Hawaii Workers Compensation Claim Kit

Workers Compensation Claim Kit - Alaska

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

Dear Policyholder:

Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC). We look forward to working with you to fulfill all your workers compensation needs.

Enclosed you will find documentation necessary for the processing and administration of a claim in the event of a workplace injury, as well as important information regarding workers compensation requirements for your state. Please utilize the documents included to collect valid information regarding the injured employee and incident, and send the documents in when reporting the claim or upon request.

It is critical that you promptly report all new claims using one of the following methods: Online, Phone, Fax, or E-mail.

EMPLOYER'S NOTICE OF INSURANCE

TO THE EMPLOYEES OF THE UNDERSIGNED:

Your employer is insured by:

Insurer:

Street and Number:

City: State: Zip Code:

For the period from: Through:

Adjusting Company:

Street and Number:

City: State: Zip Code: Telephone:

This insurance pays benefits for job-connected injuries, illnesses or death as provided by the Alaska Workers' Compensation Act.

Employer:

By: Title:

Witness: Witness:

EMPLOYER REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO DIVISION OF WORKERS’ COMPENSATION

1. Employer Name*:

2. Industry (NAICS) Code*:

3. Employer Contact Name & Telephone:

4. FEIN*: 5. UI Number:

6. Employer Mailing Address*:

7. Employer Physical Address:

8. Employee Name:

9. Employee Mailing Address*:

10. Date of Birth*: 11. Date of Death:

12. Employee ID Type & Number*:

13. MTC Report*: 14. JCN / AWCB*:

15. Claim Status*: 16. Claim Type*: 17. Late Reason Code:

18. Full Denial Reason Code: 19. Full Denial Effective Date:

20. Denial Reason Narrative:

21. Policy Information Number: Effective Date: Expiration Date:

22. Insurer Name: 23. Insurer FEIN: 24. Insurer Type Code*:

RELEASE OF MEDICAL INFORMATION

RE: v.

Alaska Workers' Compensation Claim No.:

TO: Any doctor, chiropractor, hospital, clinic, health insurer, physical therapist, government agency, insurer, employer or other person, entity, firm, or organization having custody of medical records or medical information pertaining to me, the undersigned person

I, the undersigned person, give my consent and authorize you to release the following medical records and information in your possession to the defendants, or representative of the defendants, in the above Workers' Compensation Claim filed by me.

Medical records and information relating to the treatment of my injury or illness at work, and the following parts of my body, diagnoses or conditions, organ systems, chief complaints and/or symptoms:

This authorization releases medical information from:

This release of information is intended to include records maintained in my maiden or other names as follows:

This release, and all authority to disclose information pertaining to me, shall expire on:

Signature: Dated this day of

Printed Name:

MEDICAL HISTORY REQUEST

Employee Name: Date of Injury:

Employer Name: Completion Date:

Please complete this form by providing your medical history for the past 5 years.

Past Injuries, Disabilities, or Other Medical Conditions

Hospitalizations

Treating Physicians or Groups

EMPLOYEE REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO EMPLOYER

1. Employee Name Last*: First*: Middle: Suffix:

2. Mailing Address & Telephone Number*:

3. Date of Birth*: 4. Date of Death:

5. Social Security Number*: 6. Gender Code:

7. Marital Status: 8. Number of Dependents:

9. Date of Injury / Illness*: 10. Time of Injury / Illness:

11. Did Injury / Illness Occur on Employer’s Premises? Yes No

12. Explain where injury / illness occurred:

13. Employer Name*:

14. Describe Nature of Injury / Illness*:

15. Describe Part of Body Affected*:

16. Describe How the Injury / Illness Happened:

17. Injury / Illness Due to Machine/Product Failure? Yes No

18. Mechanical Guard/Safeguards Provided? Yes No

19. List Any Machine/Substance/Object Causing Injury / Illness:

20. If Machine What Part?:

21. Witness Name: Witness Business Phone Number:

22. Attending Physician Name & Contact Information:

23. Hospital Name & Contact Information:

24. Initial Treatment*: 0-No Medical Treatment 1-Minor On-site Remedies 2-Minor Clinic/Hospital Remedies 3-Emergency Evaluation 4-Hospitalization > 24 Hours 5-Future Major Medical/Lost Time

25. Employee Authorization to Release Medical Records*:

Employee Signature:

26. If Employee Unavailable for Signature, Explain Circumstances:

27. Date Signed:

SUPERVISOR’S REPORT OF EMPLOYEE ACCIDENT

Employee name:

Employer name:

Date of accident: Time of accident:

Date accident reported:

Did the employee report the accident immediately? Yes No

Location of accident:

How did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were reported as injured?

Has the employee sought any medical treatment for these injuries? If so, specify where and when.

What witnesses were present when the accident occurred (including self)?

Do you have any reason to question the legitimacy of the accident? If so, please explain:

What changes could be made to eliminate or reduce the hazard(s) identified above?

Prepared by: Title: Date prepared:

WITNESS’ REPORT/STATEMENT OF EMPLOYEE ACCIDENT

Employee name:

Witness name & phone number:

Witness Address:

Date of accident: Time of accident:

Location of accident:

Did you witness the above-reported accident? If so, how did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were injured? Describe the type of injury:

What did the injured employee say at the time of injury? Did the injured employee complain of pain?

What did the employee do after the accident occurred?

Were any other witnesses present at the time of the accident? If so, please list them below.

Signature of witness: Date signed:

$1000 Reward / Fraud Hotline Notice

For information leading to the arrest and conviction of any fraudulent workers compensation claim, call 1 (800) 300-JAIL.

Spanish version poster also included in the document packet.