We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.

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RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation
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RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation loss, we want you to have everything that you will need to ensure that if a loss occurs you can get your employee taken care of quickly and that you have access to the people and resources that can provide assistance. Attached you will find the Workers Compensation Reporting Kit which contains the Nevada statemandated forms, and a step-by-step process to follow in case an employee sustains an injury. For claims handling, we have selected Pinnacle Risk Management as our claims servicing administrator. If you report claims, your claims adjusting team at Pinnacle s Las Vegas, NV office will make contact with you to get additional information about the injury and your employee and to answer any questions that you might have regarding the Nevada workers compensation process. We thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees. The following state forms have been included with your claims kit packet: 1. Nevada Form C-3- Employers report of Industrial injury or Occupational Injury- If the Employer does not complete this form and submit it to York Insurance Services Group, the state can assess a fine of $500 per offense. 2. Nevada Form C-1 Notice of Injury or Occupational Disease- The employee has 7 days to report the injury to the employer by filling in this form. Please provide this form to the employee at the time they are reporting a claim. 3. Nevada Form C-4 Employees Claim for compensation/report of Initial Treatment- The employee has 90 days to seek medical treatment after report of an injury. The insurer has 30 days to issue a determination after receipt of this form. If this form is received by the employer, they must complete a Nevada Form C-3- Employers report of Industrial injury or Occupational Injury and file with the insurer within 6 working days. 4. Nevada Form D-8- Employers Wage Verification- This form must be completed within 6 working days after the receipt of a claim for compensation and mailed within 7 days after receiving the request. The form must be signed by the employer and the administrator can impose not more then a $1,000 fine for each violation. 5. Nevada Form D-36 Request for Additional Medical Info and Medical Release- Please have the injured employee fill out and sign this form and send to Tower Group Companies at the time of an injury. Very truly yours, Tower Group Companies HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Worker s compensation claims can be reported in several different ways, you can: Complete and submit the Nevada Form C-3- Employers Report of Industrial injury or Occupational Injury- and submit the form via one of the following: the completed form to This is the preferred method of reporting an injury. Fax to Pinnacle Risk Management at Call the Pinnacle Risk Management Reporting Hotline at By contacting your broker directly and providing the appropriate first report information. Your claim will be handled by Pinnacle Risk Management: Office Location and Mailing Address: Pinnacle Risk Management 4055 Spencer Street Suite # 102 Las Vegas, NV, Main phone# IN02 08/08 TO AVOID PENALTY, THIS REPORT MUST BE COMPLETED AND MAILED TO THE INSURER WITHIN 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM Please Type or Print EMPLOYER S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE EMPLOYER Employer s Name Nature of Business (mfg., etc.) FEIN OSHA Log # Office Mail Address Location... If different from mailing address Telephone City State Zip INSURER THIRD-PARTY ADMINISTRATOR First Name M.I. Last Name Social Security Birthdate Age Primary Language Spoken EMPLOYEE Home Address (Number and Street) City State Zip Was the employee paid for the day of injury? (If applicable) Yes No Sex Male Female Marital Status Single Married Divorced Widowed How long has this person been employed by you in Nevada? In which state was employee hired? Employee s occupation (job title) when hired or disabled Department in which regularly employed: Telephone Is the injured employee a corporate officer?... sole proprietor?... partner? Yes No Yes No Yes No Was employee in your employ when injured or disabled by occupational disease (O/D)? Yes No Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM) (if applicable) Date employer notified of injury or O/D Supervisor to whom injury or O/D reported ACCIDENT OR DISEASE Address or location of accident (Also provide city, county, state) (if applicable) What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable) Accident on employer s premises? (if applicable) Yes No How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary. Specify machine, tool, substance, or object most closely connected with the accident (if applicable) Witness Part of body injured or affected If fatal, give date of death Witness Was there more than one person injured in this accident? (if applicable) INJURY OR DISEASE Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.) If validity of claim is doubted, state reason Treating physician/chiropractor name IMPORTANT Witness Did employee return to next scheduled shift after accident? (if applicable) Yes No Location of Initial Treatment Emergency Room Yes No How many days per week does employee work? From am pm To am pm Yes No Will you have light duty work available if necessary? Yes No Hospitalized Yes No Last day wages were earned Scheduled S M T W T F S Rotating days off Are you paying injured or disabled employee s wages during disability? Yes No Date employee was hired Last day of work after injury or disability Date of return to work Number of work days lost IMPORTANT LOST TIME INFO Insurer Use Only Was the employee hired to work 40 hours per week? Yes No If not, for how many hours a week was the employee hired? Did the employee receive unemployment compensation any time during the last 12 months? Yes No Do not know For the purpose of calculation of the average monthly wage, indicate the employee s gross earnings by pay period for 12 weeks prior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D-8). Gross earnings will include overtime, bonuses, and other remuneration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earnings from the date of hire to the date of injury or disability. Pay period SUN TUE THUR SAT ends on: MON WED FRI Emloyee WEEKLY MONTHLY OTHER is paid: BI-WKLY SEMI-MONTHLY On the date of injury or disability the employee s wage was: $ per Hr Day Wk Mo For assistance with Workers Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: Web site: I affirm that the information provided above regarding the accident and injury or occupational disease is correct to Employer s Signature and Title Date the best of my knowledge. I further affirm the wage information provided is true and correct as taken from the payroll records of the employee in question. I also understand that providing false information is a violation of Nevada law. Deemed Wage Account No. Class Code Claim is: Accepted Denied Deferred 3 rd Party Claims Examiner s Signature Date Status Clerk Date Form C-3 (rev.11/05) ORIGINAL EMPLOYER PAGE 2 INSURER/TPA PAGE 3 EMPLOYEE Name of Employer TICE OF INJURY OR OCCUPATIONAL DISEASE (Incident Report) Pursuant to NRS 616C.015 Name of Employee Social Security Number Telephone Number Date of Accident (if applicable) Time of Accident (if applicable) Place where accident occurred (if applicable) What is the nature of the injury or occupational disease? List any body parts involved: Briefly describe accident or circumstances of occupational disease: (Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment) Names of witnesses: Did the employee leave work because of the injury or occupational disease? If yes, when (date and time)? Has the employee returned to work? If yes, when (date and time)? Was first aid provided? If yes, by whom? Name and address of treating physician, if applicable or known Did the accident happen in the normal course of work? (if applicable) Was anyone else involved? Names of others involved MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN TIFIED OF THESE ARRANGEMENTS. Supervisor s Signature Date Signature of Injured or Disabled Employee Date TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR COMPENSATION (FORM C-4). For assistance with Workers Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: Web site: Employee should sign, date and retain a copy. Original to Employer, Copy to Employee C-1 (Rev. 10/05) EMPLOYEE S CLAIM FOR COMPENSATION/REPORT OF INITIAL TREATMENT FORM C-4 PLEASE TYPE OR PRINT EMPLOYEE S CLAIM PROVIDE ALL INFORMATION REQUESTED First Name M.I. Last Name Birthdate Sex M F Claim Number (Insurer s Use Only) Home Address Age Height Weight Social Security Number City State Zip Telephone Mailing Address City State Zip Primary Language Spoken INSURER THIRD-PARTY ADMINISTRATOR Employee s Occupation (Job Title) When Injury or Occupational Disease Occurred Employer s Name/Company Name Telephone Office Mail Address (Number and Street) Date of Injury (if applicable) Hours Injury (if applicable) am pm Address or Location of Accident (if applicable) Date Employer Notified Last Day of Work After Injury or Occupational Disease Supervisor to Whom Injury Reported What were you doing at the time of the accident? (if applicable) How did this injury or occupational disease occur? (Be specific and answer in detail. Use additional sheet if necessary) If you believe that you have an occupational disease, when did you first have knowledge of the disability and its relationship to your employment? Witnesses to the Accident (if applicable) Nature of Injury or Occupational Disease Part(s) of Body Injured or Affected I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KWLEDGE AND THAT I HAVE PROVIDED THIS INFORMATION IN ORDER TO OBTAIN THE BENEFITS OF NEVADA S INDUSTRIAL INSURANCE AND OCCUPATIONAL DISEASES ACTS (NRS 616A TO 616D, INCLUSIVE OR CHAPTER 617 OF NRS). I HEREBY AUTHORIZE ANY PHYSICIAN, CHIROPRACTOR, SURGEON, PRACTITIONER, OR OTHER PERSON, ANY HOSPITAL, INCLUDING VETERANS ADMINISTRATION OR GOVERNMENTAL HOSPITAL, ANY MEDICAL SERVICE ORGANIZATION, ANY INSURANCE COMPANY, OR OTHER INSTITUTION OR ORGANIZATION TO RELEASE TO EACH OTHER, ANY MEDICAL OR OTHER INFORMATION, INCLUDING BENEFITS PAID OR PAYABLE, PERTINENT TO THIS INJURY OR DISEASE, EXCEPT INFORMATION RELATIVE TO DIAGSIS, TREATMENT AND/OR COUNSELING FOR AIDS, PSYCHOLOGICAL CONDITIONS, ALCOHOL OR CONTROLLED SUBSTANCES, FOR WHICH I MUST GIVE SPECIFIC AUTHORIZATION. A PHOTOSTAT OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL. Date Place Employee s Signature THIS REPORT MUST BE COMPLETED AND MAILED WITHIN 3 WORKING DAYS OF TREATMENT Place Name of Facility Date Hour Diagnosis and Description of Injury or Occupational Disease Is there evidence that the injured employee was under the influence of alcohol and/or another controlled substance at the time of the accident? No Yes (if yes, please explain) Treatment: Have you advised the patient to remain off work five days or more? Yes Indicate dates: from to X-Ray Findings: From information given by the employee, together with medical evidence, can you directly connect this injury or occupational disease as job incurred? Yes No No If no, is the injured employee capable of: full duty modified duty If modified duty, specify any limitations/restrictions: Is additional medical care by a physician indicated? Yes No Do you know of any previous injury or disease contributing to this condition or occupational disease? Yes No (Explain if yes) Date Print Doctor s Name I certify that the employer s copy of this form was mailed to the employer on: Address INSURER S USE ONLY City State Zip Provider s Tax I.D. Number Telephone Doctor s Signature Degree ORIGINAL TREATING PHYSICIAN OR CHIROPRACTOR PAGE 2 INSURER/TPA PAGE 3 EMPLOYER PAGE 4 EMPLOYEE Form C-4 (rev.10/07) EMPLOYER'S WAGE VERIFICATION FORM (Pursuant to NRS 616C.045(2)(d)) Please provide the following information for the employee named below by completing this form. The information is needed so that the amount of disability compensation to which your employee is entitled may be calculated. Prompt completion and return of this form will ensure the timely payment of any compensation due this injured worker. Please answer all questions and sign the form where indicated. EMPLOYER: PLEASE PROVIDE THE FOLLOWING INFORMATION ANSWERING ALL QUESTIONS Date: Injured Employee's Name (Last/First/M.I.): Social Security # Claim No.: Date of Injury: Date of Hire: Was employee hired to work 40 hours per week: [ ] Yes [ ] No If no, # of hours per week: On the date of injury, the employee's wage was: $ Was vacation paid during the applicable twelve week period? # of days per week: per [ ] Hour [ ] Day [ ] Week [ ] Month Date the wage became effective: If so, during what pay period? Was sick leave paid during the applicable twelve week period? Was the injured employee paid for any holidays during the applicable twelve week period? Did employee receive payment for overtime during the applicable twelve week period? Did employee receive termination pay during the applicable twelve week period? Provide prior wage if current wage was in effect less than 12 weeks prior to date of injury: $ per [ ] Hour [ ] Day [ ] Week [ ] Month During this 12-week period did employee change to a job with different (1) duties, (2) hours of employment, (3) rate of pay? [ ] Yes [ ] No If so, date: Explain: Does the employee receive commissions? [ ] Yes [ ] No Period of commission earned to. Indicate the amount of commission received over the last 6 months, or since date of hire: $ Does the employee receive bonuses/incentive pay? [ ] Yes [ ] No Period of bonuses/incentive pay earned to. Indicate the amount of bonuses received over last 12 months, or since date of hire: $ Are the commission and bonus amounts included in GROSS EARNINGS below? [ ] Yes [ ] No Does the employee declare tips for the purpose of worker's compensation? [ ] Yes [ ] No See payroll declaration below. Attach declaration forms. Does the employee receive meals or lodging (excluding reimbursement for travel per diem)? [ ] Yes [ ] No (Do not include in gross earnings) How many meals per day? Monetary value of meals $ per [ ] Day [ ] Week [ ] Month Lodging $ per [ ] Day [ ] Week [ ] Month TWELVE WEEK VERIFICATION FROM PAYROLL RECORDS. Report GROSS EARNINGS, include overtime payment and any other remuneration (except reimbursement for expenses). (See NAC 616C.423) Give payroll information from through. If employed less than twelve weeks, give gross earnings from date of hire to date of injury. If absent from work for the following reasons, please specify the date(s) absent and the number code for the reason of absence. 1. Certified illness or disability; 2. Institutionalized in a hospital, or other institution; 3. Enrolled as full-time student, not employed on days of attendance; 4. In military service other than training duty conducted on weekends; 5. Absent because of officially sanctioned strike; 6. Absence because of leave approved pursuant to Family and Medical Leave Act. Payroll Period Beginning Ending Gross Salary (Excluding Tips) Declared Tips Payroll Period Beginning Ending Gross Salary (Excluding Tips) Declared Tips Dates of Absence Reason Dates of Absence Reason Dates of Absence Reason Begin End Begin End Begin End Pay period ends on (check one) [ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Saturday Employee is paid: [ ] Weekly [ ] Bi-Weekly [ ] Semi-Monthly [ ] Monthly [ ] Other Employee scheduled day(s) off: [ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Saturday [ ] Other Explain other : Date the employee last worked AFTER injury occurred: Date returned to work: This information is true and correct as taken from the employee's payroll records. Print Name: Signature: Date: Employer: Insurer: Third-Party Administrator: D-8 (rev10/10) Injured Employee's Name: Request for Additional Medical Information And Medical Release (Pursuant to NRS 616C.177 & 616C.490(4)) Claim Number: Social Security Number: Injured Employee's Address: Injury/Occupational Disease Date: Insurer's Name: Insurer's Address: Date this Notice Printed: Employer: Employer's Address: Please provide the information requested below, sign and date the form, and return it to your insurer. Your signature on this form also acts as a release to acquire information affecting your claim from other entities. This renews the release you signed on your C-4 form at the time your claim was submitted to your insurer. Failure to fully complete and return this form to your claims agent in a timely manner could affect your benefits or delay the resolution of your claim. Prior History Information Please check the appropriate box below and provide the information requested. I have no prior conditions, injuries or disabilities of which I am aware, that might affect the disposition of the claim referenced above. (If you checked this box, no further information is needed at this point) I have a prior condition, injury or disability that could affect the disposition of the claim referenced above. This can include birth defects, prior surgeries, injuries, etc., whether work related or not. (If you checked this box, indicating a pre-existing condition, please explain in detail in the space below. Please attach additional sheets of paper to this form if necessary to fully explain the condition) I certify that the above is true and correct to the best of my knowledge and that I have provided this information in order to obtain the benefits of Nevada s industrial insurance and occupational diseases acts (NRS 616A to 616D, inclusive or chapter 617 of NRS). I hereby authorize any physician, chiropractor, surgeon, practitioner, or other person, any hospital, including veterans administration or governmental hospital, any medical service organization, any insurance company, or other institution or organization to release to each other, any medical or other information, including benefits paid or payable, pertinent to this injury or disease, except information relative to diagnosis, treatment and/or counseling for aids, psychological conditions, alcohol or controlled substances, for which I must give specific authorization. A photostat of this authorization shall be as valid as the original. Signature Date D-36 (Rev. 12/07)
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