MCDONALD'S WORKERS' COMPENSATION - STORE SAFETY AND CLAIMS GUIDE
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McDonald’s
WORKERS’
COMPENSATION
STORE SAFETY AND
CLAIMS GUIDE
Phone: 877-200-1718
Fax: 877-644-3670
McDonalds@BesnardInsurance.com
www.ProfitingFromSafety.com
“The Best Run McDonald’s Choose Besnard Insurance”
Amerisure Client Book
1
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)
Section 9
Claims Management
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Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)
Attention Store Managers
SAFETY IS NO ACCIDENT
YOU CAN CONTROL YOUR WORKERS’ COMPENSATION COSTS!
Experience has demonstrated that some employees will take advantage of an unmanaged claims
situation. A cost control approach is simple when you follow these steps with every report of
injury.
MANAGEMENT PROCEDURES FOR CLAIMS HANDLING:
1. If the injury is serious or life threatening and requires immediate
treatment, call 911 and have employee transported to the nearest
medical facility.
2. For all serious or disabling injuries, you must immediately phone in
the injury report.
3. For all other injuries, instruct the employee that it is mandatory to
seek medical treatment from an approved medical facility/physician
and to comply with post injury drug testing requirements.
SEND EMPLOYEE TO HOSPITAL ONLY IF SERIOUS OR A LAST RESORT!
1. All claims must be reported to The Insurance Company within 24 hours of
occurrence by either the company office manager, manager on duty, or the supervisor.
Make sure someone is prepared to answer questions about the claimant and events
surrounding the accident.
2. Prompt reporting of injuries has been shown to dramatically reduce claims costs
and legal involvement!
3. If an employee refuses medical treatment, they should sign the waiver of medical
treatment, but a post injury drug test should still be performed if this is a part of your
HR policy.
4. Hand the employee their responsibilities packet and inform them to ask the doctor to
contact you after the employee is treated to help establish Return to Work opportunities. It
is imperative to get the employee back to work as soon as possible to lower workers’
compensation costs among many other benefits.
5. Any reported injuries that are felt to be “questionable” should still be reported as normal
incidents, but let the adjuster know your concerns by phone.
6. Report to the adjuster immediately any of the following regarding Preexisting Conditions.
o Pre-existing conditions which existed for the employee before the injury
o Existing conditions which may have contributed or worsened the injury
o Copy of any medical accommodation form which might have documented existing
conditions
54
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)
Workers Compensation
CLAIM MANAGEMENT CHECK-LIST
(Please attach this document to the outside of internal claim folder)
Workers Name: ____________________ Date of Accident: ______ Store #: _____
STORE MANAGER
Offered the injured worker medical treatment
o provided them with a list of clinics and corresponding forms to take to the physician
Send the injured worker for a post-accident drug screen (if applicable in your HR policy)
If the injured worker declines care, have them sign the waiver of medical treatment form
Complete and perform an Accident Investigation (complete the form)
Report Claim – immediately (always within 24 hours)
o Everything sent to the Insurance Company (or your Main Office)
CLAIMS MANAGER
Help Store Secure the video (gather surveillance tapes as soon as possible)
Return to Work
o Follow-up with the worker to schedule their return shift
o Request that the injured worker return to you with a work status and Dr’s note – remember
the 7 DAY PERIOD. It is important to get the injured worker back to work within 7 days.
Return to Work (Leadership Communication)
o Contact your leadership if it is not going to be possible to return them in 7 days from
accident date or if they do not follow up with you
o Call your claims adjuster with an update
Follow-up with Store Manager
o Ensured worker returned by the specified time/date
Download this Form at
http://www.besnardinsurance.com/resources/MCD/MCD_WC_ClaimsChecklist.pdf
55
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)EMPLOYEE WAIVER
OF MEDICAL TREATMENT
DATE:
EMPLOYEE NAME:
As of the date noted above, I am notifying my employer of an injury that occurred on
, 201__
My supervisor did not receive notification of this incident.
My supervisor did receive notification of this incident on , 201__
This injury, (briefly describe condition)
occurred during the normal scope and duties of employment.
At this time, I have been requested by my employer to be medically evaluated by a preferred medical
provider within the managed care network. I decline to be medically evaluated for the above
noted condition.
I understand that by signing this document, any future claims regarding this injury will require a medical
evaluation by a preferred medical provider within the managed care network or I may be responsible for
any medical bills or lost wages. I also understand that should I seek treatment for this injury, I must first
notify my supervisor and go to a provider in the managed care network.
SHOULD THE CONDITION BECOME LIFE THREATENING
SEEK APPROPRIATE EMERGENCY CARE IMMEDIATELY
EMPLOYEE STATEMENTS
By signing this form I acknowledge:
I have not sought medical treatment for this injury
I understand that it is the policy of my employer to have a post-accident drug screen and this refusal
of medical treatment does not remove the requirement that I receive a post-accident drug screen.
I have read the above information and agree it is factual and true statement. I authorize any
physician, hospital or healthcare provider to release and furnish any and all medical records or
other information pertaining to the above listed condition.
_
Employee Signature Supervisor/Witness Signature
_
Date Date
Download this Sample Form at
http://www.besnardinsurance.com/profitingfromsafety/downloads/MCD_EMPLOYEE_WAIVER.pdf
56
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)McDonald’s Worker Injury
NOTICE OF INJURY
1. Caller’s Name:
2. Caller’s Job Title:
3. Caller’s Contact Phone:
4. Caller’s Fax Number:
5. Operator Name:
6. Operator’s Office
Mailing Address:
7. Name of Injured:
8. Male or Female:
9. Injured’s Home Phone:
10. Injured’s Social Security:
11. Injured’s Date of Birth:
12. Injured’s Home Address:
13. Job Duty When Injured:
14. Full or Part Time:
15. Date of Injury: 16. Time of Injury:
17. Address & Store Number
Where Injury Occurred:
18. Was Injury on Property: 19. If not, where?
20. Body Part Affected:
21. Description of Accident:
22. Description of Injured: (height, weight,
color hair, length of hair, facial hair,
glasses, etc.)
23. Any Video of the Accident? 24. Do you agree with accident?
25. Did injured receive medical treatment? 26. If yes, where?
27. Was treatment authorized? 28. Has Injured Returned to Work?
29. Injured’s Hourly Rate of Pay: 30. Average Hours Per Week:
31. Injured’s Supervisor: 31. Has Supervisor Been Notified?
33. Date the Injured Last Worked: 34. Injured returned to work yet?
Please use as a tool to help you when calling the claim into your insurance company. It is very important to
get as much detail as you can about the claim including witness statements.
Contact your claims adjuster for more specific reporting questions, State specific forms, etc.
Download this Form at
http://www.besnardinsurance.com/profitingfromsafety/downloads/MCD_InjuryNotice_Sample.pdf
57
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Benefits of a Thorough Investigation
A thorough investigation often results in many benefits:
It may prevent incident recurrence.
It reveals the possible causes of operational interruptions and indicates
possible corrective action.
It eliminates economic losses resulting from possible damaged tools,
machines, and materials.
It creates an awareness of areas to consider.
It may reveal how methods and procedures can be improved.
Investigations Reduce Claim Frequency
Studies have shown that investigation also results in a substantial decrease in claim
frequency. Through investigation, the cause of an incident may be determined,
potentially reducing the risk of a similar incident recurring.
What to Investigate
Explore as many details as necessary to uncover the root cause of the incident.
Details could include:
Practices utilized. Was there a departure from the proper procedure?
Physical conditions. Was there a physical issue with equipment or tools?
Incident source. Were there any tools, materials, or equipment involved?
Type of incident. How was the person affected or what damage occurred?
Part of body affected. Which part(s) of the body is the subject of complaint?
Personal factor. What was the reason for the person's unsafe action or practice?
Whom to Interview and How
Interview all crew members or customers involved immediately following the incident. Follow these
basic guidelines when interviewing those involved and those who witnessed the incident.
Put the person at ease. Emphasize prevention as your goal.
Interview at the scene of the incident, if possible.
Ask for the person's version of the incident. Let the person speak without interruption.
Ask only necessary questions. Avoid "why" questions to avoid defensiveness.
Repeat the person's story as you understand it. This assures the person that you understand
clearly what happened and allows the person to correct any mistakes, if necessary.
Close the interview on a positive note of prevention. This reaffirms the purpose of the interview
and sets the tone for the rest of your investigation
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Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)MANAGER’S ACCIDENT
INVESTIGATION FORM
DATE TIME
AM PM
EMPLOYEE INVOLVED AGE
NOTE TO SUPERVISOR:
POSITION DATE EMPLOYED
Remember, an accident
investigation is not
designed to find fault or
MANAGER ON DUTY HAS THIS INCIDENT BEEN REFERRED TO
blame. It is an analysis to THE SAFETY COMMITTEE?
determine because that YES NO
can be controlled or
HOW LONG HAS THE EMPLOYEE BEEN WAS THE TASK:
eliminated. DOING THIS TASK? ROUTINE INFREQUENT
When completing the NEW EXPERIENCE
investigation, try to answer HAS THE EMPLOYEE HAD THE PROPER WERE THERE WITNESSES? IF SO,
TRAINING? ATTACH STATEMENT
these questions.
How did the accident DID THE ACCIDENT RESULT IN INJURY? HAVE SECURITY RECORDINGS BEEN
occur? RETAINED?
Where did it happen? NATURE AND EXTENT OF INJURY?
What station did this
occur? DATE INJURY REPORTED? WAS FIRST AID GIVEN?
Who was injured?
HOW DID THE ACCIDENT OCCUR?
When did it happen?
RECOMMEND PRIMARY CAUSE OF ACCIDENT?
CHANGES:
No investigation is RECOMMENDATIONS TO PREVENT RECURRENCE
complete unless corrective
action is suggested.
NAME OF PERSON RESPONSIBLE FOR CORRECTIVE ACTION
FOLLOW-UP:
Determine what action is
being taken on your WHAT ACTION HAS BEEN TAKEN?
recommended changes.
SIGNED DATE
Download this Form in both English/Spanish at:
http://www.besnardinsurance.com/resources/MCD/MCD_ManagersAccidentInvestForm.pdf
59
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Accident Additional Statements
Please use this form to gather additional written statements
from the claimant about the accident as well as any additional witnesses
CLAIMANT STATEMENT
(Please explain in detail how the accident occurred? What are your complaints/injuries?)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________
Name: __________________________
Signature____________________ Date__________
I confirmed this information is accurate and true.
WITNESS STATEMENT
(What did you see, what do you remember? Were there any additional witnesses? What did the injured
worker tell you?)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________
Name: __________________________
Signature____________________ Date__________
I confirmed this information is accurate and true.
Download this Form at
http://www.besnardinsurance.com/profitingfromsafety/downloads/MCD_ADDITIONAL_STATEMENTS.doc
60
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Insurance Claims
When accurate and detailed information is sent to an insurance carrier immediately, claims are
more accurately evaluated and costs are reduced. Claim costs increase significantly when
claims are reported more than 3 days after the accident occurred.
Benefits of Prompt Reporting
Reduces fear and anxieties of those affected by the incident
Assures proper medical attention and future medical direction
Creates earlier return-to-work results
Eliminates hidden costs of workers' compensation
Initiates case management
Report All Incidents within 24 Hours
Report any incident at your restaurant within 24 hours. Reporting incidents within 24 hours
ensures that the injured employee will get the care they need as quickly as possible, and also, that
further investigations may be performed. Also, corrective action can be accessed and shared with
other locations immediately.
Fraud
Worker’s Compensation fraud can be a costly to your stores. Working closely with insurance
adjuster is one way to reduce the potential for fraud. Being familiar with the indicators of fraud is
another way. Whenever fraud indicators are identified and reported to the insurance company,
there is a good chance that the claim can be denied (if it is confirmed to be fraudulent).
Indicators of fraud include:
Injury that has no witness other than the employee
Injury occurring late Friday or early Monday
The circumstances of the injury change as time goes by
The injury changes, or becomes worse
Employee is disgruntled
Injury not reported until a week or more after it supposedly occurred
Injury occurring before a holiday, or in anticipation of termination
Injury occurring in a location where the employee would not normally work
Injury that is inconsistent with normal job duties
Employee observed in activities inconsistent with the reported injury
Employee history of workers' comp claims
Conflicting diagnoses from subsequent treating providers
Evidence of employee working elsewhere while drawing benefits
Note – Report all injuries, even if multiple indicators of fraud are identified. Indicators of fraud are not
guarantees that the injury did not happen. It is important to ensure that employees are taken care of, and
to let the insurance company investigate the claim. Alerting them to your concerns will trigger the
investigation!
61
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Return to Work Procedures
Returning an injured crew member to the restaurant is important to all of the parties.
Employees heal faster when they return to work, and make more money while
working than while on Worker’s Compensation. Employers also benefit from
keeping a trained employee on staff, and not having to shift schedules around for
the missing employee, or worse yet, having to train a new employee. Return to
work keeps insurance costs down, and is easier to implement than one might think.
The key in the process then is how to create an effective program that allows
employees to return to gainful employment, as fast as possible? The first key is
having transitional duty job tasks available prior to the injury. Obviously it is
impossible to know who will be injured, when, and what the restrictions will be, but it
is possible to identify tasks that any injured employee can perform. Looking for
tasks in four major categories can cover just about any type of injury an employee
will have. Restrictions typically cover the amount an employee may lift, whether or
not they can use both hands, or whether or not they can stand.
Here are the categories to address:
Lifting 25 Pounds Or Less – This restriction is common on any strain injury.
At a McDonalds, there items that weigh more than 25 pounds. Boxes of
frozen foods and containers of iced tea are some of these items. Most
positions can be easily modified with lifting eliminated.
Use of One Arm – Employee’s who strain an arm, burn a hand, or fall and
injure an arm/hand will have this restriction.
Sitting – If an employee suffers an injury to his or her leg or back, the
restriction may be for the employee to sit.
Sitting and Standing – Some doctors will want the employee to take
frequent breaks, or alternate sitting and standing. The Drive Through
attendant may be a good position for this restriction, or cashier.
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Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Return to Work Procedures (continued)
Once the program is in place, it is important that all employees in the store be
trained. Supervisors should be made aware that employees will be returned to
work, and may need assistance once they return. Employees should be trained
from their first day that if at any point they have an injury, they will be returned to
work. Employees should be made aware of how Worker’s Compensation works,
and that they will make more money when they return to work, than if they are
away.
Use the modified duty program defined below to assist a crew member in
returning to work.
Modified Duty Program
The modified duty program includes four job classifications. These classifications
define the physical abilities required for the task and allow you and the attending
physician to determine the type of work a crew member may be able to handle
when he or she returns to work. The table below outlines the classifications of
duties including various restrictions.
Note: Jobs may need to be varied for specific restrictions offered by the attending physician.
McDonalds Transitional Duty Jobs by Classification
Sedentary-type Work
Light Work
Medium Work
Heavy Work
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Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)McDonalds Transitional Duty Jobs by Classification
Classification Definition
Sedentary-type work Sedentary-type work includes lifting 10 pounds (4.5
kilograms) maximum. This work involves sitting, occasional
walking, standing, and wrapping and packaging finished food
products, such as hamburgers and fries. The following
positions would be considered sedentary-type work:
- Drive-thru or front counter order-taker cashier
- Assemble Kids Meals Boxes
Light work Light work involves lifting 20 pounds (9.1 kilograms)
maximum, with frequent lifting or carrying up to 10 pounds
(4.5 kilograms). These jobs also include a small degree of
pushing and pulling of arm and leg controls, and walking or
standing, some to a significant degree. The following
positions are light- work positions:
- Runner
- Milkshakes and soft serve preparation
- Fry station
- Production caller
- Biscuit preparation
- Salad assembly
- Setup transition or service
- Hotcakes preparation
- Pie preparation
- Host or hostess
Medium work Medium work involves lifting 50 pounds (22.7 kilograms)
maximum, with frequent lifting or carrying of objects
weighing up to 25 pounds (11.3 kilograms). These jobs
include the following:
- All grill area positions
- Grill setup or transition
- Dining room and restroom pre-close and close
- Service pre-close and close
- Back room pre-close and close
Heavy Work Heavy work involves lifting 100 pounds (45.4 kilograms)
maximum with frequent lifting, or carrying objects weighing
up to 50 pounds (22.7 kilograms) these positions include the
following:
- Maintenance
- Unloading Trucks
64
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)RETURN-TO-WORK POLICY
(Sample)
Please read the following carefully. This policy applies to all employees with work
related injuries.
Our Company is committed to maintaining the safety, health and productivity
of our employees.
Modified and transitional duty is a temporary work offer pending determination
of an employee’s ability to return to regular duty work.
It is this company’s policy that injured employees accept and fully cooperate
with modified and transitional duty work found suitable by the attending
physician.
Failure to accept modified or transitional duty work that the attending
physician has found to be within the employee’s capabilities may result in the
reduction or suspension of time loss benefits.
Failure to comply with the company’s return-to-work policy and procedures
without authorized exception may subject the employee to disciplinary action.
All employees are responsible for reading and understanding this company’s
policy and procedures for return-to-work and discussing any questions or
concerns with management.
Employee Name: ______________________________
Employee Signature: ______________________ Date: ________
Download the English/Spanish of this document at
http://www.besnardinsurance.com/profitingfromsafety/rtw-a-win-for-all/
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Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Return to Work Letter - SAMPLE
Instructions for Employer:
This is to be sent by the employer to employee with a copy of the doctor’s release via regular and certified
mail. Please be sure to copy your insurance company.
A reasonable time has to be given for the employee to show up timely for light duty work.
__________
(Date)
________________
________________
________________
(Address)
Dear :
We are pleased to learn that you have been released to return to employment at ____________.
According to _________________, you are able to return to ____ duty position. Such a position is
available at _____________________, the details of which are as follows:
Position Title: ________________________________________________
Job Description: ______________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date to Report to Work: ________________________________________
Location to Report to: _________________________________________
Person to Report to: ___________________________________________
Time to Report: ______________________________________________
Schedule as Follows: __________________________________________
__________________________________________
Wage rate: ____________
We are please to be able to offer you this position within the work guidelines established by
_____________________. If you have any questions prior to your start date, please call me at
_______________.
Very truly yours,
Download the English/Spanish of this SAMPLE document at
http://www.besnardinsurance.com/profitingfromsafety/downloads/ReturntoWorkLetter.doc
66
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Section 10
Other Resources
67
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Helpful Safety Web Sites
McDonald’s Safety Resources (and Newsletter)
www.ProfitingFromSafety.com
www.mcdsafety.com
Insurance Company Specific Sites
Amerisure: www.mcdAmerisure.com
Other Sites
Workers Compensation 101 – Learn the Basics
http://www.besnardinsurance.com/workers-compensation-2/faqs/
Hiring Support
http://www.besnardinsurance.com/profitingfromsafety/hiring-support/
Automobile Safety
http://www.besnardinsurance.com/profitingfromsafety/category/automobile/
Property and General Liability
http://www.besnardinsurance.com/profitingfromsafety/category/propertyliab/
Employment Practices Liability
http://www.besnardinsurance.com/profitingfromsafety/category/employment-practices/
68
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)The Latest in Slip and Fall Prevention
Preventing slips and falls is most directly related to a clean floor, but there are new,
cutting edge techniques that can not only help keep your floors clean, but also
reduce the time and effort it takes to keep them clean. Also, floors can be treated to
help to increase the coefficient of friction. Here are a few of the many cutting edge
methods to help keep the floor clean, and reduce slip and falls:
Automated Floor Scrubbers – Automated floor scrubbers put down water and
cleaning solution, scrub the floor, and vacuum it back up again. This helps to clean
the floors, and also reduce drying times as well. Cleaning is much faster, and
requires less effort by your employees. In addition to a cleaner floor, the potential
for strains is also reduced. Approved floor scrubbers can be found at
www.profitingfromsafety.com. See ‘Safety Product – ECOLAB Scrub N Go’.
Weighted Deck Brushes – A weighted deck brush is similar to a regular deck brush,
with the exception that it has a weighted head. This allows for the brush to provide
the pressure to the floor, opposed to the employee. The issue with standard deck
brushes is that as the employee fatigues, the scrubbing of the floor is reduced,
causing sections of the floor to be not as clean as others. If the employee is tired by
the time they arrive at the fryer, then most likely, the floor of the restaurant will not
clean, as grease can be tracked from the fryer to other parts of the restaurant.
In addition to the weighted deck brush, additional deck brushes are available with U-
Shaped heads, that are helpful in cleaning around fixed tables, and V-Shaped
heads, that are helpful in cleaning baseboards. Note, all three of these brushes can
help to reduce time and effort in cleaning effectively. Approved, alternative deck
brush reviews can be found at www.profitingfromsafety.com, to include videos and
analysis of the problem. See ‘Smarter Floor Cleaning,’ and ‘The Meaning of Dirty
Mop Water.’
Floor Treatments – Older tile may not have the same coefficient of friction, even
when clean, as newer tile. Years of foot traffic and scrubbing may have created a
smoother surface that can lead to increased slips and falls. Even new tile can be
made to have a higher coefficient of friction, even when wet, after being treated
properly. All floor treatments, however, are not the same. First, not all are
approved. Also, some can etch the floor and remove group sealants. Approved
floor treatment articles and reviews can be found at www.profitingfromsafety.com.
See ‘Reducing Slips and Falls in Restaurants.’ This article reviews the NO-Slip floor
treatment.
69
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)WORKER INJURY
SERIOUS OR LIFE-THREATENING
EMERGENCY REPORTING PROCEDURES
Report all work-related injuries and illnesses that have, or will, result in
medical attention other than on-site first aid to:
AMERISURE MUTUAL INS CO
24 Hour Reporting Hotline
(888) 784-6609
(MCMC – Amerisure’s Claims Adjusting Company)
IF ACCIDENT/ILLNESS/ THEN REPORT TO AMERISURE:
INCIDENT RESULTS IN:
1) Fatality Call Report in Immediately
2) Serious or Severe Injury Call Report in Immediately
3) Hospitalization Call Report in Immediately
4) Loss of Consciousness Call Report in Immediately
5) Disability Call Report in Immediately
Any other illness or injury Mail or fax report within 5 calendar days.
WHEN IN DOUBT CALL IN REPORT TO
AMERISURE MUTUAL INS CO
AS SOON AS POSSIBLE
70
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Introductory letter to Physician
Coventry/ First Health
Date: __________________________
Employer Name: ________________________________________________________________________________
Employer Telephone Number ______________________________________________________________________
Dear Health Care provider,
____________________________________________________ is scheduled for an initial visit as an employee of
____________________________________________________, which is a participant in the AMERISURE INSURANCE COMPANY /
COVENTRY FIRST HEALTH NETWORKThis letter does not confirm that the injury or condition is covered by Workers’ Compensation
Insurance. That determination will be made as soon as an investigation is completed by our claims adjsuter.
DRUG TESTING IS REQUIRED:
□ Urinalysis
□ Breathalyzer (blood test if necessary)
We are working closely with COVENTRY/ FIRST HEALTH and the envolved medical providers to ensure that out employees receive access to
timely and medically necessary treatment for their industrial injuries. In the best interest of our employees, we will have modified work available,
which would allow the employee to return to work at the earliest possible date.
PLEASE CONTACT AMERISURE INSURANCE COMPANY
At (800) 282-2743
WHEN ONE OF THE FOLLOWING OCCURS
1. New Injury with disability greater than 7 days
2. Hospitilization
3. Anticipated Surgery
4. Physical Therapy of Chiropractic Treatment Recommended
5. Referral to provider
6. Assistance Required to Return Injured Employee to Work
7. Repeat Major Diagnostic Studies
All claims for treatment must be submitted to the address below on a HCFA 1500, UB 92, or the appropriate form required by the state.
Please submit all medical reports with the Bills within the time frame required by the apllicable state law. .
AMERISURE INSURANCE COMPANY
P.O. BOX 33478- Detroit, Michigan 48232
Phone: (800) 282-2743- o- Fax: (727) 561-7153
Should you have questions regarding your participation in the COVENTRY/FIRST HEALTH NETWORK, please refer to the provider’s
manual.
Sincerely,
Print Name Signature
Download at: www.mcdAmerisure.com
71
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Carta Introductoria al Médico
(Coventry/ First Health)
Fecha: __________________________
Nombre del Empleador: ________________________________________________________________________________
Numero de Teléfono del Empleador: ______________________________________________________________________
Estimado Proveedor de Cuidados de Salud:
____________________________________________________ está programado para una visita inicial como empleado de
____________________________________________________, el cual es participante de AMERISURE INSURANCE
COMPANY / COVENTRY FIRST HEALTH NETWORK. Esta carta no confirma que la lesión o la condición esté cubierta por el Seguro de Compensación para
Trabajadores (Workers’ Compensation Insurance). Esa determinación se hará tan pronto nuestro ajustador de reclamos complete la investigación.
ES REQUERIDO EL EXAMEN DE DROGAS:
□ Análisis de Orina
□ Breathalyzer (análisis de sangre si es necesario)
Estamos trabajando conjuntamente con COVENTRY/ FIRST HEALTH y con los proveedores de salud involucrados para asegurar que nuestros empleados
reciban acceso al tratamiento médico oportuno y necesario para sus lesiones laborales. En el mejor interés de nuestro empleado, nosotros modificaremos los
trabajos disponibles, lo cual le permitirá al empleado regresar al trabajo lo más pronto posible. Por favor tenga esto presente al tratar a este empleado.
POR FAVOR PONGASE EN CONTACTO CON AMERISURE INSURANCE COMPANY
AL: (800) 282-2743
CUANDO ALGUNO DE LOS SIGUIENTES OCURRA:
8. Nueva lesión con incapacidad mayor a 7 días y No dada de alta para regresar al trabajo
9. Hospitalización
10. Cirugía anticipada
11. Terapia física o Tratamiento Quiropráctico Recomendado
12. Referido al proveedor
13. Asistencia requerida para regresar al empleado lesionado a trabajar
14. Repetir estudios de Diagnóstico Mayor
Todas las reclamaciones para tratamiento tienen que ser sometidas o presentadas a la dirección que aparece debajo, en un
HCFA 1500, UB 92 o los formularios apropiados requeridos por el Estado. Por favor someta o presente todos los reportes
médicos dentro del margen de tiempo requerido por la ley del Estado aplicable.
AMERISURE INSURANCE COMPANY
P.O. BOX 33478- Detroit, Michigan 48232
(800) 282-2743- o- Fax: (727) 561-7153
Si usted tiene alguna pregunta acerca de su participación en COVENTRY/ FIRST HEALTH NETWORK, por favor refiérase al
manual de proveedores.
Sinceramente,
Nombre Firm
Download at: www.mcdAmerisure.com
72
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Your McDonald’s Insurance Team
3000 Bayport Drive Suite 400
Tampa, FL 33607
PHONE: (877) 200-1718
FAX: (877) 644-3670
Joe Besnard
Account Executive, Ext. 204
Joe.Besnard@BesnardInsurance.com
Adam Besnard
Account Executive, Ext. 205
Adam.Besnard@BesnardInsurance.com
Vivian Arencibia (Florida)
Account Service Manager, Ext. 203
Vivian.Arencibia@BesnardInsurance.com
Vanessa Alfonso (Non-Florida/Other States)
Account Service Manager, Ext. 208
Vanessa.Alfonso@BesnardInsurance.com
Kristina Baker
Account Services, Ext. 201
Kristina.Baker@BesnardInsurance.com
Milly Travieso
Account Services, Ext. 207
Milly@BesnardInsurance.com
73
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)Disclaimers
Besnard & Associates and its insurance company partners assist employers in evaluating workplace safety
exposures. Surveys, materials, and related services may not reveal every hazard, exposure and/or violation
of safety practices. Inspections by your insurance company do not result in any warranty that the
workplace, operations, machinery, appliances or equipment are safe or in compliance with applicable
regulations. Any recommendations and related services are not and should not be construed as legal advice
or be used as a substitute for legal advice. Employee protection and safety is ultimately the responsibility of
the employer.
Statements in this book or on web sites as to forms, policies, coverages, or other information provide
general information only. This information is not an offer to sell insurance. Insurance coverage cannot be
bound or changed via submission of any online form/application provided on this site or otherwise, email,
voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance
coverage go into effect unless and until confirmed directly by a licensed broker. Any proposal of insurance
we may present to you will be based upon the information you provide to us via this online form/application
and/or in other communications with us. Please contact our office at (877) 200-1718 to discuss specific
coverage details and your insurance needs. All coverages are subject to the terms, conditions and exclusions
of the actual policy issued. Not all policies or coverages are available in every state. Information provided
on this Site does not constitute professional advice; if you have loss control, HR, legal, tax (or financial
planning questions), you should contact an appropriate professional. Any hypertext links to other sites are
provided as a convenience only; we have no control over those sites and do not endorse or guarantee any
information provided by those Sites.
McDonald’s, Big Mac, the Golden Arches Logo and McDonald’s building design are trademarks of McDonald’s
Corporation and its affiliates, used with permission.
All material in this book is © 2012 Copyright Besnard & Associates All Rights Reserved.
Unauthorized reproduction or use of any materials is strictly prohibited by law.
http://www.besnardinsurance.com/profitingfromsafety/disclaimer/
74
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