CSRMA Programs

Claim Handling Procedure <----------

Workers' Compensation claims are administered by:

Ralph Matthews

Gregory B. Bragg & Associates, Inc.

One Sierra Gate Plaza, Suite 250B

Roseville, CA 95678

(916) 783-0100

Fax: (916) 783-0334

On the following pages are the procedures and reporting forms to be used in submitting a claim. If you have any questions concerning claims, please contact Ralph Matthews.

Also included in this section you will find a copy of the service contract and the standards that the Claims Administrator is to follow.

ADDITIONAL CODING REQUIREMENT
You are asked to place one of the following codes on line 12 of the Form 5020, "Employers Report of Occupational Injury or Illness" (See attached example):


	Classification


	Code


	Collection line maintenance


	CM


	Collection line construction


	CM


	Treatment plant operation


	TO


	Treatment plant maintenance


	TM


	Laboratory operations


	LO


	Administration (100% office work)


	AD


	Miscellaneous out-of-office work


	MI


	(supervisors/engineers)

	Please place the code on line 12 following the name of the department in which the employee is regularly employed or under which the injury occurred if the employee's time is split.

CLAIM REPORTING PROCEDURE

Workers' Compensation covers work-incurred injuries or illnesses only. It does not cover illnesses or diseases of non-work origin. If you are unable to decide if any injury is work-related, report to us and we will obtain information to determine if the injury should be covered by Workers' Compensation.

The Workers' Compensation Reform Act of 1989 requires that an employer, within one (1) working day of notice of an injury, provide the Employee's Claim for Workers' Compensation Benefits (DWC-1) to the injured worker or to their dependents in the case of death.

Failure to comply with this requirement may result in penalties from $100 to $5,000. (See Section 2 for a schedule of these penalties.)
Notice of an injury can come from any source, including, but not limited to the following:


	1)

	2)

	3)

	4)


	The injured employee

	Co-workers

	Treating Physicians

	Family members in the case of serious injury or death. (If so, the claim form should be sent to a family member via certified mail.)


	When the Supervisor or Department Manager receives notice from any of the above sources, the following procedure must be followed within one (1) working day: (Copy of forms and sample form letters can be found under Section 3)


	1)

	2)

	3)

	4)

	5)

	6)

	7)

	8)


	The Supervisor or Department Manager completes Lines 9 though 17 of the DWC-1.

	Provide the employee with the DWC-1 and, whenever possible, have them fill out the employee section (lines 1 through 8) then and there.

	Ask the employee to sign and date the Acknowledgment of Receipt of Employee Claim (Form WC004).

	If the employee completes the DWC-1 as in #2, give them the green copy (Employee's Temporary Receipt).

	Complete the Supervisor's Report of Injury (WC001) and send it along with the Acknowledgment of Receipt of Claim Form (WC004) and the Employee Claim (DWC-1) to the person designated by your company to complete the Employer's Report of Occupational Injury or Illness (From 5020) for immediate completion.

	The three remaining copies of the Employee Claim Form (DWC-1) should be date stamped. The Employee's Copy (pink) should be sent to the injured employee. The Insurer/Claims Administrator Copy should be sent immediately to Bragg & Associates along with the completed Employers' Report of Injury (Form 5020), the Acknowledgment of Receipt of Employee Claim Form (WC004) and Supervisor's Report or Injury (WC001).

	To assist in complying with State law, which dictates we must either accept, delay or deny claims within fourteen (14) days of the employer's date of acknowledge of a claim, please forward the claim to Bragg & Associates immediately. In any event, the 5020 form should be received in our office no later than seven (7) days after the employer's date of knowledge of a claim. If necessary, please fax the reports to us to meet this requirement. PLEASE REPORT TO THE FOLLOWING OFFICE: Bragg & Associates P.O. Box 1406 Roseville, CA 95678-1406 PH: (916) 783-0100 • (800) 422-7244 FAX: (916) 783-0334

	If you feel a claim is questionable, please call your claims person to discuss it.

PLEASE NOTE: THIS PROCEDURE APPLIES ONLY TO NOTICES OF INJURY WHERE THERE IS LOST TIME OR MEDICAL TREATMENT BEYOND FIRST AID TREATMENT.

If the employee is absent from the work site when knowledge of the injury is obtained by the Supervisor or Manager, the Employee Claim Form (DWC-1) must be sent within one (1) working day, certified mail with return receipt, as proof of service, or personally, delivered within (1) working day to the employee's home.

In the event the employee is so seriously injured that he/she cannot complete the form, it must be sent certified mail or personally delivered to the spouse or person acting on behalf of the employee. If requested by the employee, the Manager or Supervisor can complete the form on behalf of the employee.

The following documents should be forwarded to Bragg & Associates upon receipt:


	A)

	B)

	C)

	D)

	E)


	Notice of Hearing or Application for Adjudication of Claim before the Workers' Compensation Appeals Board.

	Letters from attorneys or representatives of injured employees or from any State or Federal agencies.

	Letters, telephone calls or complaints made by employees or others.

	Subpoenas in industrial injury cases.

	Any notices or citations received from Cal/OSHA.


	*Send any report you may receive from an injured employee's private physician to Bragg & Associates. Please forward the original report and retain a copy for your file.* *Do not discuss information concerning employees' injuries with anyone. Refer all such inquiries to Bragg & Associates.*


	SUMMARY


		I.

		II.

		III.

		IV.

		V.

	VI.


	If medical treatment is needed, refer injured employee to medical facility.

	When or if the Employee Claim Form is returned, immediately prepare "Employer's Report of Occupational Injury or Illness", Form 5020, and forward to: Bragg & Associates P.O. Box 1406 Roseville, CA 95678-1406 Please send the original 5020 and one copy, and one copy of the Supervisor's Report and one copy of the Acknowledgment Form.

	In case of fatal accident or serious injury, immediately telephone Bragg & Associates at (916) 783-0100.

	Each time an injured employee leaves or returns to work as a result of a job injury, notify Bragg & Associates immediately.

	Refer any inquiries for information on workers' compensation claim to Bragg & Associates.

	In case of a questionable claim advise Bragg & Associates as soon as possible.

SPECIAL NOTE: State law requires that all industrial injuries must be reported to the Claims Administrator within five (5) days. Failure of an employer to report workers' compensation injuries within the required time period may result in case penalties or imprisonment by the State of Jurisdiction and/or possible lawsuits by employees. Noncompliance may cost you more in the long run than the actual payment of benefits.

MEDICAL CONTROL

All employees should be required to report injuries - even though minor - to their immediate Supervisor who should be instructed to give the employee the "Employee Claim Form" and to send the employees for first aid treatment at once. Many minor scratches, small lacerations, puncture wounds and contusions can be given adequate first aid by qualified personnel.

Employees with injuries requiring the attention of a physician should be sent for medical treatment to the designated medical facility. This facility has been especially selected for the treatment of your employees' injuries, and the doctor is familiar with Workers' Compensation laws regarding reporting and billing. The employee should never receive a bill.

An employee who has given written notice by way of the Selection of Physician Form to the employer, prior to injury, of his desire to be treated by a personal physician, may immediately consult that physician. However, in the event of an emergency situation, proper medical aid should be rendered immediately.

RETURN TO WORK

When an injured employee returns to work, immediately notify Bragg & Associates in writing or by telephone. This serves as notification to terminate the employee's disability benefits. We find that we cannot always expect busy physicians to remember to report the employee's termination of disability to us, and it is felt that you are in a better position to provide this information than the physician. It will also be helpful to you, if industrially injured employees who have lost time from work, are required to report to your Personnel Department before being permitted to return to their jobs.

UNUSUAL CASES

From time to time, employees will claim injuries or disabilities and give an obscure or vague history. In other cases, your experience will indicate that the employee's complaints are not work-related; and there may be instances in which you have reason to believe the employee's claim is not legitimate.

In all such cases, personnel who are reporting industrial injuries should take a careful chronological history from the employee then immediately telephone Bragg & Associates. We will arrange for additional investigation if indicated and necessary medical opinions and/or treatment.

COMMENTS

You need not and should not be drawn into arguments with employees over questionable claim situations. If questions come up that you cannot answer, advise the employee that the matter will be referred to Bragg & Associates immediately. Any inquiries may be directed to the following personnel in the offices of Bragg & Associates.

Gregory B. Bragg
President

Ralph Matthews
Regional Claims Manager