TABLE OF CONTENTS

Table of Contents Page 1 Predesignation of Personal Physician-English Page 2 Predesignation of Personal Physician-Spanish Page 3 Notice of Personal Chiropractor or Personal Acupuncturist-English Page 4 Notice of Personal Chiropractor or Personal Acupuncturist-Spanish Page 5 First Aid Claims Page 6 Fraud Memo Regarding Reporting Claims Page 7 New Injury Workflow Page 8 Accident Investigation Report Page 9 Red Flag Indicators Page 10 Form 5020 and It’s Importance to You Page 11 Form 5020 Instructions Page 12 Pacific Compensation Free Rapid Reporting Hotline Page 13 Express Scripts Pharmacy Benefit Management Page 14-21

PREDESIGNATION OF PERSONAL PHYSICIAN

In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

your employer offers group health coverage; the doctor is your regular physician, who shall be either a physician who has limited his

or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records;

your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries;

prior to the injury your doctor agrees to treat you for work injuries or illnesses; prior to the injury you provided your employer the following in writing: (1) notice that you

want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor’s name and business address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN

Employee: Complete this section.

To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by:

_______________________________________________________________________ (name of doctor)(M.D., D.O., or medical group)

______________________________________________________(street address, city, state, ZIP)

___________________________________________(telephone number)

Employee Name (please print):

Employee’s Address: ________________________________________________________________________

Employee’s Signature_______________________________________________Date:_____________

Physician: I agree to this Predesignation:

Signature:____________________________________________________Date:__________ (Physician or Designated Employee of the Physician or Medical Group)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician’s agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).

Title 8, California Code of Regulations, section 9783. (Optional DWC Form 9783 March 1, 2007 )

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DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR

En caso de que usted sufra una lesión o enfermedad relacionada con su empleo, usted puede recibir tratamiento médico por esa lesión o enfermedad de su médico particular (M.D.), médico osteópata (D.O.) o grupo médico si:

su empleador le ofrece un plan de salud grupal el médico es su médico familiar o de cabecera, que será un médico que ha limitado su

práctica médica a medicina general o que es un internista certificado o elegible para certificación, pediátra, gineco-obstreta, o médico de medicina familiar y que previamente ha estado a cargo de su tratamiento médico y tiene su expediente médico

su "médico particular" puede ser un grupo médico si es una corporación o sociedad o asociación compuesta de doctores certificados en medicina u osteopatía, que opera un integrado grupo médico multidisciplinario que predominantemente proporciona amplios servicios médicos para lesiones y enfermedades no relacionadas con el trabajo.

antes de la lesión su médico está de acuerdo a proporcionarle tratamiento médico para su lesión o enfermedad de trabajo

antes de la lesión usted le proporcionó a su empleador por escrito lo siguente: (1) notificación de que quiere que su médico particular le brinde tratamiento para una lesión o enfermedad de trabajo y (2) el nombre y dirección comercial de su médico particular.

Puede usar este formulario para notificarle a su empleador que desea que su médico particular o médico osteópata le proporcione tratamiento médico para una lesión o enfermedad de trabajo y que los requisitos mencionados arriba han sido cumplidos.

NOTICIA DE DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR

Empleado: Rellene esta sección.

A: ____________________________ (nombre del empleador) Si sufro una lesión o enfermedad de trabajo, yo elijo recibir tratamiento médico de:

_______________________________________________________________________ (nombre del médico)(M.D., D.O., o grupo médico)

______________________________________________________(dirección, ciudad, estado, código postal)

___________________________________________(número de teléfono)

Nombre del Empleado (en letras de molde, por favor):

Domicilio del Empleado: ________________________________________________________________________

Firma del Empleado_______________________________________________Fecha:_____________

Médico: Estoy de acuerdo con esta Designación Previa:

Firma:____________________________________________________Fecha:__________ (Médico o Empleado designado por el Médico o Grupo Médico)

El médico no está obligado a firmar este formulario, sin embargo, si el médico o empleado designado por el médico o grupo médico no firma, será necesario presentar documentación sobre el consentimiento del médico de ser designado previamente de acuerdo al Código de Reglamentos de California, Título 8, sección 9780.1(a)(3).

Código de Reglamentos de California, Título 8, sección 9783. (Formulario Opcional 9783 de la DWC 1 de marzo 2007 )

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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:_______________

DWC FORM 9783.1 (March 14, 2006)

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AVISO SOBRE QUIROPRÁCTICO PERSONAL O ACUPUNTURISTA PERSONAL Si su empleador o la compañía de seguros de su empleador no tiene una Red de Proveedores Médicos, usted podría cambiar al médico que lo trata por su quiropráctico personal o acupunturista personal, después de la ocurrencia de una lesión o enfermedad relacionada con el trabajo. Para reunir los requisitos para efectuar este cambio, usted deberá dar a su empleador, por escrito, el nombre y la dirección del consultorio de su quiropráctico personal o acupunturista personal, antes de la ocurrencia de la lesión o enfermedad. El administrador de su reclamo generalmente tiene derecho a elegir al médico que lo va a tratar, dentro de los 30 días posteriores a la fecha en que su empleador supo de la lesión o enfermedad. Después de que el administrador de su reclamo disponga el inicio de su tratamiento con otro doctor dentro de este período, entonces usted puede solicitar que su tratamiento sea transferido a su quiropráctico o acupunturista personal.

Usted puede usar este formulario para proporcionar información a su empleador sobre su quiropráctico o acupunturista personal.

Información de su quiropráctico o acupunturista personal: ______________________________________________________________________________________ (Nombre del quiropráctico o acupunturista) ______________________________________________________________________________________ (Dirección: número, calle, ciudad, estado, código postal) ______________________________________________________________________________________ (Número de télefono) Nombre del empleado (sírvase usar letra de molde): _____________________________________________________________________________________

Dirección del empleado:

_____________________________________________________________________________________

Firma del empleado:____________________________________________ Fecha ___________________

DWC Form 9783.1 (March 14, 2006)

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www.pacificcomp.com

FIRST AID CLAIMS

The definition of First Aid claims continues to be a hotly-debated topic. Recently, it was clarified again by the Legislature, and I would like to share the legal definition and provide specific examples Following is the state of California’s Criteria for determining if a minor injury qualified as a FIRST AID CLAIM, or should be reported to your workers’ compensation insurer:

Regulations 5401(a) and 14311(3)(c) define First aid claims as “any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters etc., which do not ordinarily require medical care. Such one-time treatment and follow-up visit for the purpose of observation, is considered first aid, even though provided by a physician or registered professional personnel.” Labor Code 6409.1 and Regulation 14001 both outline the responsibility of employers to file complete reports of occupational injury and illness in all instances where such injury or illness results in lost time beyond the date of the injury or illness, or which requires medical treatment beyond first aid.

Section 6409(a) requires a physician who treats an injured employee to file a DFR ("Doctor’s First Report of Injury") with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work. Although the Labor Code contains "first aid" exceptions for the Employers’ Report (Form 5020) and the Employee Claim Form (DWC-1), there is no such exception for the DFR. The insurance carrier (or the employer if the employer is self-insured) must forward these DFR’s to the Department of Industrial Relations. There is no "first aid" exception to this statute.

When evaluating a new injury for First Aid status, if there is lost time beyond the date of injury or a change in medical treatment, you are

required to notify your carrier immediately so that a file can be established First Aid programs are voluntary and First Aid claims are covered under your workers’ compensation policy if you choose. If you choose to retain liability for the First Aid claim, you are responsible for payment of medical bills.

EXAMPLES OF FIRST AID INCLUDE:

• Application of Antiseptics during first

visit to medical personnel • Application of bandages during any

visit to medical personnel • Application of hot or cold compresses

during first visit to medical personnel • Soaking therapy on initial visit to

medical personnel or removal of bandages by soaking

• Application of ointments to abrasions to prevent drying or cracking

• Removal of foreign bodies from wound if procedures are not complicated and are, for example, by tweezers or by simple technique

• Use of non-prescription medications and administration of a single dose of prescription medicine on first visit for mild injury or discomfort. If medications are dispensed with milligrams above those listed below, a claim is not considered first aid: Motrin 400mg, Tylenol 500mg, Advil 200mg, and Aleve 220mg.

• Treatment of first degree burns • Administration of a tetanus shot • Observation of injury during visits to

medical personnel If you are unclear as to whether an injury is “ First Aid” or if you would like more information about this topic, please contact our Claims Department at (818)575-8500 or via email at claims@pacificcomp.com

AN IMPORTANT ANNOUNCEMENT FOR EMPLOYERS, PHYSICIANS, AND INSURERS

CONCERNING FIRST AID TREATMENT FOR WORKERS’ COMPENSATION INJURIES

First aid treatment is included as medical care that all employers must provide for their injured employees. In conjunction with the Department of Industrial Relations, Division of Workers’ Compensation, CDI wants to remind all employers, physicians, insurance carriers, and self- insurers of the need to comply with Section 6409(a) of the California Labor Code.

Section 6409(a) requires a physician who treats an injured employee to file a DFR ("Doctor’s First Report of Injury") with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work. Although the Labor Code contains "first aid" exceptions for the Employers’ Report (Form 5020) and the Employee Claim Form (DWC-1), there is no such exception for the DFR. The insurance carrier (or the employer if the employer is self-insured) must forward these DFR’s to the Department of Industrial Relations. There is no "first aid" exception to this statute.

CDI and DIR believe there are improper arrangements in place between some medical providers and employers that allow the employer to dictate how injuries are to be classified by the physicians. In some cases, and at the request of the employers, the physicians send the "Doctors First Report of injury" (DFR) only to the employers and not to the insurance carriers. This arrangement occurs even though the injuries clearly are beyond first aid. This agreement is often marketed to employers as a way to keep premiums from rising or to lower them. Such marketing practices are both improper and may also contribute to possible criminal violations related to premium fraud and the fraudulent denial of workers’ compensation benefits to injured workers.

© California Department of Insurance

Page 7

New Injury Workflow

New Injury Workflow 01.11

Catastrophic Injury?

Is it life or limb threatening?

Injured Worker Immediately

notifies Supervisor of the

occurrence

On the Job Injury

Occurs

Employer MUST Notify Cal-

OSHA within 8 hours of

occurrence for SEVERE

(amputation, hospitalization or

death) injury

Los Angeles (213) 576-7451

Santa Ana (714) 558-4451

Oakland (510) 622-2916

San Francisco (415) 972-8670

San Diego (619) 767-2280

Have employee’s

Supervisor complete the

Accident Investigation

Form and forward to

PacificComp within five

(5) days Notify Pacific Compensation

Insurance Company with any

additional information as it

occurs

Call 911 or the

employer transports

injured worker to the

nearest Emergency

Room

Refer employee to

Industrial Clinic within

the MPN

(Medical Provider

Network)

NO

Complete the Employers Report of Occupational

Injury

(Form 5020) within 24 hours of the injury via one of

the following methods:

A. PacificComp Injury Hotline at 1-800-474-8080

B. Report On-line at pacificcomp.com

C. Fax completed 5020 form to 1-818-575-8575

Employer must have injured

employee complete DWC-1

Claim Form for submission to

PacificComp and provide

Express Scripts First Fill form to

injured employee. We also

recommend the Employer

provide “Facts for Injured

Workers” pamphlet and PCIC on

the Job MPN Emplyee

Notification Guide to injured

employee at this time

Evaluate the root cause of injury,

to determine if any change in

processes are required.

For more information, please contact Pacific Compensation Insurance Company at

(818) 575-8500.

Mail DWC-1 (Employee’s Claim for

Work Comp Benefits form) along

with “Facts for Injured Workers”,

complete copy of MPN and

Express Scripts First Fill Form via

certified mail to the employee’s

home

YES

PACIFIC COMPENSATION INSURANCE COMPANY ACCIDENT INVESTIGATION REPORT

REPORTE DE INVESTIGACION ACCIDENTAL LOSS CONTROL SERVICES EMPLOYER/PATRON: _______________________________________________________ DIVISION/DIVICION: ________________ ADDRESS/DIRECCION: ________________________________________________________________________________________ NAME OF INJURED/NOMBRE DEL LESIONADO:____________________________________________________________________ DATE OF ACCIDENT-TIME/FECHA Y HORA DEL ACCIDENTE: ________________________________________________________ OCCUPATION/OFICIO: _________________________________________________________________________________________ HOW LONG EMPLOYED ON THIS OR SIMILAR OPERATION/CUANTO TIEMPO A ESTADO EMPLEADO EN ESTE O TRABAJO SIMILAR?: ___________________________________________________________________________________________________ LOCATION OF ACCIDENT/LUGAR DEL ACCIDENT: _________________________________________________________________ DATE REPORTED/FECHA QUE SE REPORTO: _____________________________________________________________________ WAS FIRST AID GIVEN/SE LE DIO AYUDA DE PRIMEROS AUXILIOS? __________________________________________________ BY WHOM/QUIEN DIO LA AYUDA? _______________________________________________________________________________ WAS EMPLOYEE SENT TO DOCTOR/SE MANDO EL EMPLEADO AL MEDICO?:__________________________________________ WAS TIME LOST/SE PERDIO TEMPO? ______________________ HOW MANY DAYS/CUANTOS DIAS? ______________________

IDENTIFICATION OF THE ACCIDENT FACTORS IDENTIFICACION DE LOS FACTORES DEL ACCIDENTE

INJURY AND/OR DAMAGE/LESIONO/Y DANO: _____________________________________________________________________ BRIEF DESCRIPTION OF ACCIDENT (WHAT HAPPENED)/BREVEMENTE DESCRIBA EL ACCIDENTE (QUE PASO?):_________________________________________________________________________________________________________________________________________________________________________________________________________________ ACCIDENT TYPE (CHECK ONE)

Struck by Struck against Overexerted Fall – same level Fall – Different level Caught in, on or between Inhalation Ingestion Absorption Contact with electrical current Exposure to Temperature Extremes

TYPO DE ACCIDENTE (MARQUE UNO) Golpeado Por Golpeado Encontra Sobre extencion De Musculo Caida de Mismo Nivel Caida de differente Nivel Atrapado Entre o contra algo Inhalcion Ingenir por la Boca Absorcion Contacto con le Electricidad Contacio con Temperaturas Extremas

ACCIDENT CAUSES/CAUSAS DEL ACCIDENTE WHAT SPECIFIC UNSAFE ACT WAS RESPONSIBLE FOR THIS ACCIDENT/QUE HECHO MALO FUE RESPONSABLE POR ESTE ACCIDENTE? ________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ WHAT SPECIFIC UNSAFE CONDITION WAS RESPONSIBLE FOR THIS ACCIDENT/QUE CONDICION MALA FUE RESPONSABLE POR EESTE ACCIDENTE? ______________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ REASONS- WHY WAS THE UNSAFE ACT COMMITTED AND/OR WHY DID THE UNSAFE CONDITION EXIST/ RASONES-POR QUE FUE EL HECHO MALO COMETIDO Y/O POR QUE EXISTO LA CONDICION MALA?

Improper attitude/ Actitud impropia Lack of Knowledge/Experience/ Falta de conocimiento/experiencia

Human Limitation/Limitaciones humanas Condition / Afección ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

CORRECTIVE ACTION/ACCION CORRECTIVA WHAT DO YOU SUGGEST BE DONE TO PREVENT A SIMILAR ACCIDENT/QUE SUGIERE LISTED SE HAGA PARA PREVENIR UN ACCIDENTE IGUAL?

Instruction/Training Motivation/Discipline Proper placement Repair/Eliminate Recommend to management

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ SIGNATURE OF SUPERVISOR/FIRMA DEL MAYORDOMO: ___________________________________________________________ DEPARTMENT/NOMBRE DEL DEPARTAMENTO: ___________________________________________________________________ DATE/FECH: _________________________________________________________________________________________________

Confidential Toll-Free Fraud Hotline: 877-748-7242

Red Flag Indicators

The following 28 “red-flag” indicators are used as a tool or “lead” to determine claims that warrant additional scrutiny. No red-flag indicator by itself should automatically determine that a claim be considered “suspicious”. Multiple red-flag indicators (which could suggest the possibility of fraud) cannot be used as evidence to prove beyond a reasonable doubt that fraud has been committed on the part of the Claimant. Circumstances related to the alleged work-place injury:

1. Delayed reporting of injury or claim 2. Discrepancies between Claimant’s statement and history 3. Questionable accident: unwitnessed or possibly staged 4. Accident occurs in an area the claimant should not have been 5. Claimant provides vague details regarding injury 6. Alleged injury does not correspond with job description 7. Injury occurred the morning after the Claimant returned to work from a day off or

vacation, etc. 8. Claimant stats asking, “How much am I going to get?” 9. Co-Workers hear rumors that the accident was not “legitimate”

Circumstances related to the Claimant’s employment: 10. Claimant received poor performance review just before reporting claim 11. Claimant is on probation and files unwitnessed claim 12. Claimant had knowledge of potential lay-offs and files a claim 13. Claimant has been repeatedly unhappy with work situation 14. Claimant expresses hostile feelings towards the workplace 15. Claimant states that he/she is too ill to perform modified work 16. Short-term employee 17. Claimant has history of reporting subjective injuries 18. Concurrent employment, especially if the secondary employer was paying wages

“under the table” Circumstances Related to Claimant’s personal situation:

19. Claimant uses an alias 20. Unsresolved family issues, such as, child custody, ill family member, etc. 21. Financial problems: creditors, wage garnishment, levies 22. Claimant is never home when examiner attempts to contact 23. Claimant refuses to provide a physical address 24. Claimant is actively participating in sports, weight-lifting, going to the gym, etc.

Circumstances related to treatment: 25. Doctor states claimant is 100% non-feasible after minor injury 26. ISO search indicates prior injuries to the same body part, which the Claimant did

not reveal during medical appointments, etc. 27. Subjective ailments are increasing while objective findings are decreasing 28. Subjective complaints do not match doctor’s findings

30301 Agoura Road Agoura Hills, California 91301-2096 Toll Free 866.374.8500 818.575.8500 www.pacificcomp.com

EMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS (FORM 5020) AND IT’S IMPORTANCE TO YOU

We understand that filling out the Form 5020 requires a lot of information to be passed on from you to Pacific Compensation Insurance Company. The information provided is vital to the success of your program and we as your partner want to ensure we have accurate and detailed information to best serve you and minimize loss costs. Optimally, our goal is to receive your completed reports of injury within 24 hours. Fully completed forms provide Pacific Compensation Insurance Company with a clear picture of the injury or allegations a s well as provide mandatory details regarding wages, date of hire, wo rk status, and class coding to name a few. This information allows us to process your claims appropriately and efficiently, identify red flags, reduce calls to our claims coordinator and respond to your employees quickly. In turn, it also allows us to produce accurate loss reports and analysis to you so you can manage your Workers Compensation Program effectively. There are thirty-nine (39) fields of information th at need to be completed on the 5020. Refer to the sample and the definition 50 20 included. Thank you for your cooperation in this very importa nt matter. For more information on this subject, please call P acific Compensation Insurance Company at (818)575-8500 and speak with y our Claims Examiner or assistance.

State of California Please complete in triplicate (type if possible) Mail two copies to:

EMPLOYER'S REPORT OF

OCCUPATIONAL INJURY OR ILLNESS

Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony.

California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the

date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or

illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death

must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

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6. TYPE OF EMPLOYER:City School DistrictPrivate CountyState Other Gov't, Specify:

17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OFINJURY/ILLNESS (mm/dd/yy)

18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM15. PAID FULL DAYS WAGES FOR DATE OF SEX16. SALARY BEING CONTINUED?NJURY OR LAST FORM (mm/dd/yy)Yes NoDAY WORKED? Yes No

19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning AGE

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R

Y

21. ON EMPLOYER'S PREMISES?20a. COUNTY20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)

Yes No

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop. 23. Other Workers injured or ill in this event?

Yes No

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PART OF BODY

ATTENTION 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

while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.

Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2*.

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35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)

37b. UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED

37a. EMPLOYMENT STATUS37. EMPLOYEE USUALLY WORKS

regular, full-time part-time

EXTENT OF INJURY

total weekly hoursdays per week,hours per day,

temporary seasonal

39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?38. GROSS WAGES/SALARYper$ Yes No

Date (mm/dd/yy)Signature & TitleCompleted By (type or print)

• Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insuranceclaim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and.

federal workplace safety agencies.

FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

OSHA CASE NO.

FATALITY

1. FIRM NAME Ia. Policy Number

2. MAILING ADDRESS: (Number, Street, City, Zip) 2a. Phone Number

3. LOCATION if different from Mailing Address (Number, Street, City and Zip) 3a. Location Code

4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc. 5. State unemployment insurance acct.no

Please do not use

this column

CASE NUMBER

OWNERSHIP

INDUSTRY

OCCUPATION

7. DATE OF INJURY / ONSET OF ILLNESS(mm/dd/yy)

8. TIME INJURY/ILLNESS OCCURRED

PMAM

9. TIME EMPLOYEE BEGAN WORK

PMAM

10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)

1 1. UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY?

Yes No

12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) 14. IF STILL OFF WORK, CHECK THIS BOX:

DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY

SOURCE

EVENT

SECONDARY SOURCE

Pacific Compensation Insurance CompanyP.O. Box 5042,Thousand Oaks, CA 91359-5042

WC ISSUED ON BINDER

PHYSICAL LOCATION OF THE COMPANY (818) 999-9999

WRITE SAME IF SAME OR ADDRESS IF DIFFERENT THAN ABOVE IF APPLICABLE

TYPE OF WORK THE COMPANY DOES

✔

WHAT WAS THE BODY PART THAT WAS INJURED, WHAT WAS THE TYPE OF INJURY (cut, bruise, sprain, fracture, etc)

PHYSICAL ADDRESS OF WHERE INJURY OCCURED

DEPT., (KITCHEN, WAREHOUSE, PARKING LOT, ACCOUNTING DEPT., ETC

STATE ALL ITEMS THAT WERE USED AT THE TIME OF INCIDENT (FORKLIFT, HAND TOOLS, COMPUTER, LADDER,ETC)

DESCRIBE IN DETAIL THE JOB DUTIES/FUNCTIONS INJURED WORKER WAS DOING AT THE TIME OF INCIDENT

COMPLETE NAME (FIRST/MIDDLE/LAST) 000-00-0000 01/01/00

MUST PROVIDE (000) 000-0000

JOB TITLE APPROVED BY YOUR HUMAN RESOURCES DEPT. 01/01/00

SUPERVISOR/HUMAN RESOURCES

STATE WHETHER THE INJURED WORKER WAS FOLLOWING PORPER PROCEDURES OR INCORRECTLY PERFORMINGTHE TASK, WERE THERE DISTRACTIONS, OTHER EMPLOYEES AROUND, NOISE ISSUES, ENVIRONMENTAL ISSUES,ETC.27. Name and address of physician (number, street, city, zip) 27a. Phone Number

28. Hospitalized as an inpatient overnight? If yes then, name and address of hospital (number, street, city, zip)No Yes

Yes No

29. Employee treated in emergency room?

28a. Phone Number

30. EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. DATE OF BIRTH (mm/dd/yy)

33. HOME ADDRESS (Number, Street, City,Zip) 33a. PHONE NUMBER

36. DATE OF HIRE (mm/dd/yy)34. SEX

Male Female

PACIFIC COMPENSATION FREE RAPID REPORTING HOTLINE

1-800-474-8080 Statistics prove that early reporting of claims minimize overall costs. Our toll free service is available 7 days a week, 365 days a year to ensure prompt notification of all claims. Your calls will always be answered by a live operator. Please be ready with the following information to minimize the amount of time spent on the call. Date of loss Did employee miss any time from work on date of

injury? If “yes” last day worked Time of loss Date disability began Policyholder’s name, address and/or policy number. Specify location code

Date employee last received full pay

Nature of business Has employee received any pay after injury? Type of business (corporation, partnership, or sole proprietorship)

How many work days has employee missed?

Did the incident occur on employers premise? How is employee paid (hourly, salary, variable)? Employee’s annual salary? If hourly wages/hour, # hours and days

Nature of business Date employer notified of injury Name, address and phone number of loss location Activity employee was engaged in when injury

occurred Employee’s name, address, phone number and social security number

Description of injury

Gender Were any materials in use that affected injury? Marital Status Was safety equipment provided? If “yes”, was it

used Date of birth Was medical attention authorized? If “yes”, what

date Employee’s title Hospital name address and phone number Employee’s Department Physician’s name, address, phone number Employment status (f/t, p/t) Did employee choose physician? Employee’s date and state of hire Was there a witness? If “yes” name, address and

phone number Time employee began work on date of injury Name, address, phone number, time and place to

reach contact person Employee’s supervisor name and phone number Name, address, phone number, time and place to

reach Supervisor What Language does the employee primarily speak? English, Spanish or other?

Are you completing 5020 due to written/oral request from PacificComp?

If the employee is no longer working for the company, please explain: Termination, Lay-Off, etc.

Does the employee have Group Health Coverage through your company? If so, with which provider?

If the claim is questionable, please explain why? Do you have any additional comments?

30301 Agoura Road Agoura Hills, California 91301-2096 Toll Free 866.374.8500 818.575.8500 www.pacificcomp.com

Dear Policyholder: Pacific Compensation Insurance Company has teamed up with Express Scripts, Inc. (ESI), a pharmacy benefit management company, to provide your company with a prescription drug program for work-related injuries. Some features of this pharmacy program include:

• Availability for all compensable work-related injuries. • Access to over 57,000 pharmacies nationwide. • Immediate claim adjudication. • Availability of a registered pharmacist 24 hours per day via a toll-free line.

The PBM is designed to effectively deliver medications to injured workers. It also provides greater control over the quantity and type of medications your employee receives through a custom formulary developed by Pacific Comp. Included in your claims kit is a first fill form that can be given to your employee at the time of injury. Express Scripts will allow the dispensing of a 14 day supply of medicationwhile the claim is being processed. This will prevent your injured worker from having to incur out-of-pocket expenses for medication. Shortly after claim approval, the injured worker will automatically be issued a Pharmacy Benefit Program packet (sample enclosed) from Express Scripts that includes a prescription card and background information on the program. Please relay this information to the personnel at all locations within your company who most often assist injured workers. For a complete list of participating pharmacies, call the toll-free number 1-800-945-5951 access Express Scripts’ website at www.express-scripts.com. The prescription card is only valid for work-related prescriptions. We have also included a one page frequently asked questions to provide to the injured worker. If you have any questions please feel free to contact Linda Taylor, Medical Cost Containment Manager at 818-575-8563. Sincerely, Pacific Compensation Insurance Company

NOTE: This form is not valid in the state of Ohio. For all other states, liability of a workers’ compensation claim is not assumed based on the dispensing of medication(s) to a patient.

TEMPCARD 8.2008

Temporary Prescription Services ID

Attention Injured Worker• On your first visit, please give this notice to any pharmacy listed below to expedite the processing of your approved workers’

compensation prescriptions. (Based on the established parameters by your employer.) • Questions or need assistance locating a participating pharmacy: Call the Express Scripts Contact Center at 800.945.5951.

Atencion Trabajador Lesionado: • Este formulario de Identificación para Servicios Temporales de Prescripción de Recetas por Compensación del Trabajador

DEBERÁ SER PRESENTADO a su farmacéutico al surtir su(s) receta(s) inicial(es). • Si tiene cualquier duda o necesita localizar una farmacia participante, por favor contacte al área de Atención a Clientes de

Express Scripts, en el teléfono 800.945.5951.

Attention Supervisor: Please complete the following information for the injured worker.

Express Scripts

ID #: SSN to be presented to the pharmacy at the time prescription is filled

Date of Injury: / /

MM/DD/CCYY

Group #: JZHA

Employee Date of Birth: / / MM/DD/CCYY

Employee Information

First M Last

Mailing Address

Street Address or PO Box

City State Zip

Employer’s Name

Attention Pharmacist

• Express Scripts administers this workers’ compensation prescription program. Follow the steps below to submit a claim. • For assistance, call the Express Scripts Contact Center at 800.945.5951.

Pharmacy Processing Steps

Step 1 Enter bin number 003858 Step 2 Enter processor control A4 Step 3 Enter the group number as it appears above Step 4 Enter the injured worker’s 9 digit ID# Step 5 Enter first name & last name Step 6 Enter the injured worker’s date of injury (enter in PA field in the format ccyymmdd)

Participating Pharmacy Chains

A & P Acme Pharmacy Albertson’s Albertson’s/Acme Albertson’s/Osco Albertson’s/Sav-On AmerisourceBergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg's Bi-Lo Bi-Mart BJ’s Wholesale Club Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs

Cash Wise Coborn's Costco Cub CVS D&W Dahl's Dierbergs Discount Drugmart Doc's Drugs Dominicks Drug Emporium Drug Fair Drug Town Drug World Duane Reade Eckerd Econofoods EPIC Pharmacy Network FamilyMeds Farm Fresh

Farmer Jack Food City Food Lion Fred's Gemmel Giant Giant Eagle Giant Foods Hannaford Happy Harry's Harris Teeter H-E-B Hi-School Pharmacy Hy-Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs LeaderNet (PSAO)

Longs Drug Store Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare Network Pharmaceuticals Northeast Pharmacy Services Osco P & C Food Markets Pamida Park Nicollet Pathmark Pavilions Price Chopper

Publix Quality Markets Raley's Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam’s Club Sav-On Save Mart Schnucks Scolari's Sedano Shaw's Shop 'N Save Shopko ShopRite Snyder Star Markets Stop & Shop

Sun Mart Super Fresh Target Texas Oncology

Services The Pharm Thrifty White Times Tom Thumb Tops Ukrop's United Drugs United Supermarkets Vons Waldbaums Walgreens Wal-Mart Wegmans Weis Winn Dixie

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Dear Injured Employee: Effective immediately your pharmacy program services for your workers’ compensation prescriptions will be through Express Scripts. A new Express Scripts prescription-drug ID card is enclosed in this packet. You should begin using the Express Scripts card at any Express Scripts Workers’ Compensation participating pharmacy. A list of participating chain pharmacies in your area is included on the back of this letter. In addition, you can access Express Scripts’ Pharmacy Locator at www.express-scripts.com/custom/expresscomppharm to search for participating pharmacies in your area, or call the Express Scripts Customer Service number below if you need help locating a network pharmacy. Begin using the Express Scripts card now for your work-related injury prescriptions. When using the Express Scripts card, you will pay nothing out of pocket for prescriptions approved for your work-related injury. The Express Scripts card is valid only for prescriptions related to your workers’ compensation claim. In addition, no changes are being made to your current prescriptions; only the processing information for your pharmacy to submit to Express Scripts. To avoid delays in the processing of your prescription, be sure to present your new Express Scripts ID card to your pharmacy now. Enjoy the Convenience of Home Delivery In addition, if you’re taking long-term medications for your work-related injury, you can start filling your prescription through the Express Scripts Home Delivery pharmacy effective immediately. With Home Delivery, you can receive up to a 90-day supply of medication, which is mailed directly to your home. You may call Express Scripts Customer Service at the number provided below to learn more and request a Home Delivery form. Questions? If you have questions, call Express Scripts Customer Service at 800.945.5951 to speak with a patient care advocate. Customer Service is available 24 hours a day, 7 days a week. Sincerely, Express Scripts

IMPORTANT TOLL-FREE PHONE NUMBERS

Customer Service ………….. 800.945.5951 Hearing Impaired TTD …….. 800.972.4348

A & P Acme Pharmacy Albertson’s Albertson’s/Acme Albertson’s/Osco Albertson’s/Sav-On AmerisourceBergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg's Bi-Lo Bi-Mart BJ’s Wholesale Club Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs Cash Wise Coborn's Costco Cub CVS D&W Dahl's Dierbergs Discount Drugmart Doc's Drugs Dominicks Drug Emporium Drug Fair Drug Town Drug World Duane Reade

Eckerd Econofoods EPIC Pharmacy Network FamilyMeds Farm Fresh Farmer Jack

Food City Food Lion Fred's Gemmel Giant Giant Eagle Giant Foods Hannaford Happy Harry's Harris Teeter H-E-B Hi-School Pharmacy Hy-Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs LeaderNet (PSAO) Longs Drug Store Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare

Network Pharmaceuticals NE Pharmacy Services Osco P & C Food Markets Pamida Park Nicollet

Pathmark Pavilions Price Chopper Publix Quality Markets Raley's Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam’s Club Sav-On Save Mart Schnucks Scolari's Sedano Shaw's Shop 'N Save Shopko ShopRite Snyder Star Markets

Stop & Shop Sun Mart Super Fresh Target TX Oncology Services The Pharm

Thrifty White Times Tom Thumb Tops Ukrop's United Drugs United Supermarkets Vons Waldbaums Walgreens Wal-Mart Wegmans Weis Winn Dixie

Attention Pharmacist

Express Scripts administers this workers’ compensation prescription program. Follow the steps below to submit a claim.

Step 1 Enter Bin Number 003858

Step 2 Enter Processor Control A4

Step 3 Enter the Group Number: JZHA

Step 4 Enter the injured worker’s 9 digit ID# XXXXXXXXX (no dashes, no spaces) Step 5 Enter injured worker’s first name & last name Step 6 Enter the injured worker’s date of injury (enter in PA field in the format ccyymmdd)

NEED ASSISTANCE?

Pharmacist: If you have questions while processing the claim, please call the Express Scripts Contact Center at 800.945.5951.

Estimado trabajador lesionado: Si necesita que le surtan una receta por una lesión o enfermedad relacionada con el trabajo, Pacific Compensation Insurance Company cuenta con un programa para que le resulte mucho más fácil obtener su receta. Hemos seleccionado a Express Scripts para que administre este servicio. Tarjeta de identificación para medicamentos de venta con receta. A partir de ahora, puede llevar la tarjeta adjunta (en la parte superior … está troquelada para retirarla fácilmente) a una farmacia minorista participante. Si utiliza una farmacia de venta minorista, siempre y cuando la receta médica corresponda a una lesión o enfermedad relacionada con su trabajo, no tendrá costos a su cargo. Además, no tendrá que presentar ningún formulario a Pacific Compensation Insurance Company. Express Scripts le paga a la farmacia directamente. Para encontrar una farmacia minorista participante en su vecindario, consulte la lista en el reverso de esta página, o llame a Express Scripts al 1.800.945.5951. También cuenta con otra opción conveniente: puede usar la Farmacia de Envío por Correo de Express Scripts para surtirse de las recetas de medicamentos que deba seguir tomando durante un período de tiempo prolongado. En la Farmacia de Envío por Correo, por lo general sus recetas se surten dentro de las 48 horas de su recepción y se le envían directamente por correo a su hogar. Recibirá sus recetas dentro de las dos semanas. Una vez más, usted no tiene que pagar nada por adelantando por estas recetas por lesiones relacionadas con el trabajo. Llame a Servicio al Cliente de Express Scripts al 1.800.945.5951 para pedir un Formulario de Solicitud de Envío por Correo. Cuando reciba el Formulario de Solicitud de Envío por Correo, simplemente complete las secciones “Información del paciente” y “Enviar a”, incluya su(s) receta(s) y envíelo a Express Scripts. Cada vez que reciba una receta mediante el servicio por correo de Express Scripts, recibirá un nuevo “Formulario de autorización de reposición” y un nuevo sobre que podrá usar cuando solicite su próxima receta para envío por correo. Si tiene alguna pregunta, llame a Express Scripts al 1.800.945.5951. Un amable representante de Servicio al cliente estará disponible para atender su llamada en cualquier momento. Gracias por elegir Express Scripts. Preguntas frecuentes sobre sus beneficios relacionados con recetas ¿Qué es Express Scripts? Express Scripts es una compañía que administra beneficios en farmacias con una vasta experiencia en el tema de las recetas en casos de compensación del trabajador. Express Scripts posibilita que su farmacia local le surta su receta relacionada con una lesión, sin costo alguno para usted. Simplemente lleve su tarjeta de farmacia adjunta y su receta a una farmacia de alguna de las redes participantes que aparecen más adelante y preséntela al farmacéutico. ¿Cuánto cuesta la tarjeta de identificación para medicamentos de venta con receta? La tarjeta de identificación para medicamentos de venta con receta es gratuita y cubre todas las recetas por lesiones relacionadas con el trabajo. ¿Puedo usar la tarjeta de identificación para recetas inmediatamente? Sí, la puede usar en cualquier farmacia minorista participante. Simplemente lleve su receta y su tarjeta de identificación a la farmacia. Para localizar una farmacia en su vecindario, consulte la lista adjunta o llame a Express Scripts al 1.800.945.5951. ¿Quién me puede brindar más información? Llame a Express Scripts al 1.800.945.5951 si tiene alguna pregunta adicional o alguna inquietud sobre el programa. continúe por favor leyendo

A continuación se incluye una lista de las cadenas de Farmacias participantes de la Red Express Comp. Este listado de farmacias está sujeto a cambio sin previo aviso.

A & P Acme Pharmacy Albertson’s Albertson’s/Acme Albertson’s/Osco Albertson’s/Sav-On AmerisourceBergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg's Bi-Lo Bi-Mart BJ’s Wholesale Club Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs Cash Wise Coborn's Costco Cub CVS D&W Dahl's Dierbergs Discount Drugmart Doc's Drugs Dominicks Drug Emporium

Drug Fair Drug Town Drug World Duane Reade Eckerd Econofoods EPIC Pharmacy Network FamilyMeds Farm Fresh Farmer Jack Food City Food Lion Fred's Gemmel Giant Giant Eagle Giant Foods Hannaford Happy Harry's Harris Teeter H-E-B Hi-School Pharmacy Hy-Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs Kroger LeaderNet (PSAO) Longs Drug Store

Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare Network Pharmaceuticals Northeast Pharmacy

Services Osco P & C Food Markets Pamida Park Nicollet Pathmark Pavilions Price Chopper Publix Quality Markets Raley's Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam’s Club Sav-On Save Mart Schnucks

Scolari's Sedano Shaw's Shop 'N Save Shopko ShopRite Snyder Stop & Shop Sun Mart Super Fresh Super Rx Target Texas Oncology Srvs The Pharm Thrifty White Times Tom Thumb Tops Ukrop's United Drugs United Supermarkets Vons Waldbaums Walgreens Wal-Mart Wegmans Weis Winn Dixie

Nuestra política de divulgación y confidencialidad Para Express Scripts es importante proteger la confidencialidad de la información que usted y su proveedor de

atención de la salud comparten con nosotros. Nos comprometemos a usar esta información únicamente para brindar

los servicios para los cuales nos contrató su plan de salud, o bien para ofrecerle toda la información que le pueda

resultar de utilidad. En el desempeño normal de nuestras actividades, a veces necesitamos compartir información

sobre usted con su administrador del plan, médico o farmacéutico o plan de salud, de total conformidad con los

términos de su plan de beneficios sobre recetas. También podemos usar cierta información sobre usted para

identificar a las personas que se beneficiarán de los programas que su plan de salud nos contrató para prestar.

Además, podemos: (1) analizar información sobre uso en su general (sin vincularla con su identidad) para estudiar y

sugerir el diseño de beneficios de su administrador del plan o plan de salud, y divulgar estos datos generales a

terceros; y (2) otorgar en licencia los datos generales (sin vincularlos con su identidad) a terceros, con fines de

investigación. En respuesta a una orden judicial, citación, orden de allanamiento, ley o reglamentación, podemos

vernos legalmente obligados a divulgar su información personal. Si se produjese esa circunstancia, le notificaremos

al respecto, salvo que al hacerlo estuviéramos en contravención de la ley o de una orden judicial.

Con la excepción de las circunstancias mencionadas, no usaremos ni divulgaremos información personal a terceros

sin su autorización expresa.

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