,
6th floor
Oakland, CA 94612-1519
(510) 622-2861
San Diego
7575 Metropolitan Drive,
Suite 202
San Diego, CA 92108-4424
(619) 767-2082
Bakersfield
1800 30th Street,
Suite 100
Bakersfield, CA 93301-1929
(661) 395-2514
Oxnard
1901 N. Rice Ave., Ste. 200
Oxnard, CA 93030-7912
(805) 485-3528
San Francisco
455 Golden Gate Avenue,
2nd floor
San Francisco, CA 94102-7014
(415) 703-5020
Eureka
100 "H" Street,
Room 202
Eureka, CA 95501-0481
(707) 441-5723
Pomona
732 Corporate Center Drive
Pomona, CA 91768-2653
(909) 623-8568
San Jose
100 Paseo de San Antonio,
Room 241
San Jose, CA 95113-1402
(408) 277-1292
Fresno
2550 Mariposa Mall,
Room 2035
Fresno, CA 93721-2219
(559) 445-5355
Redding
2115 Civic Center Drive
Suite 15
Redding, CA 96001-2740
(530) 225-2047
San Luis Obispo
4740 Allene Way,
Suite 100
San Luis Obispo, CA 93401-8736
(805) 596-4159
Goleta
6755 Hollister Avenue,
Room 100
Goleta, CA 93117-5551
(805) 968-4158
Riverside
3737 Main Street,
Suite 300
Riverside, CA 92501-3337
(951) 782-4347
Santa Ana
605 W Santa Ana Blvd, Bldg 28
Suite 451
Santa Ana, CA 92701-4070
(714) 558-4597
Long Beach
300 Oceangate Street,
Suite 200
Long Beach, CA 90802-4304
(562)590-5001
Sacramento
160 Promenade Circle,
Suite 300
Sacramento, CA 95834-2962
(916) 928-3158
Santa Rosa
50 "D" Street,
Suite 420
Santa Rosa, CA 95404-4771
(707) 576-2452
Los Angeles
320 W. 4th Street,
9th floor
Los Angeles, CA 90013-1954
(213) 576-7389
Salinas
1880 North Main Street,
Suite 100
Salinas, CA 93906-2037
(831) 443-3058
Stockton
31 East Channel Street,
Room 344
Stockton, CA 95202-2314
(209) 948-7980
Marina del Rey
4720 Lincoln Blvd
2nd floor
Marina del Rey, CA 90292-6902
(310) 482-3858
San Bernardino
464 W. Fourth Street,
Suite 239
San Bernardino, CA 92401-1411
(909) 383-4522
Van Nuys
6150 Van Nuys Blvd.,
Suite 105
Van Nuys, CA 91401-3370
(818) 901-5367
EMPLOYEE CHIROPRACTOR PRE-DESIGNATION FORM
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST
If your employer or your employer’s insurer does not have a Medical Provider Network, you may be
able to change your treating physician to your personal chiropractor or acupuncturist following a
work-related injury or illness. In order to be eligible to make this change, you must give your
employer the name and business address of a personal chiropractor or acupuncturist in writing prior
to the injury or illness. Your claims administrator generally has the right to select your treating
physician within the first 30 days after your employer knows of your injury or illness. After your
claims administrator has initiated your treatment with another doctor during this period, you may
then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.
You may use this form to notify your employer of your personal chiropractor or acupuncturist.
Your Chiropractor or Acupuncturist’s Information:
(name of chiropractor or acupuncturist)
(street address, city, state, zip code)
(telephone number)
_____________________________________________________________________________________________
Employee Name (please print):
______________________________________________________________________________
Employee’s address:
______________________________________________________________________________
Employee’s Signature_______________________________________________Date:_______________ FORMULARIO DE DESIGNACIÓN PREVIA DE QUIROPRÁCTICO DEL
EMPLEADO
NOTIFICACIÓN DE QUIROPRÁCTICO PERSONAL O ACUPUNTURISTA PERSONAL
Si su empleador o la aseguradora de su empleador no tienen una Red de Proveedores Médicos (MPN, por sus siglas
en inglés), usted puede cambiar a su médico tratante por su quiropráctico o acupunturista personal, luego de una
lesión o enfermedad ocupacional. A fin de ser elegible para hacer este cambio, usted debe dar a su empleador el
nombre y dirección comercial de un quiropráctico o acupunturista personal por escrito antes de la lesión o
enfermedad. Su administrador de reclamaciones generalmente tiene el derecho de seleccionar a su médico tratante
en el periodo de los primeros 30 días a partir de cuando su empleador se entere de su lesión o enfermedad. Después
de que su administrador de reclamaciones ha iniciado su tratamiento con otro médico durante este período, es
posible que, previa solicitud, usted disponga la derivación de su tratamiento a su quiropráctico o acupunturista
personal designado.
Usted puede usar este formulario para notificar a su empleador acerca de su quiropráctico o acupunturista personal.
Información de su quiropráctico o acupunturista:
(nombre de quiropráctico o acupunturista)
(dirección calle, ciudad, estado, código postal)
(número de teléfono)
Nombre de empleado (por favor usar letra de imprenta):
_____________________________________________________________________________________________
Dirección del empleado:
_____________________________________________________________________________________________
Firma del empleado ____________________________________________________Fecha:___________________

Welcome to Tower Group Companies` Workers Compensation

Transcripción

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