=====

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

Pekin Insurance® sincerely thanks you for choosing us as your insurance carrier. As business owners too, we understand that keeping a business running smoothly takes effort. We have dedicated Loss Control and Workers Compensation professionals who are trained, knowledgeable, and ready to provide you with Beyond the expected® service.

ALL potential claims should be reported in a timely fashion. State fines and penalties can result if claims are not reported immediately following the incident. Also, cost containment measures are most effective when claims are reported promptly.

Pekin Insurance takes all claims seriously and proudly serves you with a 24-hour, 7-days a week Claim Call Center. Simply call 888-735-4611 when you need to file a claim.

This claims kit is designed to guide you through the process. Start with the Employee/Employer checklist as they outline the steps and other forms which need completion. Any time you have questions, please contact your claim representative.

Thank you again for choosing Pekin Insurance as your Commercial Insurance provider. Rest assured that when it comes to the claim service and coverage you deserve and you desire, Pekin Insurance will always strive to go Beyond the expected!®

4085

Updated 10/16

Pharmacy ProgramThe program provides discounts on workers compensation prescriptions submitted by your injured employee. The service gives preferred access to a national pharmacy network of over 65,000 retail pharmacies. Benefits include 18% lower costs per fill and 33% increase in generic drug utilization.• YOU provide the First Fill

Prescriptions Information Sheetto the employee reporting awork-related incident and injury.This form should be kept in asecure location.

• The injured employee completesthe form, then presents it with the prescription to a participatingpharmacy. The claim will beelectronically submitted by thepharmacy.

• After the claim is reported toPekin Insurance, a permanentplastic ID drug card will beissued directly to theemployee for all future workerscompensation prescriptions.

Medical Cost ContainmentPekin Insurance contracts with a medical bill review service which reviews all provider charges for appropriateness, usual and customary, and adherence to state mandatory fee schedules.

Further cost control is achieved through the use of a PPO Network. Providers in the network have agreed to discount their billings on treatment for your injured employees. Contact your Pekin Insurance claim specialist for a list of PPOs in your area.

Diagnostic Testing ProgramTo further contain cost, we have partnered with a vendor to save money on any diagnostic testing (CT scans, MRIs & EMGs) ordered by a treating doctor. To make this program successful, we ask you to encourage your employees to contact their Pekin Insurance claim specialist as soon as they know a test will be needed.

At that time, the vendor will be contacted. They will schedule the test, then notify the employee of the test location, date, and time. This process also expedites test results.

The “Did You Knows” of workers compensation medical expenses:

• In 2009 approximately $30billion was spent on workerscompensation medical expenses.

• 58% of all workers compensationexpenses are related to medicalexpenses.

• 15% to 19% of all medicalexpenses are related toprescription drugs (pharmacy).

• Pharmacy costs are increasingby 3% to 5% a year.

Pekin Insurance takes a proactive approach to controlling these medical expenses by participating in several medical cost containment programs. Use of the programs helps reduce your workers compensation costs. They are most effective when claims are reported immediately.

WORKERS COMPENSATION

COST CONTAINMENT

PROGRAMS

• Injured workers off work longer than six months have only a 50% chance of returning to their jobs; if time loss exceedsone year, there is a 90% chance they will never return to work.

• The good news is studies also show 80-90% of injured employees would rather return to work than collect disability.

Pekin Insurance has dedicated Loss Control and Workers Compensation professionals to assist employers with their return to work programs.

THE IMPORTANCE OF A RETURN

TO WORK PROGRAM

• Claims reported within 3 days have significantlylower average claim costs.

• 60% of workers off the job 14 days are alreadyexperiencing financial difficulty, which will mostlikely result in attorney involvement.

• The chances of litigation are 50% lower if theemployee understands their workers compensationbenefits. We encourage ongoing communicationfrom the employer and employer representative.

• The average workplace injury has quadrupled incost to $20,000 over the past 15 years.

THE IMPORTANCE OF PROMPT REPORTING

Claims can be reported to Pekin InsurancePhone – 800-322-0160, Fax – 309-346-9466

Handle the immediate medical needs of your injured employee.

Notify Pekin Insurance immediately of any injury that may be covered by your policy. Please remember to report incidents even when immediate medical treatment is not required.

You must submit a First Report of Injury and all medical documentation you have received. These documents should be sent directly to us or your local insurance agent.

Pekin Insurance Company 2505 Court Street Pekin, IL 61558

Phone: 800-322-0160 Fax: 309-346-9466

Have your injured employee’s supervisor complete the Supervisor Incident Report. Also, provide the name, address, and phone numbers of all witnesses to the incident.

Take out of use and keep all materials, machinery, or tools that may have contributed to the incident or caused the injury. Secure the name, address, and phone numbers of anyone you feel may be responsible for the incident. Pekin Insurance may be able to seek recovery from a responsible party.

Provide your injured employee with a copy of the First Fill Prescription Information Sheet. It is a temporary card that allows him or her to receive an initial supply of medication. A permanent card will be mailed to the employee once the claim is set up. Keep this form in a safe and secure location.

If the injured employee needs diagnostic treatment or durable medical equipment, contact us to make arrangements. These items include MRIs, CT scans, crutches, or braces.

Provide the injured employee with a copy of the Return to Work Form. The completed copy should be submitted directly to us by the doctor, employer, and/or employee.

Let us know if any light duty work is available to offer the employee once he or she is capable of returning to work.

Employer’s ClaimReporting Checklist

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

4085

If needed, seek immediate medical care for your injuries. Notify your employer of all incidents and injuries, even if you do not seek immediate medical care.

Request that your employer submit the First Report of Injury to us ASAP.

Secure and report the names of any witnesses to the incident. Also, identify any materials, machinery, or tools that you feel contributed to or caused your injury.

Request a copy of the Return to Work Form from your employer. It is your responsibility to ensure this is completed by your doctor, then returned to your employer or us after every visit.

Let your claim specialist know if your treatment has included or will include diagnostics or durable medical equipment such as MRIs, CT scans, crutches, or braces.

Provide your employer and us with the names and addresses of ALL medical providers who have treated you for the injuries.

Promptly complete and return all forms you receive from your claim specialist.

Your claim specialist may contact you to obtain additional information needed to complete the investigation of your claim. You may also contact your claim specialist with questions on the claim:

Pekin Insurance Company 2505 Court Street Pekin, IL 61558

Phone: 800-322-0160 Fax: 309-346-9466

This form is for the injured employee’s use.

Injured Worker’s ClaimReporting Checklist

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

4085

Injured worker’s name: Sex: ____Male ____Female

Social Security number: Date of Birth:

Address: Phone:

Date of Hire:

Job Title & Department:

Date of injury: Time of injury: Medical attention sought? YES NO

Name of facility or physician that provided treatment:

Witness to the incident:

Was or will a drug screen be completed? YES NO (please circle one)

Last Day Worked: Return to work date:

Scheduled work week at time of injury

Hours: Days per week: Start time: End time:

Injured worker’s normal/usual schedule

Hours: Days per week: Start time: End time:

Injured worker’s statement regarding the injury (list all circumstances and equipment involved)

Body Parts affected:

Type of injury:

The answers I have provided to the above questions are true to the best of my knowledge.

Injured worker’s signature: Date:

Supervisor signature: Date:

Supervisor Incident Report

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

4085

Injured Worker Name: ____________________ Social Security #:_____________________________

Date Of Injury:___________________________

Dear Injured Worker,

On your first visit, please give this notice to any pharmacy listed on this insert to expedite the processing of your approved Workers Compensation prescriptions, based on the established parameters by Pekin Insurance™. With the CorVel CorCareRx program, you do not need to complete any paperwork or claim forms. Simply present this CorVel First Fill Prescription Information Sheet to the pharmacy. You should not incur any costs or copayments at the pharmacy and will be allowed up to a 14 day supply of medications.

Dear Pharmacist,

Please use the Injured Worker’s SSN plus 8 digit Date of Injury (SSN+MMDDYYYY) as the 17-digit identification number when entering the following information to process an online claim to CorVel on behalf of Pekin Insurance injured workers:

BIN: 004336 PCN: ADV RxGrp: RXFFWC596

Pharmacies can contact CorVel Pharmacy Help Desk at (800) 563-8438 for assistance with claims processing. The Pharmacy Help Desk is available 24 hours a day, 7 days a week for your convenience.

There are 70,000 Participating Pharmacies in the CorVel Network. Below is a sample listing. Bi-Lo Pharmacy Fred’s Pharmacy Marsh Drugs Safeway Pharmacy Brooks Pharmacy Fry’s Pharmacy Medical Arts Pharmacy Sav-On Drug Store Brookshire Pharmacy Giant Eagle Pharmacy Medicap Pharmacy Schnuck’s Pharmacy City Market Pharmacy Happy Harry’s Medicine Shoppe Shop N’ Save CostCo Pharmacy H.E.B. Pharmacies Meijer Pharmacy Snyder’s Drug Store CVS Hy-Vee Pharmacy Minyard Pharmacy Target PharmacyDiscount Drug Mart Ingles Pharmacy NeighborCare Thrifty Drug Store Drug Mart Kash N’ Karry Osco Drug Tom Thumb Pharmacy Duane Reade Kerr Drug Pathmark Pharmacy United Drugs Fagan Pharmacy King Soopers Payless Pharmacy Von’s Pharmacy Family Drug K-Mart Pharmacy Price Choppers Wal-Mart Pharmacy Farmer Jack Kroger Pharmacy Publix Pharmacy Walgreens Pharmacy FarmFresh Longs Drug Store Raley’s Drug Center Wegman Pharmacy Food Town Marc’s Pharmacy Rite Aid Pharmacy Winn Dixie Pharmacy

PLEASE TAKE THIS INSERT TO THE PHARMACYInjured Worker’s First Fill Prescription Information Sheet

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

4085

Employer: Employee Name:

Address:

Job Title:

Completed by: Date completed:

Title of person completing form:

ACTIVITY NEVER OCCASIONALLY FREQUENTLY CONSTANTLY(0 hours) up to 3 hours per day 3 - 6 hours per day 6 - 8+ hours per day

SittingWalkingStandingBending (neck) Bending (waist SquattingClimbing (stairs/ladders) KneelingCrawlingTwisting (neck) Twisting (waist) Reaching (below shoulder level) Reaching (above shoulder level)

DOES THIS JOB REQUIRE LIFTING? (please circle) yes no How many times per day? Lifting (check appropriate box)

0-25lb 26-60lb 61lb and above

DOES THIS JOB REQUIRE CARRYING? (please circle) yes no How far? (estimate distance):

Carrying (check appropriate box) How many times per day? 0-25lb 26-60lb 61lb and above

DOES THIS JOB REQUIRE (please check if applicable): Driving cars Driving trucks Operating forklifts Walking on uneven ground Exposure to excessive noise Exposure to dust, gas, fumes, or chemicals

Working at heights Operation of foot controls or repetitive foot movement Use of special auditory equipment Working with bio-hazards such as blood borne

pathogens, sewage, or hospital waste

Job Duties

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

4085

Physician: Please fill out this form and fax to:

Employee: Completed form must be returned to your employer following each examination.

Employer: When received, route this form to Pekin Insurance.

Employer:Claim Number:

Date of Injury/Illness:

Date of Treatment:

Diagnosis AND Treatment Plan:

RETURN TO WORK: YES______ NO_______ FULL DUTY: __________________ (date)

MODIFIED DUTY: ___________________ (date) Check appropriate box below

Sedentary Work. Lifting 10lbs maximum and occasionally lifting and/or carrying such articles as dockets, ledgers, and small tools. Although a sedentary job is defined as one that involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met. Light Work. Lifting 20lbs maximum with frequent lifting and/or carrying of objects weighing up to 10lbs. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling of arm or leg controls. Light Medium Work. Lifting 30lbs maximum with frequent lifting and/or carrying of objects weighing up to 20 lbs. Medium Work. Lifting up to 50lbs maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs. Light Heavy Work. Lifting up to 75lbs maximum with frequent lifting and/or carrying of objects weighing up to 40lbs. Heavy Work. Lifting up to 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 50lbs.

EXPECTED DATE FOR MMI (maximum medical improvement):___________________________

NEXT APPOINTMENT:______________________________________________________________

MD SIGNATURE:___________________________________________________________________

Return to Work

Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

4085

EMPLOYER’S FIRST REPORT OF INJURY OR DISEASE Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 http://www.dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov

Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay.

Fatal Injuries: Employers subject to ch.102, Wis. Stats., must report injuries resulting in death to the Department and to their insurance carrier, if insured, within one day after the death of the employee. Non-Fatal Injuries: If the injury or occupational illness results in disability beyond the three-day waiting period, the employer, if insured, must notify its insurance carrier within 7 days after the injury or beginning of disability. Medical-only claims are to be reported to the insurance carrier only, not the Department. Electronic Reporting Requirement: All work-related injuries and illnesses resulting in compensable lost time, with the exception of fatalities, must be reported electronically to the Department via EDI or Internet by the insurance carrier or self-insured employer within 14 days of the date of injury or beginning of disability. Employer may fax claims for fatal injuries to the Imaging Fax Server number on this form.

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. (Please read the instructions on page 2 for completing this form)

Employee Name (First, Middle, Last) Social Security Number - -

Sex M F

Employee Home Telephone No. ( ) -

Employee Street Address City State Zip Code -

Occupation

Birthdate Date of Hire County and State Where Accident or Exposure Occurred?

Employer Name WI Unemployment Ins. Acct No. Self-Insured? Yes No

Nature of Business (Specific Product)

Employer Mailing Address City State Zip Code -

Employer FEIN -

Name of Worker’s Compensation Insurance Co. or Self-Insured Employer Insurer FEIN -

Name and Address of Third Party Administrator (TPA) Used by the Insurance Company or Self-Insured Employer TPA FEIN -

Wage at Time of Injury

$

Specify per hr., wk., mo., yr., etc.

Per:

In Addition to Wages, Meals No. of Meals/wk. Check Box(es) if Room No. of Days/wk Employee Received: Tips Avg. Weekly Amt. $

Is Worker Paid for Overtime? Yes No If Yes, After How Many Hours of Work Per Week? For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work, and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks.

No. of Weeks: Gross Amount Excluding Tips: $ If Piece-Work, No. of Hrs. Excluding Overtime:

Start Time Hours Per Day Hours Per Week Days Per Week

Employee’s Usual Work Schedule When Injured: : AM PM Employer’s Usual Full-Time Schedule for This

Type of Work at Time of Employee’s Injury: Part-Time Employment Information:

Are there Other Part-Time Workers Doing the Same Work With the Same Schedule?

Yes No If yes, how many?

Number of Full-Time Employees Doing The Same Type Of Work:

Injury Date Time of Injury

: AM : PM Last Day Worked Date Employer Notified Date Returned to Work

Estimated Date of Return Did Injury Cause Death?

Yes No Date of Death Was This a Lost Time or Other

Compensable Injury? Yes No

Did Injury Occur Because of: Substance Failure to Use Failure to

Abuse Safety Devices Obey Rules Was Employee Treated in an Emergency Room? Yes No Was Employee Hospitalized Overnight as an In-Patient? Yes No Name and Address of Treating Practitioner and Hospital: Case Number from the OSHA Log: Injury Description - Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were Involved.

What Happened to Cause This Injury or Illness? (Describe How The Injury Occurred)

What Was The Injury or Illness? (State the Part of Body Affected and How It Was Affected)

Report Prepared By Work Phone Number

( ) - Position Date Signed

WKC-12 (R. 02/2009) SEND REPORT IMMEDIATELY - DO NOT WAIT FOR MEDICAL REPORT

INJU

RY

INFO

RM

ATI

ON

WA

GE

INFO

RM

ATI

ON

EMPL

OYE

REM

PLO

YEE

4085

EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS

The employer must complete all relevant sections on this form and submit it to the employer’s worker’s compensation insurance carrier or third party claim administrator within seven (7) days after the date of a work-related injury which causes permanent or temporary disability resulting in compensation for lost time. The employer’s insurance carrier or the third-party claim’s administrator may request that this form also be used to immediately report any injury requiring medical treatment, even though it does not involve lost work time.

For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality.

An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department of Workforce Development within 14 days of the date of work injury.

MANDATORY INFORMATION

In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to the sender if the mandatory information is not provided.

Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the “Date of Hire” is the date the employee was hired for the job on which he or she was injured.

Employer Section: Provide all requested information to identify the injured worker’s employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self-insured employer responsible for the worker’s compensation expenses for this injury. Also identify the third party claim administrator, if one is used for this claim.

Wage Information Section: Provide the information requested regarding the injured employee’s wage and hours worked for the job being performed at the time of injury.

Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached, if additional information is needed. This form was designed to include information required by OSHA on form 301. If this section is completed and retained, the employer will not have to complete the OSHA 301 form.

4085