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HomeMy WebLinkAboutMN workers compensation Information Kit JUL 1 �j 1 0200072919 OAK PARK HEIGHTS, CITY OF PO BOX 2007 OAK PARK HEIGHTS MN 55082 League of Minnesota Cities Insurance Trust 145 University Avenue West,St. Paul,MN 55103-2044 (651)281-1200 • (800)925-1122 LMC 8\ C � Fax:(651)281-1298 • TDD:(651)281-1290 www.lmnc.org MINNESOTA WORKERS' COMPENSATION INFORMATION KIT This information is provided to assist you in understanding your workers' compensation coverage and reporting workers' compensation claims in a thorough and timely manner. Please read the information carefully, or forward this entire kit to the person responsible for filing work- related injury reports. The following information is included: • Minnesota workers' compensation general employer information • First Report of Injury forms with instructions • Minnesota workers' compensation system employee information sheet • Supervisor's Report of Accident forms with instructions • Workers' compensation and employers' liability coverage agreement • LMCIT workers' compensation contact information • Employee's Rights and Responsibilities—information to be posted by the City If you need additional copies of any of the information included, please contact the LMCIT Workers' Compensation department: Barb Meyer, Policy Services Technician Jan Kodet,Underwriting Supervisor Phone: 651-215-4173 Phone: 651-215-4082 Fax: 651-281-1297 Fax: 651-281-1298 Email: bmeyer2 @lmnc.org Email: jkodet @lmnc.org Deb Anger, Claims Manager Bill Everett, Associate Administrator Phone: 651-215-4170 Phone: 651-281-1216 Fax: 651-281-1297 Fax: 651-281-1298 Email: danger @lmnc.org Email: beverett@lmnc.org Any of the above listed individuals can also be reached at 800-925-1122 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER League of Minnesota Cities Claims Department 145 University Avenue West,St. Paul,MN 55103-2044 (651)281-1200 • (800)925-1122 Loamy: Cftiea Fax: (651)281-1297 • TDD:(651)281-1290 ' °�"B�7 °"�' www.Imnc.org To: Employers From: Deb Anger-Account Manager RE: EMPLOYEE INFORMATION SHEET Date: December 4, 2003 On April 27, 2000, Governor Ventura signed a workers' compensation bill that, amongst other things, has created an additional responsibility for employers. Pursuant to M.S. 176.231, sub. (2), "the employer must give the employee the `Minnesota Workers' Compensation System Employee Information Sheet' at the time the employee is given a copy of the first report of injury." Attached you will find copies of this information sheet. You can request a supply of these forms in the same manner as the First Report of Injury forms from us. If you have any questions concerning this issue, feel free to contact me at (651) 215- ' 4170 or via email at danger@lmnc.org. LM 2535 (12/03) AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER Minnesota Workers' Compensation System Employee Information Sheet What does workers' compensation pay for? • Medical care for the work injury,as long as it is reasonable and necessary • Wage-loss benefits for part of your lost income (there is a three-calendar-day waiting period before these benefits start) • Benefits for permanent damage or loss of function of a body part • Benefits to your spouse and/or dependents if you die of a work injury • Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer How are workers' compensation benefits paid? Your workers' compensation benefits are paid by an insurance company or your employer, if your employer is self- insured. State law sets the benefit levels. Please note: pursuant to statute, the insurer can obtain medical information specific to your work injury without your authorization. If the insurer accepts your claim for wage loss benefits and you have been disabled for more than three calendar days. • The insurer will send you a copy of the Notice of Insurer's Primary Liability Determination form stating your claim is accepted. • The insurer must start paying wage-loss benefits within 14 days of the date your employer knows about your work injury and lost wages. The insurer must pay benefits on time. Wage-loss benefits are paid at the same intervals as your work paychecks. If the insurer denies your claim for wage loss benefits: • The insurer will send you a copy of the Notice of Insurer's Primary Liability Determination form stating it is denying primary liability for your claim. The form must clearly explain the facts and reasons why the insurer believes your injury or illness did not result from your work. • If you disagree with the denial, you should talk with the insurance claims adjuster who is handling your claim. Your employer's insurance company can answer most questions about your claim. • Insurer name: League of Minnesota Cities Insurance Trust Phone: (651)281-1200 • If you are not satisfied with the response you receive from the insurer and still disagree with the denial, you should contact the Department of Labor and Industry at one of the numbers listed below to see what to do next. If you have other questions or need more help, call the Minnesota Department of Labor and Industry Workers' Compensation Hotline: Twin Cities and Southern Minnesota: (651)284-5032 or 1-800-342-5354; TDD(651)297-4198 Duluth and Northern Minnesota: 218)733-7810 or 1-800-365-4584 Your call will be answered by experienced workers' compensation specialists, who can provide instant and accurate information and assistance. Additional workers' compensation information is available on the department's Web site at www.doli.state.mn.us. Your employer is required by law to give you this information. This material can be made available in different formats,such as large print,Braille or on audiotape,by calling the numbers printed above. Date April 2003. This form may be copied or reproduced electronically. Do not file this form with the department. LM2535(12/03) League of Minnesota Cities Insurance Trust Workers' Compensation Contact Information To Report a Claim: On-Line: A UserID and password is needed to use the on-line claims reporting system. Please contact Amy Mansager at 651-281-1200 or 800-925-1122 to receive a UserID and password for your City. Fax: 888-234-7839 651-215-4185 Mail: LMCIT Workers' Compensation Claims 145 University Avenue West St.Paul,MN 55103-2044 Phone Assistance: 651-281-1200 800-925-1122 Policy Questions, Copies of Forms,Billing Questions, or Loss Runs: Barb Meyer, Policy Services Technician Jan Kodet,Underwriting Supervisor Phone: 651-215-4173 Phone: 651-215-4082 Fax: 651-281-1297 Fax: 651-281-1297 Email: bmeyer2 @lmnc.org Email: jkodet @lmnc.org Deb Anger,Account Manager Phone: 651-215-4170 Fax: 651-281-1297 Email: danger @lmnc.org Loss Control(Injury Prevention): Chris White,Loss Control Specialist Ellen Longfellow,Loss Control Attorney Phone:651-215-4069 Phone: 651-281-1269 Fax: 651-281-1297 Fax: 651-281-1297 Email: cwhite @Inmc.org Email: elongfel @lmnc.org Doug Holm, Loss Control Services Coordinator Phone:651-215-4079 Fax: 651-281-1297 Email: dholm @lmnc.org MINNESOTA WORKERS' COMPENSATION GENERAL EMPLOYER INFORMATION WHAT INJURIES TO REPORT State law requires that you report any and all injuries and illnesses that your employees believe are work- related. The League of Minnesota Cities Insurance Trust (LMCIT) will then determine if any workers' compensation benefits are payable to the injured employee. Remember, filing a First Report of Injury with us does not mean that you are admitting any liability. It means only that you are reporting a claimed injury or condition, which your employee thinks is related to work activities. Do not deliberately obstruct or attempt to prevent an employee from seeking workers' compensation benefits. If you do,you could be liable for any workers' compensation benefits plus triple damages to that employee. If an employee claims a work-related injury,report it to us along with all relevant information. Let us investigate and determine if any workers' compensation benefits are due; we are experts in Minnesota workers' compensation. By law you must post the name and address of your workers' compensation carrier(The League of Minnesota Cities Insurance Trust) in a conspicuous place. We have enclosed an"Employees' Rights"poster specifically for that purpose. WHO REPORTS AN INJURY-- The injured employee is required to report an injury to you,the employer, within 180 days of its occurrence. You are then required to report that claimed injury to us on a First Report of Injury form. It is neither the injured employee's, nor your insurance agent's,responsibility to report the injury to us. Do not ask the injured employee or your agent to complete the form. If they cause any delay in reporting the injury to us,the City can be penalized by the Minnesota Department of Labor and Industry. WHEN TO REPORT AN INJURY If an employee is killed or suffers a life-threatening injury (amputation of limb,massive internal injuries, etc.) you must report by phone to LMCIT within 48 hours of the occurrence. You must also send a completed First Report of Injury form to us within 7 days of the injury. You must report any other work-related injury or illness within 10 days of your first knowledge of its occurrence. If the employee's supervisor or manager knows about the injury,then the City is also deemed to have knowledge. Be sure supervisory staff know their responsibilities. We recommend that you complete and mail the original First Report on the same day you are notified of the injury. Do not wait for the employee to return to work or for medical bills or other information. The Minnesota Department of Labor and Industry can assess fines for late reporting by a city, as well as penalties for any delayed payment of benefits. HOW TO REPORT AN INJURY State law requires that you use a Minnesota First Report of Injury (FROI) form. This form can be submitted in paper form to LMCIT via mail or fax, or this form can be completed electronically on the LMCIT web site located at www.lmcit.lmnc.org. - over- Also have the employee's supervisor complete the Supervisor's Report of Accident(SRA). This form will assist in any internal investigation of the accident and what caused it. The FROI form can be completed using information from the SRA, personnel records, and elsewhere. If there are any unusual circumstances or you need to provide more information, you should attach a letter to the report. Send the original FROI and SRA to LMCIT. Keep a copy of each for your records. Also give a copy of the FROI and the Minnesota Workers' Compensation System Employee Information Sheet to the injured employee, as required by law. If the claim results in the employee's inability to work for a period of more than three days, send a copy of the FROI to the employee's local union office, if any. HOW TO REPORT LOST TIME If an employee loses work time (even 10 minutes) due to a work-related injury,you must report it. In Box#21 on the FROI form, enter the date when lost time first occurred. If an employee begins to lose time from work after you've mailed the FROI form, call us immediately to let us know. HOW TO HANDLE AN INJURED EMPLOYEE Be sure to give the employee a copy of the FROI and the Minnesota Workers' Compensation System Employee Information Sheet. Do not ignore your injured employees. Communicate with them regularly and let them know you are concerned about them. It is especially important if they are losing time from work that you keep them mentally "connected"to their job. If at all possible, provide light duty or part-time work to help return them to health and productivity as soon as possible. This is not only good for your employees, it also-helps to reduce your claim costs. Call us as soon as an employee returns to work after a work-related injury. We can then discontinue time-loss benefits and avoid the possibility of overpaying your employee. HOW TO HANDLE MEDICAL BILLS FOR AN INJURED EMPLOYEE Promptly send us all injury-related medical bills you or your employee receive. Medical providers often bill only one party, so if you receive a bill, it probably means that we have not. Before we pay a bill, we review it to ensure that it's related to the work injury and we request medical records for it. The law allows up to 30 days from the date we receive those records to pay a bill so it may sometimes be several months from the date of treatment before we're able to pay. Do not pay medical bills for your employee's work-related injuries. First, it may be illegal for you to do so. Second, by paying a bill, you may be legally accepting liability for an injury which is not really work-related. Third, because of the Medical Fee Schedule, we can often pay less that what the medical provider charges which saves you money. HOW TO PREVENT WORK INJURIES For your benefit and assistance, we offer safety services, which can be tailored to your needs to help prevent work-related injuries. Our Loss Control Representatives are available for consultation regarding safety in the workplace and for safety surveys of your facilities. They can also assist you in complying with OSHA regulations and the development of your own accident prevention and loss control program. These services are provided at no additional charge to you. To schedule a visit or for more information on safety and loss control topics,please contact Chris White at 651-281-1200 or 800-925-1122 or via email at cwhite @lmnc.org. You may also contact Ellen Longfellow at the same phone numbers, or via email at elongfel @lmnc.org. League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Information Page 1. The "City" RENEWAL Agreement No.: 0200072919 OAK PARK HEIGHTS, CITY OF PO BOX 2007 "City" is: x City OAK PARK HEIGHTS MN 55082 _ Joint Powers Entity Other(describe) 2. The Agreement Period is from 12:01 a.m. 7/07/2005 to 12.01 a.m. 7/07/2006 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: 4. Retro-rating option selected? _Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item, except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS Manual Premium 37791. Experience Modification .82 6802. Standard Premium 30989. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 570.40 Premium Discount 2469. 00874 FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 28520. 232 S LAKE ST FOREST LAKE MN 55025- 7/01/2005 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 The "City" Agreement No.: 0200072919 Agreement Period From: 7/07/2005 OAK PARK HEIGHTS, CITY OF To: 7/07/2006 PO BOX 2007 OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR INFORMATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 17422. 6.71 5506 STREET CONSTRUCTION 1169. 108889. 2.89 7520 WATERWORKS 3147. 65334. 3.84 7580 SEWAGE DISPOSAL PLANT 2509. 703877. 3.86 7720 POLICE 27170. 367466. .58 8810 CLERICAL OFFICE EMPLOYEES NOC 2131. 4865. 2.42 9016 SKATING RINK OPERATION 118. 20109. 3.06 9102 PARKS 615. 79101. 1.05 9410 MUNICIPAL EMPLOYEES 831. 26000. .39 9411 ELECTED OR APPOINTED OFFICIALS 101. Manual Premium 37791. Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- 7/01/2005 LM 4680(8/99) Minnesota Department of Labor and Industry First Report of Injury 1111111 I III IIi I I I I I III I Workers'Compensation Division 443 Lafayette Road North See Instructions on Reverse Side. F R CO '1 St.Paul,MN 55155-4305 Please PRINT or TYPE your responses. (651)284-5030 Enter dates in MM/DD/YYYY format. 1.EMPLOYEE SOCIAL SECURITY# 2.OSHA Case# DO NOT USE THIS SPACE 3.DATE OF CLAIMED INJURY 4.Time ❑am 5.Time employee began ❑am of injury ❑pm work on date of injury ❑pm 6.EMPLOYEE Name(last,first,middle) 7.Gender 8. Marital 0 Married ❑ M ❑ F Status ❑ Unmarried 9.Home address 10.Home phone# 11. Date of birth City State Zip Code 12.Occupation 13.Regular department 14.Date hired 15.Average weekly wage 16.Rate per hour 17.Hours per day 18.Days per week 19.Employment ❑Full time ❑ Part time Status ❑Seasonal ❑Volunteer 20.Weekly value of: Meals Lodging 2nd income 21.Apprentice ❑ Yes ❑No 22.Tell us how the injury occurred and what the employee was doing before the incident(give details). Examples: "Worker was driving lift truck with a pallet of boxes when the truck tipped,pinning worker's left leg under drive shaft." "Worker developed soreness in left wrist over time from daily computer key entry." 23.What was the injury or illness(include the part(s)of body)? Examples: 24.What tools,equipment,machines,objects,or substances were involved? chemical burn left hand,broken left leg,carpal tunnel syndrome in left wrist. Examples: chlorine,hand sprayer,pallet lift truck,computer keyboard. 25. Did injury occur on 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury(DOI) employer's premises? ❑Yes ❑ No 0 Yes ❑No ❑No lost time on DOI If no, indicate name and address of place of occurrence 28. Date employer notified of injury 29. Date employer notified of lost time 30. Return to work date 31.Date of death 32.TREATING PHYSICIAN(name,address,and phone) 33. HOSPITAUCLINIC(name and address)(if any) 34. Emergency Room Visit ❑Yes ❑ No 35.Overnight in-patient ❑ Yes ❑No 36. EMPLOYER Legal name 37. EMPLOYER DBA name(if different) OAK PARK HEIGHTS, CITY OF 38.Mailing address 39. Employer FEIN 40. Unemployment ID# PO BOX 2007 City State Zip Code 41. Employer's contact name and phone# OAK PARK HEIGHTS MN 55082 42. Physical address(if different) 43.Witness(name and phone) City State Zip Code 44.NAICS code ' 45. Date form completed 46.INSURER name 51.CLAIMS ADMIN COMPANY(CA)name(check one) ❑ Insurer League of Minnesota Cities Insurance Trust Berkley Risk Administrators Company, LLC ®TPA 47. Insured legal name 52. CA Address 145 University Avenue West 48.Policy#or self-insured certificate# City State Zip Code 02 -000729 St. Paul MN 55103-2044 49.Insurer FEIN ' 50.Date insurer received notice 53.CA FEIN 54.Claim# 0698639002 MN FRO1 (05/03)Copies to:Insurer,Employer,Employee,and Workers'Compensation Division(if no insurer) LM 2510 (5/03) GENERAL INSTRUCTIONS TO THE EMPLOYER Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work- related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days,the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim.Your insurer will forward a copy of this form to the Department, if necessary. If the claim involves death or serious injury(including injuries that later result in death),you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284- 1 5731), or personal notice.The initial notice must be followed by the filing of this form within seven days of the occurrence. Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employee's local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department's web site at www.doli.state.mn.us. Employees are not responsible for completing this form. SEND REPORT TO INSURER IMMEDIATELY—DO NOT WAIT FOR DOCTOR'S REPORT SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM • Item 2: OSHA Case#. Fill in the case number from the OSHA 300 log.This form contains all items required by the OSHA form 301. • Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. • Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s)of body injured(back, arm,etc.);and the tools, equipment, machines, objects or substances involved. • Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. • Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. • Item 28: Fill in the date you first became aware of the injury or illness. • Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury. • Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to work, fill in the date and notify your insurer if the employee misses time due to this injury after that date. • Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on Employer ID Number under Business. • Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS)code which are both assigned by the Department of Economic Security(651-296-6141). • Items 46-54:Your insurer or claims administrator will complete this information. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee's name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn .Stat. § 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department. • Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self- insured company or group. • Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure,fill in the certificate number. • Item 49: Fill in the insurer's Federal Employment ID number(FEIN)number. • Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the"Insurer"or"TPA" box. • Item 53-54: Fill in the claims administrator's FEIN and claim number. This material can be made available in different forms, such as large print,Braille or on a tape. To request, call(651)284-5030 or 1-800-342-5354(DIAL-DLI)Noice or TDD(651)297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52,SUBDIVISION 3. LM 2510(5/03) SUPERVISOR'S REPORT OF ACCIDENT This form should be completed by the supervisor as soon after a work accident as possible. It is useful in gathering information for investigating accidents and their causes so that corrective action can be taken and future accidents avoided. Every accident should be investigated and the causes corrected. Name of Employee: City/City Organization: Dept.: Date of Accident: Time of Accident: Did employee lose time from work? YES ❑ NO ❑ Hours lost on day of accident: Has employee returned to work? YES ❑ NO n Employee's job title: Years of employee's service with City/City organization: Years employee has been in present job: Number of hours employee works per week: GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK"YES"OR"NO" 1. HAD INJURED PERSON BEEN PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? YES 0 NO ❑ 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? YES❑ NO ❑ 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN?(IF APPLICABLE) YES 0 NO ❑ 4. DID POOR HOUSKEEPING CONTRIBUTE TO INJURY? YES O NO ❑ 5. DID HORSEPLAY CAUSE THE INJURY? YES 0 NO 0 6. WAS INJURY CAUSED BY SOMETHING THAT NEEDED REPAIRS? . YES❑ NO ❑ 7. SHOULD A GUARD BE PROVIDED? YES❑ NO ❑ 8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? YES 0 NO 0 9. WAS INJURY CAUSED BY AN UNSAFE ACT? YES❑ NO ❑ 10. DID INJURED REPORT THE INJURY TO YOU,THE SUPERVISOR,IMMEDIATELY? YES n NO n ACCIDENT. (Describe what the injured employee was doing at the time of the accident,what happened,who was involved,nature of the injury.) Witnesses'Names UNSAFE ACTS. (Did the injured employee or another person do something incorrectly?) UNSAFE CONDITIONS. (What unguarded or unsafe condition of machinery,equipment,building or premises was involved?) ACTIONS TAKEN. (After the injury,what did the employer do to correct the conditions that caused the injury?) REMEDIES. (What should the employer do to prevent other injuries like this?) MEDICAL CARE. Did the employee go to the Doctor or Hospital? YES ❑ NO ❑ If yes,please complete the following: Name of Doctor or Hospital: Date of initial visit: Address: Telephone number: AS SUPERVISOR,DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS'COMPENSATION? YES❑ NO ❑ Reasons why or why not: Report Submitted By: Date: League of Minnesota Cities Insurance Trust "VIC 145 University Avenue West St. Paul, MN 55103-2044 (651) 215-4173 League of Minnesota Cities Fax: (651) 281-1297 Cities promoting excellence J Workers' Compensation and Employers' Liability IMPORTANT Report all workers' compensation injuries to the office of: League of Minnesota Cities Insurance Trust 145 University Avenue West,St. Paul,MN 55103-2044 Phone (651)215-4173 Fax 888-234-7839 O In the Twin Cities 651-215-4185 For assistance on Fax First call 651-215-4176 If an employee is injured: (1) Assist in obtaining medical attention if necessary. (2) Notify the office listed above. **IMPORTANT** PLEASE READ YOUR AGREEMENT LM 4660(12/2001)(01/2005) In consideration of the deposit of the premium with the League of Minnesota Cities Insurance Trust(herein LMCIT)and in reliance upon the statements in the Information Page,and subject to all terms of this agreement and the LMCIT trust document,LMCIT,acting on behalf of its members,pursuant to their obligations,all acting through Berkley Risk Administrators Company,LLC, which is the Administrator named in the Information Page made a part hereof,agrees with you,the City,named in the Information Page as follows: GENERAL SECTION A. The Agreement contractors;or a relief association and its officers,employees and members. This agreement includes at its effective date the Information Page and all amendments and schedules listed there. It is an agreement C. Workers' Compensation Law of participation between you(the employer named in item I of the Information Page) and us (LMCIT). The only agreements Workers'Compensation Law means the workers'compensation relating to this plan are stated in this agreement and the LMCIT law and occupational disease law of the States named in item 3.A Trust document. The terms of this agreement may not be of the Information Page. It includes any amendments to that law changed or waived except by amendment issued by us to be part which are in effect during the period of this agreement. It does of this agreement. not include the provisions of any law that provides non-occupational disability benefits. B. Who is Covered D. Locations You are covered if you are the "City" named in item 1 of the Information Page. "City"means the city or other governmental This agreement covers all of your workplaces listed in items 1 or body,political subdivision,board or department or entity named 5 of the Information Page; and it covers all other workplaces in in the Information Page. Unless specifically named in the any state unless you have other insurance for such workplaces. Information Page, "City" shall not include a gas, electrical or steam utilities commission; port authority, housing and E. Incidental Coverages redevelopment authority, or similar agency, board or commission; hospital or nursing home board or commission; 1. Part One of this agreement applies to work performed by you welfare or public relief agency; school board; or joint powers subject to the Longshoremen's and Harborworkers'Act. board. 2. Part Two of this agreement applies to work performed by For purposes of Part Two-Employers'Liability Coverage and for you subject to the Federal Employer's Liability Act. purposes of damages sought against them under Section 176.82 of the Minnesota workers'compensation law,the following are 3. Part Two of this Agreement applies to work performed by additional covered parties for actions performed within the scope you subject to the Jones Act or U.S. Maritime Law. of their duties: A member of the city council; a member of any board or commission of the city that is named in the Information This paragraph does not apply to bodily injury covered under any Page;an elected or appointed official of the city;an employee of other policy,agreement or plan issued to you. It does not apply the city;a volunteer person or organization while acting on behalf even if the other policy, agreement or plan does not apply of the city;any other authorized person or agent of the city while because of an other insurance clause,deductible or limitation of acting on behalf of the city, but excluding independent liability clause,or any similar clause. PART ONE -WORKERS' COMPENSATION COVERAGE A. How This Coverage Applies agreement. This workers'compensation coverage applies to bodily injury or B. We Will Pay death by accident or by disease, provided the following conditions are met: We will pay promptly from the assets of LMCIT,when due,the benefits required of you by the workers' compensation law. 1. Bodily injury by accident must occur during the period of this agreement. C. We Will Defend 2. Bodily injury by disease must be caused or aggravated by the We have the right and duty to defend, at LMC1T expense, any conditions of your employment. The employee's last day of claim,proceeding or suit against you and any other covered party last exposure to the conditions causing or aggravating such for benefits payable under this agreement. We have the right to bodily injury by disease must occur during the period of this investigate and settle these claims, proceedings or suits. Page 1 of 7 LM 4660(12/2001)(01/2005) We have no duty to defend a claim,proceeding or suit that is not from another,those rights are transferred to LMCIT to the covered by this agreement. extent of LMCIT's payment. That person or organization must do everything necessary to secure our rights and must D. We Will Also Pay do nothing before or after a loss to impair them. We will also pay from the assets of LMCIT these costs, in However, the city may waive the city's rights against addition to other amounts payable under this agreement as part of another party in writing prior to a covered loss. The city any claim,proceeding or suit we defend: does not need to notify LMCIT in writing. 1. Reasonable expenses incurred at our request,but not loss of 1. Except as otherwise required by statute,any"net recovery" earnings; from a third party on a covered loss will be allocated between the city and LMCIT in proportion to their 2. Premiums for bonds to release attachments and for appeal respective shares of the total covered loss. "Net recovery" bonds in bond amounts up to the amounts payable under this means the total amount recovered from a third party,minus agreement; the cost of obtaining that recovery;but"net recovery"does not include any amounts LMCIT recovers from a reinsurer. 3. Litigation costs taxed to you; The city's share of the covered loss is the applicable deductible, if any. 4. Interest on a judgment as required by law until we offer the amount due under this agreement;and 2. You authorize us to pursue and settle on your behalf any increased premium claim to which you may be entitled 5. Expenses we incur. under Minn.Stat.Section 175.061,subd.5(b). In return,in addition to your share of the "net recovery" calculated E. Other Insurance pursuant to paragraph 2, you will also receive 10% of LMCIT's share of the"net recovery",not to exceed 50%of We will not pay more than our share of benefits and costs your premium for the most current year. We will retain the covered by this agreement and another insurance policy or remainder and apply it to reduce the incurred cost of the self-insurance plan. Subject to any limits of liability that may claim for purposes of calculating your experience apply, all shares will be equal until the loss is paid. If any modification. insurance policy or self-insurance plan is exhausted,the shares of all remaining insurance policies or self-insurance plans will be H. Statutory Provisions equal until the loss is paid. These statements apply where they are required by law. F. Payments You Must Make 1. As between an injured worker and us,we have notice of the You are responsible for any payments in excess of the benefits injury when you have notice. regularly provided by the workers' compensation law including those required because: 2. Your default or your bankruptcy or insolvency will not relieve us of our duties under this agreement after an injury 1. Of your serious and willful misconduct; occurs. 2. You knowingly employ an employee in violation of law; 3. We are directly and primarily liable to any person entitled to benefits payable under this agreement. Those persons may 3. You fail to comply with a health or safety law or regulation; enforce our duties; so may an agency authorized by law. or Enforcement may be against us or against you and us. 4. You fail to comply with the reporting requirements of the 4. Jurisdiction over you is jurisdiction over us for purposes of Workers' Compensation Law, causing late payment of the workers'compensation law. We are bound by decisions benefits to your employee and resulting in assessment of against you under the law, subject to the provisions of this penalties. agreement that are not in conflict with that law. If we make any payments in excess of the benefits regularly 5. This coverage conforms to the parts of the workers' provided by the workers' compensation law on your behalf,you compensation law that apply to: will reimburse us promptly. A. Benefits payable by this agreement;or G. Recovery From Others B. Special taxes, payments into security or other special 1. If any person or organization to or for whom LMCIT makes funds, and assessments payable by us under that law. payment under this covenant has rights to recover payments Page 2 of 7 LM 4660(12/2001)(01/2005) a 6. Terms of this agreement that conflict with the workers' to that law. Nothing in these paragraphs relieves you of your compensation law are changed by this statement to conform duties under this agreement. PART TWO -EMPLOYERS' LIABILITY COVERAGE A. How This Coverage Applies C. Exclusions This employers' liability coverage applies to bodily injury or This agreement does not cover: death by accident or by disease, provided the following conditions are met: 1. Liability assumed under a contract,except that this exclusion does not apply to a warranty that your work will be done in a 1. The bodily injury must arise out of and in the course of the workmanlike manner; injured employee's employment by you. 2. Punitive or exemplary damages because of bodily injury to 2. The employment must be necessary or incidental to your an employee employed in violation of law; work. 3. Bodily injury to an employee while employed in violation of 3. Bodily injury by accident must occur during the period of law with your actual knowledge or the actual knowledge of this agreement. any of your executive officers; 4. Bodily injury by disease must be caused or aggravated by the 4. Any obligation imposed by a workers' compensation, conditions of your employment. The employee's last day of occupational disease, unemployment compensation, or exposure to the conditions causing or aggravating such disability benefits law,or any similar law; bodily injury by disease must occur during the period of this agreement. 5. Bodily injury intentionally caused or aggravated by you; 5. If you are sued,the original suit and any related legal actions 6. Bodily injury occurring outside the United States of for damages for bodily injury by accident or by disease must America, its territories or possessions, and Canada, except be brought in the United States of America, its territories or that this exclusion does not apply to bodily injury to a citizen possessions,or Canada. or resident of the United States of America or Canada who is temporarily outside these countries; or B. We Will Pay 7. Damages arising out of the discharge of, coercion of, or We will pay from the assets of LMCIT all sums you legally must discrimination against any employee in violation of law. pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers'Liability D. We Will Defend coverage. We have the right and duty to defend, at LMCIT expense, any The damages we will pay,where recovery is permitted by law, claim,proceeding or suit against you for damages payable under include damages: this agreement. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a 1. For which you are liable to a third party by reason of a claim claim,proceeding or suit that is not covered by this agreement. or suit against you by that third party to recover the damages We have no duty to defend or continue defending after we have claimed against such third party as a result of injury to your paid our applicable limit of liability under this agreement. employee; E. We Will Also Pay 2. For care and loss of services; We will also pay these costs, in addition to other amounts 3. For consequential bodily injury to a spouse, child, parent, payable under this agreement as part of any claim,proceeding,or brother or sister of the injured employee; provided those suit we defend: damages are the direct consequences of bodily injury that arises out of and in course of the injured employee's 1. Reasonable expenses incurred at our request;but not loss of employment by you; and earnings; 4. Because of bodily injury to your employee that arises out of 2. Premiums for bonds to release attachments and for appeal and in the course of employment, claimed against you in a bonds in bond amounts up to the limit of our liability under capacity other than as an employer. this agreement; Page 3 of 7 LM 4660(12/2001)(01/2005) • 3. Litigation costs taxed against you; Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 4. Interest on a judgment as required by law until we offer the amount due under this agreement;and 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this agreement. 5. Expenses we incur. H. Recovery From Others F. Other Insurance 1. If any person or organization to or for whom LMCIT makes If any claim against you is also covered by another insurance payment under this covenant has rights to recover payments policy or self-insurance plan, we will pay only for our from another, those rights are transferred to LMCIT to the proportionate share of the loss. Our proportionate share will be extent of LMCIT's payment. That person or organization determined by applying the ratio that the limit of liability must do everything necessary to secure our rights and must provided by this agreement bears to the total of all limits of do nothing before or after a loss to impair them. liability provided by all policies or plans in effect to the total amount payable for the loss. The limits of liability and amount However, the city may waive the city's rights against payable under this agreement and any other policy or plan shall another party in writing prior to a covered loss. The city be calculated as if each plan or policy were the only one does not need to notify LMCIT in writing. applicable.The limits of liability and amount payable under any other policy or self-insurance plan in effect shall be included in 2. Except as otherwise required by statute,any"net recovery" the calculation,regardless of whether it is described as primary, from a third party on a covered loss will be allocated excess,contributory,contingent,or otherwise,unless that policy between the city and LMCIT in proportion to their respective or plan is specifically described as providing coverage in excess shares of the total covered loss. "Net recovery"means the of the limits of this agreement. total amount recovered from a third party,minus the cost of obtaining that recovery. "Net recovery"does not include any G. Limits of Liability amounts recovered from a reinsurer. The city's share of the covered loss include any applicable deductible and any Our liability to pay for damages is limited. Our limits of liability amounts which exceed the applicable coverage limit. are shown in item 3.B. of the Information Page. They apply as explained below: I. Actions Against Us 1.. Bodily Injury - Each Occurrence. The limit shown for There will be no right of action against us under this agreement "Bodily Injury-Each Occurrence" is the most we will pay unless: for all damages covered by this agreement because of bodily injury by accident or disease to one or more employees in 1. You have complied with all the terms of this agreement;and any one accident,regardless of the number of claimants. 2. The amount you owe has been determined with our consent 2. Bodily Injury by Disease - Agreement Limit. The limit or by actual trial and final judgment. shown for"Bodily Injury by Disease-Agreement Limit" is the most we will pay for all damages covered by this This agreement does not give anyone the right to add us as a agreement and arising out of bodily injury by sustain bodily defendant in an action against you to determine your liability. injury by disease,and regardless of the number of claimants. PART THREE - INFECTIOUS DISEASE DIAGNOSTIC TESTING A. We Will Pay B. Definitions Subject to the conditions listed below, LMCIT agrees to pay For purposes of this Coverage Part, the following definitions from its assets the usual and customary costs and expenses for apply: 1. Diagnostic testing of your employees who have had an 1. Exposure Incident means a specific eye, mouth, or other Exposure Incident that could result in an Infectious Disease; mucous membrane,non-intact skin or parenteral contact with and blood or other potentially infectious materials that result from the performance of an employee's duties. 2. Diagnostic testing of the person or persons who were the source of the blood or other potentially infectious materials 2. Infectious Disease means any form of viral or infectious when an employee has had an Exposure Incident. hepatitis, human immunodeficiency virus(HIV),acquired Page 4 of 7 LM 4660(12/2001)(01/2005) immunodeficiency syndrome(AIDS),tuberculosis(TB), or made independent of the city's obligations, if any, under Bacillus anthracis(anthrax). Minnesota Workers' Compensation Law and is intended to meet the city's obligation under Federal OSHA law to provide C. Limits and Conditions at no cost to the employee, medical evaluations and treatment after an Exposure Incident. LMCIT's responsibility to pay costs and expenses for diagnostic testing is limited and conditioned as follows: 4. In accordance with the provisions of Minn. Stat. Sec. 176.221 subd. 1, payment for diagnostic testing as described I. The Exposure Incident must occur during the term of this in this agreement is not an admission that an employee's agreement. contraction of an Infectious Disease constitutes a compensable Occupational Disease under Minnesota 2. The most LMCIT will pay for diagnostic testing associated Workers' Compensation law; and it does not constitute a with an Exposure Incident to any one employee is$2,500. waiver of the city's or LMCIT's right to contest the issue of whether an employee's contraction of an Infectious Disease 3. An Exposure Incident does not alone constitute a Personal constitutes a compensable Occupational Disease under Injury as that term is defined under Minnesota Workers' Minnesota Workers'Compensation law. Compensation law. Accordingly, absent actual contraction of an Infectious Disease, payment for diagnostic testing 5. LMCIT reserves the right to discontinue payment of costs subsequent to an Exposure Incident is not required under and expenses for diagnostic testing if in its opinion further Minnesota Workers'Compensation Law. Rather, payment diagnostic testing is no longer medically appropriate under for diagnostic testing as described in this endorsement is the particular circumstances of the Exposure Incident. PART FOUR- PEACE OFFICERS'POSTTRAUMATIC STRESS SYNDROME BENEFIT A. Intent and Purpose C. Conditions and Limitations The purpose of Part Four is to assist the city in providing the LMCIT will not pay or reimburse any benefits which have been benefits required by law for peace officers suffering from paid or reimbursed by any of the following: posttraumatic stress syndrome as a result of lawful use of force resulting in taking of life or great bodily harm. The benefits 1. Workers compensation; provided by Part Four are intended to supplement,rather than to replace, benefits provided by any other source. 2. The city's employee health benefit plan; B. We Will Pay 3. Any disability insurance policy;or Subject to the conditions and limitations listed below, LMCIT 4. PERA or any other retirement plan. will reimburse the city for any benefits which the city is required to provide to a peace officer pursuant to Minnesota Statutes LMCIT will not reimburse any health benefit plan or carrier or Section 299A.411. any disability insurance carrier for any benefits provided by that plan or carrier. PART FIVE -YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this 4. Cooperate with us and assist us, as we may request, in the agreement. Your other duties are listed here: investigation,settlement or defense of any claim,proceeding or suit. 1. Provide for immediate medical and other services required by the workers' compensation law. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may 6. Do not voluntarily make payments, assume obligations or need. incur expenses,except at your own cost. This particular duty does not apply to Part 4 — Peace Officers' Posttraumatic 3. Promptly give us all notices, demands, and legal papers Stress Syndrome Benefits. related to the injury, claim,proceeding or suit. Page 5 of 7 LM 4660(12/2001)(01/2005) PART SIX—PREMIUM A. Our Manuals amendments is an estimate. The final premium will be determined after this agreement ends by using the actual,not the All premiums for this agreement will be determined by our estimated,premium basis and the proper classifications and rates manuals of rules,rates,rating plans and classifications. We may that lawfully apply to the business and work covered by this change our manuals and apply the changes to this agreement. agreement. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will B. Classifications refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications Item 5 of the Information Page shows the rate and premium basis covered by this agreement. If this agreement is canceled, final for certain business or work classifications. These classifications premium will be determined in the following way unless our were assigned based on an estimate of the exposures you would manuals provide otherwise. have during the period of this agreement. If your actual exposures are not properly described by those classifications,we 1. If we cancel,final premium will be calculated pro rata based will assign proper classifications, rates and premium basis by on the time this agreement was in force. Final premium will amendment to this agreement. not be less than the pro rata share of the minimum premium. C. Remuneration 2. If you cancel, final premium will be more than pro rata. It will be based on the time this agreement was in force,and Premium for each work classification is determined by increased by our short rate cancellation table and procedure. multiplying a rate times a premium basis. Remuneration is the Final premium will not be less than the minimum premium. most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the F. Records period of this agreement for the services of: You will keep records of information needed to compute 1. All your officers and employees engaged in work covered by premium. You will provide us with copies of those records when this agreement; and we ask for them. 2. All other persons engaged in work that could make us liable G. Audits and adjustments under Part One(Workers' Compensation Coverage)of this agreement. If you do not have payroll records for these You will let us examine and audit all your records that relate to persons, the contract price for their services and materials this agreement. These records include ledgers,journals,registers, may be used as the premium basis. This paragraph 2 will not vouchers, contracts, tax reports, payroll and disbursement apply if you give us proof that the employers of these records, and programs for storing and retrieving data. We may persons have lawfully secured their workers' compensation conduct the audits during regular business hours during the obligations. period of this agreement and within three years after this agreement ends. Information developed by audit will be used to D. Premium Payments determine final premium. Except for premium adjustments pursuant to a retro-rating plan,no premium adjustments will be You will pay all premium when due. You will pay the premium used to determine final premium. Except for premium even if part or all of a workers' compensation law is not valid. adjustments pursuant to a retro-rating plan, no premium adjustments will be made for any coverage period after one year E. Final Premium following completion of the audit for that coverage period. The premium shown on the Information Page, schedules, and PART SEVEN—CONDITIONS A. Duty to Indemnify 3. Which constitutes bad faith;or Our duty to pay on behalf of or to indemnify a covered party other than the"city"shall not apply to any act,error or omission: 4. For which the "city" is not authorized to indemnify any person by statute;or 1. Which constitutes malfeasance in office; or 5. Which constitutes dishonesty on the part of a covered party; 2. Which constitutes willful neglect or duty;or or Page 6 of 7 LM 4660(12/2001)(0l/2005) 6. Which constitutes the willful violation of a statute or E. Transfer of Your Rights and Duties ordinance by any official,employee or agent of the "city". Your rights or duties under this agreement may not be transferred The terms "malfeasance", "willful neglect of duty", and "bad without our written consent. faith"shall be given the same meaning in this agreement as given in the applicable statute with respect to the"city's"duty to defend F. Cancellation or indemnify its officials, employees or agents. 1. You may cancel this agreement. You must mail or deliver B. No Waiver of Statutory Liability Limitations or advance written notice to us stating when the cancellation is Immunities. to take effect. 1. It is the express intent of the city and of LMCIT that the 2. We may cancel this agreement. We must mail or deliver to procurement of this agreement shall not waive any monetary you written notice of cancellation at least: limits of liability provided by Minnesota Statute 466.04,by any comparable or successor statute, or by common law, a. thirty days before the effective date of cancellation if which may be applicable to the "City" or to any other LMCIT cancels for nonpayment of premiums;or covered party;and that any previous waiver of liability limits is revoked to the extent that it may apply to claims covered b. sixty days before the effective date of cancellation if under this agreement. LMCIT cancels for any other reason. 2. It is the express intent of the "City" and of LMCIT that the Mailing the notice to you at your mailing address shown in procurement of this agreement shall not waive any other item 1 of the Information Page will be sufficient to prove immunities,limitations,or defenses imposed by or available notice. under any statute or common law which is applicable to the "City" or to any other covered party. 3. The period of this agreement will end on the day and hour stated in the cancellation notice. C. Inspection 4. Any of these provisions that conflicts with a law that controls We have the right,but are not obliged to inspect your workplaces the cancellation of the coverage in this agreement is changed at any time. Our inspections are not safety inspections. They by this statement to comply with that law. relate only to coverage and the premiums to be charged. We may also recommend changes. While they may help reduce losses,we G. Accessibility do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not All "cities" that participate in this program are jointly and warrant that your workplaces are safe or healthful or that they severally liable for all claims and expenses of the program. The comply with laws,regulations,codes or standards. amount of any liabilities in excess of assets may be assessed to the participants when a deficiency is identified. D. Long Term Agreement H. Sole Representative If the period of this agreement is longer than one year and sixteen days,all provisions of this agreement will apply as though a new The City first named in item 1 of the Information Page will act on agreement were issued on each annual anniversary that this behalf of all covered entities to change this agreement,received agreement is in force. return premium,and give or receive notice of cancellation. IN WITNESS WHEREOF,the City agrees to look solely to the League of Minnesota Cities Insurance Trust for reimbursement of all losses, costs and expenses arising under this agreement;and further agrees that in no event shall claim be made or asserted against the revenues or property,real or personal,of the League of Minnesota Cities. Acceptance of this agreement by the City constitutes acceptance of all terms hereof. League of Minnesota Cities Insurance Trust By: jUi/iyjk Peter Tritz, Its Authorized Representative Page 7 of 7 LM 4660(12/2001)(01/2005) Minnesota Workers' Compensation Employee's rights and responsibilities This notice is required by law to be posted in a conspicuous location wherever the employer is engaged in business. If you are injured: • Report any injury to your supervisor as soon as possible,no matter how minor it may appear. You may lose the right to workers'compensation benefits if you do not timely report the injury to your employer. The time limit may be as short as 14 days,although under certain circumstances,it may be longer. • Provide your employer with as much information as possible about your injury so that a proper injury report can be filed. • Get any necessary medical treatment as soon as possible. If you are not covered by a certified managed care organization(CMCO),you may treat with a doctor of your choice. Your employer must notify you if you are covered by a CMCO. • Cooperate with all requests for information concerning your workers'compensation claim. Please note: the law provides that the workers'compensation insurer can obtain medical information specific to your work injury without your authorization,provided you are sent written notification of this request at the time the request is made. • Get written confirmation from your doctor on any authorization to be off work. What does workers'compensation pay for? • Medical care for your work injury,as long as it is reasonable and necessary. • Wage-loss benefits for part of your lost income(There is a three-calendar-day waiting period before these benefits start.) • Compensation for permanent damage to or loss of function of a body part • Benefits to your spouse and/or dependents if you die as a result of a work injury • Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer due to your work injury What the insurance company must do: • Investigate your claim promptly. • Within 14 days of when the claimed injury occurred or when your employer became aware of it,either begin payment of benefits due or file a denial of liability, explaining why benefits are being denied. Your employer,as a qualified self-insured,pays any benefits due you. Benefits due you will be paid by: LMC League of Minnesota Cities Insurance Trust • Lyw 145 University Avenue West,St.Paul,MN 55103-2044 (651)215-4169 If the insurer accepts your claim for wage-loss benefits and you have been disabled for more than three calendar-days: • The insurer will send you a copy of the Notice of Insurer's Primary Liability Determination form stating your claim is accepted. • The insurer must start paying wage-loss benefits within 14 days of the date your employer knows about your work injury and lost wages. The insurer must pay benefits on time. Wage-loss benefits are paid at the same intervals as your work paychecks. If the insurer denies your claim for wage-loss benefits: • The insurer will send you a copy of the Notice of Insurer's Primary Liability Determination form stating it is denying primary liability for your claim. The form must clearly explain the facts and reasons why the insurer believes your injury or illness did not result from your work. • If you disagree with the denial,you should talk with the insurance claims adjuster who is handling your claim. Your employer's insurance company can answer most questions about your claim. • If you are not satisfied with the response you receive from the insurer and still disagree with the denial,you should contact the Department of Labor and Industry at one of the numbers listed below to discuss your options. Fraud Collecting workers'compensation benefits you are not entitled to is theft. Any theft of more than$500 is a felony. Any person who,with intent to defraud, receives workers'compensation benefits to which the person is not entitled by knowingly misrepresenting,misstating,or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to section 609.52,subdivision 3. A suspected fraud can be reported by anyone. If you have reason to suspect someone is committing workers'compensation fraud,call 1-888-FRAUD MN(1-888- 372-8366). All suspected violations will be investigated. T'iitiefid0jos2 -"I 'orkers'ula at �iviston 'i 3rkersi'�I Ba #$ 5,` j d !At 51 �7 5/t /* ll—fk •b 5 -8 584 ,^ ' of,rye ai "mil be�a u e a t?y n wo ets' co p se bony cial �vho�w l pr vide n n,ay�cc rate of nation nd ance „Additional b rorkeit,,i' m�s�on. 'anon, s vail lble o11 'r partme l: Web t LM 2580(9/O3) August 2003 This document can be made available in alternative formats,such as Braille or audiotape,by calling(651)284-5042 or(651)29 7-4 1 9 81TDD.