EP Workers` Compensation Claim Packet
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Workers’ Compensation Claim Packet Important Insurance Information – Take This Packet with You on Location! Dear Valued Client, Please take a moment to print and review the contents of this booklet which contains important information on: Reporting Workers’ Compensation claims in the event of a work-related injury or illness Notices that MUST be posted at the workplace to avoid fines and penalties Other valuable information designed to make your job easier Getting Started Print the Entertainment Partners Workers’ Compensation Show Checklist. This list will ensure that you have built a complete EP Workers’ Comp Kit. Print and POST all of the legally required notices listed on the checklist. Print a few copies of the EP Injury Report if you will not be using the eletronic version of the form. The EP Injury Report is used to report Workers’ Comp claims. Please review the AIG Insurance Medical Provider Network information at talispoint.com/aig/EP or call 877.802.5246 to find the nearest provider or ER, in case of emergency. If none of the medical providers are in your area, please use the nearest occupational medical provider. Print a few copies of the EP Injured Worker Notification Form and the AIG Workers’ Compensation Mailing Addresses sheet. These forms are used when an injured worker needs to seek any medical treatment off of the production site. Please file all of the other useful information. Your contacts in Risk Management/Legal at Entertainment Partners Bob Remmel Vice President, Risk Management Phone: 818.955.6051 [email protected] Richard Morgan Senior Manager, Workers' Compensation Phone: 818.480.4252 [email protected] Robyn Ortiz Sr. Workers’ Compensation Specialist Phone: 818.955.6199 [email protected] Tina Zargarian Staff Workers’ Compensation Specialist Phone: 818.955.6386 [email protected] Lula Ulloa Sr. Workers’ Compensation Specialist Phone: 818.955.4337 [email protected] Melina Mayilyan Associate Workers’ Compensation Specialist Phone: 818.955.4022 [email protected] Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com Page 1 of 4 2016.08.09 Workers’ Compensation Claim Packet Updated August 2016 Page 2 of 2 To Report a Workers’ Compensation Claim Do not delay reporting an injury for lack of information. It is better to fax or email the details right away and let the insurance company obtain the rest of the information after the claim is reported. Please note that Employers are subject to fines for late reporting of Workers’ Compensation claims. Any fines that result from a production company not promptly reporting the claim to EP will be the responsibility of that company. Complete the enclosed EP Injury Report Form. Email it to us at [email protected], fax it to us at 818.559.3283, or call it in to us at 800.955.HURT (4878). The Entertainment Partners Injured Worker Notification Form and AIG Workers’ Compensation Mailing Addresses sheet should be given to the injured worker to take to the medical provider. Reporting a claim to EP does not mean the claim has been accepted for coverage. The adjuster at the insurance company will make that determination. Reporting a claim to EP does not satisfy OSHA requirements. The production must notify the appropriate state office of any serious injury, fatality or hospitalization. OSHA’s website is www.osha.gov and Cal/OSHA’s is https://www.dir.ca.gov/dosh/. Some Cal/OSHA information is included for your convenience. To Request a Workers’ Compensation Certificate of Insurance Please email [email protected] and include in your request: Production company and show/event name Production office address Full name and address of any third party requesting to be named as certificate holder, if applicable EP Insurance Requirements and Questionnaire Please contact contact Bob Remmel at 818.955.6051 / [email protected], Richard Morgan at 818.480.4252 / [email protected], Robyn Ortiz at 818.955.6199 / [email protected], or email [email protected] for further information. Any use of aircraft, watercraft, stunts, pyrotechnics, or animals Any activities in foreign countries Any flight concentration of more than 10 people per flight Any employees working under U.S. government contracts If these situations apply, please complete the questionnaire and email to [email protected]. You may also refer to EP’s Insurance Requirements for more information. State-Specific Information Some states require special documents be completed when an employee is injured in or is a resident of that perspective state. Please check for any state mandated requirements. The most common states are listed on the EP Workers’ Compensation Show Checklist. For all other states, please see the List of State Contacts provided. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com 2016.08.09 Workers’ Compensation Show Checklist Please use this checklist at the beginning of each production to ensure you have all of the correct Workers’ Compensation forms and posting notices. The following list is for all states – including California. Name of Form/Document What do I do with this Form? EP Injury Report Form For Production to report a work related Injury. EP Injured Worker Notification Form Send this form with the injured worker; it is for the medical provider. Finding an MPN Medical Provider Instructions on how to locate an occupational or urgent care facility. Tmesys Pharmacy Benefit Management Program Instructions on how to enroll in the Tmesys injuryrelated prescriptions program Tmesys Temporary Pharmacy Card Instructions for getting workers’ compensation prescriptions filled. EP Insurance Requirements and Questionnaire Complete this form when there will be any use of Aircraft, Watercraft, Stunts, Pyrotechnics, etc. Insurance Requirements for EP Clients For your information only. Sample Certificate of Insurance For your information only. OSHA Forms for Recording Work-Related Injuries and Illnesses Production must use this to report serious injuries and to maintain OSHA logs at the production site. Guide for Counting Lost Workdays For your information only. List of State Contacts Workers’ Compensation Information Refer to the EP website for additional requirements for any activities outside of California. Personal Health Benefits Flyer For your information only. Whistleblowers Are Protected Notice Must be posted. Sample Injury and Illness Prevention Program (IIPP) Must be posted. Safety Management Bulletin Must be posted. Safety Tips from EP Must be posted. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2015 Entertainment Partners. All Rights Reserved. ep.com Version 2015.12.31.1 Workers’ Compensation Show Checklist Updated December 2015 Page 2 of 2 The following list is for California only. Name of Form/Document What do I do with this Form? DWC-1 Form: Workers’ Compensation Claim Form & Notice of Potential Eligibility Must be provided to an injured worker at the time of injury. EP will also send a copy to the injured worker. California Specific Requirements Please see CAL-OSHA and FED-OSHA section of your OSHA packet. DWC-7 Form: Notice to Employees – Injuries Caused by Work Must be posted in both English and Spanish. California Entertainment Partners Medical Provider Network (Chartis/EP MPN 2418) Notification Packet Must be posted in both English and Spanish. Must provide a copy to the injured worker immediately once they give you notice of a work-related injury. Time of Hire Brochure Must be provided to new hires. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2015 Entertainment Partners. All Rights Reserved. ep.com Version 2015.12.31.1 Injury Report Form Workers’ Compensation PLEASE USE THIS FORM TO REPORT WORK-RELATED INJURIES OR ILLNESSES. When an employee has been injured and wants to file a workers’ compensation claim, please complete this form and fax or email it as soon as possible to: 818.559.3283 / [email protected]. This should be done immediately upon knowledge of the injury. Do not delay for lack of information; additional details can follow later. Faxing or emailing is the fastest way to process a claim. If you do not have access to a fax or email, you may call in the info to 800.955.4878. Failure to promptly report a claim can result in fines and penalties from the State. Please Print Employer Show Name: Production Company: Injured Worker’s Supervisor: Cell: Production Contact: Cell: Employee Name: Cell: SSN (LAST FOUR): XXX-XX- DOB: M F State Hired: Date Hired: Address: Occupation on Production: Wages: Per: Work-Related Injury or Illness DATE OF INJURY: Time Employee Began Work: AM PM Time of Injury: AM PM Injury Location Name: Location Phone: Location Address: County: Specific activity employee was engaged in: How did the accident/injury occur: Object causing injury: Type of Injury: Body part(s) injured (right/left): Witness to Injury (please attach a separate page for additional witnesses) Name: Title: Address: Cell: Return to Work Did employee return to work? Prior to injury: Yes No Unknown Hiatus 1) Next scheduled work date: Date returned to work: Layoff 2) Estimated termination date: # full days lost: Date of death: On-Site Treatment Notice Only (no medical treatment beyond On-Site care)? Yes No Unknown On-Site (Set Medic/Studio Medical Facility): Phone: Off-Site Treatment Off-Site Medical Treatment Anticipated? Yes No Unknown Off-Site (Occupational Clinic): Address: Is facility an ER? State: Phone: Completed By Person completing this form: Today’s date: Comments Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2011 Entertainment Partners. All Rights Reserved. www.ep.com Revised 9/2014 Clear Form Print Form Injured Worker Notification Form Attention Production Company: In the event of a work related incident or injury, please have the injured worker take a completed and signed copy of the attached form to the nearest medical facility, hospital or occupational clinic. For employees of: Entertainment Partners 2835 North Naomi Street Burbank, CA 91504 PHONE 800.955.4878 / FAX 818.559.3283 NOTICE TO MEDICAL PROVIDER In an emergency situation, do not delay medical care. Our workers’ compensation carrier reserves the right to verify compensability and authorize additional treatment beyond the initial diagnosis and emergency care. Injury Date of Injury: _____________________________________________ Time: __________________ Incident Location: ____________________________________________________________________ Body Part(s) Injured: __________________________________________________________________ Employee Name: _____________________________________________________________________________ Signature: ________________________________________________ Date: ___________________ Production Company Name of Production Company: __________________________________________________________ Representative Name/Title: _____________________________________________________________ Signature: ________________________________________________ Date: ___________________ For more information on where to send bills and doctor reports, please see attached document. Contact Entertainment Partners at 800.955.4878 to obtain the name and number of the claim adjuster and receive additional information or authorization. Print Form Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2015 Entertainment Partners. All Rights Reserved. www.ep.com Revised 9/2015 Page 1 of 2 Injured Worker Notification Form Page 2 of 2 AIG Workers’ Compensation (WC) Mailing Addresses Benefit State(s) Mailing Address WC Medical Bills Mailing Address WC Claims Alabama, Georgia, Maine, Massachusetts, Mississippi, New Hampshire, North Carolina, Rhode Island, South Carolina and Vermont AIG P.O. Box 305901 Nashville, TN 37230 AIG P.O. Box 305902 Nashville, TN 37230 Connecticut and New York AIG P.O. Box 305901 Nashville, TN 37230 AIG P.O. Box 305902 Nashville, TN 37230 Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania AIG P.O. Box 305901 Nashville, TN 37230 AIG P.O. Box 305902 Nashville, TN 37230 Florida AIG P.O. Box 305901 Nashville, TN 37230 AIG P.O. Box 305902 Nashville, TN 37230 Indiana, Kentucky, Ohio, Tennessee, Virginia and West Virginia AIG P.O. Box 305901 Nashville, TN 37230 AIG P.O. Box 305902 Nashville, TN 37230 Michigan, Minnesota, South Dakota and Wisconsin AIG P.O. Box 305901 Nashville, TN 37230 AIG P.O. Box 305902 Nashville, TN 37230 Alaska, Arizona, Arkansas, Colorado, Hawaii, Idaho, Illinois, Iowa, Kansas, Louisiana, Missouri, Montana, Nebraska, New Mexico, North Dakota, Oregon, Utah, Washington and Wyoming AIG P.O. Box 25972 Shawnee Mission, KS 66225 AIG P.O. Box 25971 Shawnee Mission, KS 66225 California AIG P.O. Box 25978 Shawnee Mission, KS 66225 AIG P.O. Box 25977 Shawnee Mission, KS 66225 Nevada AIG P.O. Box 26149 Las Vegas, NV 89126 AIG P.O. Box 26149 Las Vegas, NV 89126 Oklahoma and Texas AIG P.O. Box 25975 Shawnee Mission, KS 66225 AIG P.O. Box 25974 Shawnee Mission, KS 66225 Eastern Zone Western Zone Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2015 Entertainment Partners. All Rights Reserved. www.ep.com Finding an MPN Medical Provider 1. Go to talispoint.com/aig/EP. 2. Find and click on Radius Search. 3. Enter the zip code for the area in which you need to find a Medical Provider. Then hit the Tab key. 4. Select Distance Range (usually 10–15 miles will yield a high number of offices). 5. Select 100 Providers per page. 6. Click on Continue. 7. Go to Provider Types and select First Treatment Providers. 8. Go to the right under Specialties and select Occupational/Industrial Medicine & Urgent Care Center/Walk-in ONLY! You can select both by pressing and holding the left mouse button down and dragging it over both selections. ** NOTE: Any other type of doctor must be approved by the adjuster. ** 9. Click on Find Providers. The next screen will take a little while to come up but it will have the listing of all of our MPN Providers sorted by distance from closest to furthest. Not all providers on this list still accept workman’s comp/take walk-ins/treat on an emergency basis. We recommend that you place a call to the medical provider prior to sending the employee to the medical provider to insure that the employee will be seen. If the injury is an emergency or life threatening, please direct the employee to the nearest Emergency Room! Version 2015.12.31.1 Cha rtis Cla ims P Ma har , Inc. and nag mac Tm esy ® em y s ent Bene Pro fit gra m The Tmesys Pharmacy Benefit Management Program is designed to meet the specific needs of workers’ compensation injuries. Our goal is to save you time and money, while providing an efficient system for your injured workers to receive their injury-related prescriptions. Program Highlights • Nationwide network of pharmacies with Internet access to Tmesys 24 hours a day • No out-of-pocket expense for your injured worker after pharmacy setup • Online processing of prescriptions • Benefits designed to an individual level • Customer Help Desk to respond to questions 24 hours a day • Online Medical Provider Listing to help injured workers find a local pharmacy Pharmacies are connected to Tmesys by a central communications system designed to process each medication request at the point of sale. Dear Employer: Please provide your injured employee with the following information to present to a participating network pharmacy: Tmesys Help Desk: 800-964-2531 Fax: 800-365-6337 Workers’ Compensation Claim Administrator: Chartis Claims, Inc. Injured workers have access to over 60,000 preferred pharmacies nationwide. In most cases, these neighborhood pharmacies are located close to your employees’ homes or places of business. Tmesys Retail Pharmacy Network* More than 60,000 pharmacies, including large chains and many neighborhood independent pharmacies A&P Supermarkets Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker’s Pharmacy Bartell Drugs Bashas’ United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy BI-LO Bi-Mart Bioscrip Pharmacy BJ’s Pharmacy Brookshire’s Pharmacy Bruno’s Pharmacy Buehler’s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn’s/Cash Wise Concord Drugs Costco Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl’s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc’s Drug Dominick’s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred’s Pharmacy Fruth Pharmacy Fry’s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi’s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen’s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry’s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith’s Knight Drugs Kohl’s Pharmacy Kohll’s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drugs Louis and Clark Lowes Marketplace Marc’s Pharmacy Marsh Drugs Martin’s Food Markets May’s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various stores) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick ’N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley’s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Red Cross Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack ’n Save Pharmacy Safeway Pharmacy Sam’s Club Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy & Discount Shaw’s Pharmacy Shaws/Osco Pharmacy Shop ’n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay Supermarket Target The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG’s Pharmacy Waldbaum’s Pharmacy Walgreens Walmart Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *List subject to change. This is a partial listing only. How to locate a Tmesys pharmacy: Call Tmesys at 866-599-5426. A Tmesys representative will assist you with the location of a participating pharmacy in your area. How to enroll in mail order delivery: Call PMSI at 800-237-7676, ext. 87602 to receive a Mail Order Pharmacy Prescription Form or fax a prescription directly to 800-532-2151. A PMSI representative will contact you directly to obtain all necessary information. © 2011 PMSI. Tmesys is a registered trademark of PMSI, Inc. 78307 05/11 Chartis is a world leading property-casualty and general insurance organization serving more than 70 million clients in over 160 countries and jurisdictions. With a 90-year history, one of the industry’s most extensive ranges of products and services, deep claims expertise and excellent financial strength, Chartis enables its commercial and personal insurance clients alike to manage virtually any risk with confidence. Chartis is the marketing name for the worldwide property-casualty and general insurance operations of Chartis Inc. For additional information, please visit our website at www.chartisinsurance.com. P.O. Box 152539 Tampa, FL 33684-2539 MAKING IT EASY... TO GET WORKERS’ COMPENSATION PRESCRIPTIONS FILLED. Helios has been chosen by your employer’s insurer, AIG, to manage your workers’ compensation pharmacy benefits on their behalf. Below is your First Fill card that will allow you to receive your injury-related prescriptions at your local pharmacy. Please fill out the card based on the instructions below. Rx Injured Employee: If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. Give this temporary card to the pharmacist. The pharmacist will fill your prescription at no cost to you. Questions? Need Help? If your workers’ compensation claim is accepted, you will receive a permanent pharmacy card in the mail. Please use that card for refills of medications for this work-related injury or illness. Rx 866.599.5426 Most pharmacies are included in the network. To find a network pharmacy call 866.599.5426 or visit www.talispoint.com/aig/EP. Attention Pharmacists: Enter RxBIN, RxPCN, and GROUP. Member ID # format is the date of injury, and SSN combined as follows: YYMMDD123456789. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk 800.964.2531 AIG CARRIER/TPA EMPLOYER RxBIN NDC 004261 or RxPCN CAL or INJURED WORKER NAME SOCIAL SECURITY NUMBER DATE OF INJURY (YYMMDD) Envoy 002538 Envoy Acct. # Notice to Cardholder: Present this card to the pharmacy to receive medication for your work-related injury. To locate a pharmacy: www.talispoint.com/aig/EP NOTE: This First Fill card is only valid for your workers’ compensation injury or illness. Employer: Print Form Immediately upon receiving notice of injury, fill in the information above and give this form to the employee. IMP14-1513-02_AIG-ENG Insurance Requirements and Questionnaire If any of the boxes below ARE checked, please continue completing the rest of this form, as these activities require prior approval by EP. If NONE of the below activities apply to your production, you do not need to fill out this form. However, a certificate of insurance is always required, so please send the Insurance Requirements on Page 3 to your insurance broker. The certificate of insurance should be emailed to [email protected]. NOTE: Payroll cannot be processed until the certificate is received and approved by EP. If any of the boxed items are added to your production at a later date, please contact [email protected] or call 800.955.4878 to request the required approval. NOTE: EP does not pay or provide Workers’ Compensation for aircraft pilots, or on-camera talent, or participants engaged in risky production activities without prior approval by EP. Please check ALL that apply to your production: Aircraft Athletes/Dancers Foreign Pyrotechnics Scuba Diving Skydiving Stunts Watercraft Weapons/Live Ammunition Wild Animals Other Hazardous Activities not listed above: U.S. Government Contract Project Any Foreign Countries listed here: http://www.treasury.gov/resource-center/sanctions/Programs/Pages/Programs.aspx Production Company: ________________________________________________________________ Production Title: ____________________________________________________________________ Production Contact Name: _________________________________ Phone: ___________________ Email: _____________________________________________________________________________ Your Insurance Broker’s Name: _____________________________ Phone: ___________________ Email: _____________________________________________________________________________ Dates for Above Activities: Locations: CONTINUED ON NEXT PAGE Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com Page 1 of 3 2016.08.02 Insurance Requirements and Questionnaire Updated August 2016 Page 2 of 3 Description of Activities: Number of EP Employees Involved (include job functions): Names of Stunt/Safety Coordinators: Name of Nearest Emergency Hospital: Number of Miles: Description of Safety Precautions and Experience of Those Participating in Hazardous Activities: Please click the Email Form button below to send your completed form by email to [email protected]. Or, you may FAX the completed form to our Risk Management team at 818.559.3283. Clear Form Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com Print Form 2016.08.02 Insurance Requirements and Questionnaire Updated August 2016 Page 3 of 3 Insurance Requirements for EP Clients Please send this to your insurance broker and forward your certificate of insurance to [email protected] (see sample certificate on next page). NOTE: Payroll cannot be processed until the certificate is received and approved by EP. Please note you must request prior approval of hazardous activities by contacting [email protected] or by calling 800.955.4878. 1. Certificate Holder and Additional Insured ENTERTAINMENT PARTNERS, ITS PARENT, SUBSIDIARIES, RELATED AND AFFILIATED COMPANIES, ITS OFFICERS, DIRECTORS, AGENTS AND EMPLOYEES 2835 N. Naomi Street Burbank, CA 91504-2024 ATTN: [email protected] 2. Notice of Cancellation/Carrier Rating Certificate Holder shall receive 30 Days Notice of Cancellation or Material Change on all policies shown below. All carriers must have a Best Rating of A+ or better. 3. Commercial General Liability Insurance Limit: $1,000,000 Limit per Occurrence 4. Commercial Auto Liability Insurance Limit: $1,000,000 Limit per Occurrence Forms: Hired and Non-Owned Auto Liability Note: Owned Auto Liability is required if the Production owns vehicles. 5. Foreign Liability Insurance (waived if all activities are in the U.S., its possessions, or Canada) Limit: $1,000,000 Limit for Bodily Injury & Property Damage 6. Aircraft Coverage (waived if no aircraft activities are involved) NOTE: EP cannot pay aircraft pilots unless acceptable Aircraft Certificates of Insurance are approved by EP Risk Management PRIOR to flight activities. In order for EP to pay the pilot, Production must provide: Non-Owned Aircraft Liability with $10,000,000 Limit per Occurrence for Bodily Injury (Including Passengers) & Property Damage (Including Damage to the Aircraft), naming EP as Additional Insured per item 1above If EP is NOT paying the pilot, Aircraft Owner or Supplier must provide: Aircraft Liability with a limit of $10,000,000 Limit per Occurrence (Including Passengers) and Hull coverage with a limit sufficient to cover the value of the aircraft, naming EP as Additional Insured per item 1 above. Must include Waiver of Subrogation with respect to Hull Coverage. 7. Non-Owned Watercraft Coverage (waived if no watercraft activities are involved) Limit: $10,000,000 Limit per Occurrence, including Hull coverage sufficient to cover the value of the vessel(s). In some cases, lower limits may be sufficient, depending on production activities. 8. SPECIAL NOTE Productions should maintain their own Workers’ Compensation policy to cover interns, volunteers, people who are injured while auditioning or rehearsing (prior to employment through EP), foreign hires working in foreign countries, and others who are not insured through EP. If you have questions, please contact Bob Remmel (818.955.6051), Robyn Ortiz (818.955.6199), or Richard Morgan (818.480.4252). Please email your certificate to [email protected] or FAX to 818.559.3283. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com 2016.08.02 ENTERTAINMENT PARTNERS, ITS PARENT, SUBSIDIARIES, RELATED AND AFFILIATED COMPANIES, ITS OFFICERS, DIRECTORS, AGENTS AND EMPLOYEES 2835 N. NAOMI ST. BURBANK, CA 91504 ATTN: [email protected] NAME OF AUTHORIZED REPRESENTATIVE OSHA Forms for Recording Work-Related Injuries and Illnesses OSHA provides a booklet which includes the forms needed for maintaining occupational injury and illness records. Many but not all employers must complete the OSHA injury and illness recordkeeping forms on an ongoing basis. Employers in State Plan states should check with their State Plan to see if the exemptions below apply. Because of the small employer exception, employers with 10 or fewer employees throughout the previous calendar year do not need to complete these forms. In addition, there is an exemption for establishments classified in certain industries. A complete list of exempt industries can be found on the OSHA web page at osha.gov. Establishments normally exempt from keeping the OSHA forms must complete the forms if they are informed in writing to do so by the Bureau of Labor Statistics or OSHA. NOTE: OSHA updated its recordkeeping rule to expand the list of severe injuries that employers must report directly to OSHA, regardless of the above exemptions. As of January 1, 2015, all employers must report: 1. All work-related fatalities within 8 hours. 2. All work-related in-patient hospitalizations, all amputations and all losses of an eye within 24 hours. You can report to OSHA by: 1. Calling OSHA's free and confidential number at 1.800.321.OSHA (6742). 2. Calling your closest Area Office during normal business hours. 3. Using the new online form that will soon be available. Only fatalities occurring within 30 days of the work-related incident must be reported to OSHA. Further, for an in-patient hospitalization, amputation, or loss of an eye, these incidents must be reported to OSHA only if they occur within 24 hours of the work-related incident. Download the OSHA Forms Booklet STATE OF CAUFORN!A DEPARTMENT OF !NDUSTR!AL RELATIONS DMSiON OF LABOR STATISTICS AND RESEARCH P .O, Box 429488, San Francisco, CaUfomla 94142 GUIDE FOR COUNTING LOST WORKDAYS Keep for Reference Counting lost workdays may STOP when: 1) The employee returns to normal workday routine; 2) The employer receives a doctor's statement releasing the employee to normal workday routine, whether or not the employee actually does return to work; 3) The employee is permanently transferred to another position as a result of the injury/illness; 4) The employee becomes totally disabled (a doctor's diagnosis date is sufficient); 5) The employee becomes eligible for vocational rehabilitation (again, a doctor's diagnosis date is sufficient for stopping lost workday count); 6) The employee would normally have been laid off or terminated due to lack of work; 7) The employee is terminated, quits, or leaves and never returns, for reasons unrelated to the work-sustained injury or illness. If an employee is terminated or quits because of the work-sustained injury or illness, the case should be recorded as a lost workday case and an estimate made of the number of workdays that would have been lost had the employee not quit or been terminated. If an injured or ill employee was still out at the end of the calendar year, the employer should estimate the number of workdays the employee will lose In following year and add that figure to the number of workdays lost in the year of onset. List of State Contacts Workers’ Compensation Information ALABAMA Workers’ Compensation Division Industrial Relations Building 649 Monroe Street Montgomery, AL 36131 Toll free: 800.528.5166 Phone: 334.242.2868, Fax: 334.353.8262 ALASKA Workers’ Compensation Division P.O. Box 115512 Juneau, AK 99811 Phone: 907.465.2790, Fax: 907.465.2797 ARIZONA Industrial Commission of Arizona 800 West Washington Street Phoenix, AZ 85007 Toll free: 800.544.6488 Phone: 602.542.5241, Fax: 542.4135 ARKANSAS Workers’ Compensation Commission Street Address: 324 Spring Street Little Rock, AR 72203 Mailing Address: P.O. Box 950 Little Rock, AR 72203-0950 Toll free: 800.622.4472 Phone: 501.682.3930, Fax: 501.682.2777 CALIFORNIA Division of Workers’ Compensation (DWC) 1515 Clay Street, 17th Floor Oakland, CA 94612-1402 Phone: 510.286.7100 COLORADO Division of Workers’ Compensation 633 17th Street, Suite 400 Denver, CO 80202 Toll Free: 888.390.7936 Phone: 303.318.8700, Fax: 303.318.8710 CONNECTICUT Workers’ Compensation Commission Capitol Place 21 Oak Street, Fourth Floor Hartford, CT 06106 Phone: 860.493.1500, Fax: 860.247.1361 DELAWARE Office of Workers’ Compensation Street Address: 4425 North Market Street, 3rd Floor Wilmington, DE 19802 Mailing Address: P.O. Box 9954 Wilmington, DE 19809-9954 Phone: 302.761.8200, Fax: 302.761.6601 DISTRICT OF COLUMBIA Office of Workers’ Compensation 64 New York Avenue, NE, 2nd floor Washington, DC 20002 Phone: 202.671.1000 FLORIDA Division of Workers’ Compensation 200 East Gaines Street Tallahassee, FL 32399-4220 Toll free: 877.693.5236, Phone: 850.413.1601 GEORGIA Georgia State Board of Workers’ Compensation 270 Peachtree Street, NW Atlanta, GA 30303-1299 Toll free: 800.533.0682, 404.656.3875 Fax: 404.656.7768 HAWAII Department of Labor & Industrial Relations (DLIR) - Disability Compensation Division Street Address: 830 Punchbowl Street, Room 209 Honolulu, HI 96813 Mailing Address: P.O. Box 3769 Honolulu, HI 96812-3769 Phone: 808.586.9174, Fax: 808.586.9219 Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com Revised 9/2014 Page 1 of 4 List of State Contacts Workers’ Compensation Information IDAHO Idaho Industrial Commission Main Office: 700 South Clearwater Lane Boise, ID 83712 Mailing Address: P.O. Box 83720 Boise, ID 83720-0041 Toll free: 800.950.2110 Phone: 208.334.6000, Fax: 208.334.2321 ILLINOIS Industrial Commission 100 West Randolph Street, Suite 8-200 Chicago, IL 60601 Toll Free within Illinois: 866.352.3033 Phone: 312.814.6611, Fax: 312.814.6523 INDIANA Workers’ Compensation Board of Indiana 402 West Washington Street, Room W-196 Indianapolis, IN 46204 Toll free: 800.824.COMP (2667) Phone: 317.232.3808, Fax: 317.233.5493 IOWA Iowa Division of Workers’ Compensation 1000 East Grand Avenue Des Moines, IA 50319-0209 Toll free: 800.562.4692 Phone: 515.281.5387, Fax: 515.281.6501 KANSAS Kansas Workers’ Compensation 800 SW Jackson, Suite 600 Topeka, KS 66612-1227 Toll free: 800.332.0353 Phone: 785.296.3441, Fax: 785.296.0839 KENTUCKY Department of Workers’ Claims 657 Chamberlin Avenue Frankfort, KY 40601 Phone: 502.564.5550 ext 4578 Fax: 502.564.5732 LOUISIANA Office of Workers’ Compensation Administration Street Address: 1001 North 23rd Street Baton Rouge, LA 70802 Mailing Address: P.O. Box 94040 Baton Rouge, LA 70804-9040 Phone: 225.342.7555, Fax: 225.342.5665 Page 2 of 4 MAINE Workers’ Compensation Board 27 State House Station Augusta, ME 04333-0027 Toll free (Maine Only): 888.801.9087 Phone: 207.287.7096, Fax: 207.287.7198 MARYLAND Maryland Workers’ Compensation Commission 10 East Baltimore Street Baltimore, MD 21202-1641 Toll Free (Outside Baltimore Metro Area): 800.492.0479 Phone: 410.864.5100, Fax: 410.333.8122 MASSACHUSETTS Department of Industrial Accidents 600 Washington Street, 7th Floor Boston, MA 02111 Toll free: 800.323.3249, Phone: 617.727.4900 MICHIGAN Bureau of Workers’ & Unemployment Disability Compensation Street Address: State Secondary Complex General Office Building 7150 Harris Drive First Floor, B-Wing Dimondale, MI 48821 Mailing Address: P.O. Box 30016 Lansing, MI 48909 Toll free: 888.396.5041 Phone: 517.322.1438, Fax: 517.322.1808 MINNESOTA Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4307 Toll free: 800.342.5354 Phone: 651.284.5005, Fax: 651.284.5733 MISSISSIPPI Mississippi Workers’ Compensation Commission Street Address: 1428 Lakeland Drive Jackson, MS 39216 Mailing Address: P.O. Box 5300 Jackson, MS 39296-5300 Toll free: 866.473.6922 Phone: 601.987.4200, Fraud: 601.359.4250 Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com List of State Contacts Workers’ Compensation Information MISSOURI Division of Workers’ Compensation Street Address: 3315 West Truman Boulevard, Room 131 Jefferson City, MO 65102 Mailing Address: P.O. Box 58 Jefferson City, MO 65102-0058 Phone: 573.751.4231, Fax: 573.751.2012 MONTANA Workers’ Compensation Court Street Address: 1625 11th Avenue Helena, MT Mailing Address: P.O. Box 537 Helena, MT 59624-0537 Phone: 406.444.7794, Fax: 406.444.7798 Page 3 of 4 NEW JERSEY Division of Workers’ Compensation P.O. Box 381 Trenton, NJ 08625-0381 Phone: 609.292.2414, Fax: 609.984.2515 NEW MEXICO Workers’ Compensation Administration 2410 Centre Ave SE P.O. Box 27198 Albuquerque, NM 87125-7198 Toll free: 800.255.7965, Phone: 505.841.6000 NEW YORK New York State Workers’ Compensation Board 20 Park Street Albany, NY 12207 Toll free: 877.632.4996 Phone: 518.474.8182, Fax: 518.486.7510 NEBRASKA Workers’ Compensation Court Street Address: State Capitol Building, 13th Floor 1445 “K” Street Lincoln, NE 68508 Mailing Address: P.O. Box 98908 Lincoln NE 68509-8908 Toll free (in Nebraska only): 800.599.5155 Phone: 402.471.6468 (Lincoln and out of state) Fax: 402.471.2700 NORTH CAROLINA North Carolina Industrial Commission 4340 Mail Service Center Raleigh, NC 27699-4340 Toll free: 800.688.8349, Phone: 919.807.2501 NEVADA Department of Business & Industry In Northern Nevada: 400 West King Street, Suite 400 Carson City, NV 89703 Phone: 775.684.7270, Fax: 775.687.6305 In Southern Nevada: 1301 North Green Valley Parkway, Suite 200 Henderson, NV 89074 Phone: 702.486.9080, Fax: 702.990.0364 OHIO Ohio Bureau of Workers’ Compensation 30 West Spring Street Columbus, OH 43215-2256 Toll free: 800.644.6292, Fax: 877.520.6446 NEW HAMPSHIRE Workers’ Compensation Division 95 Pleasant Street Concord, NH 03301 Phone: 603.271.3174 NORTH DAKOTA Workforce Safety & Insurance 1600 East Century Avenue‚ Suite 1 Bismarck ND 58503–0644 Toll free: 800.777.5033 Phone: 701.328.3800, Fax: 701.328.3820 OKLAHOMA Workers’ Enforcement Compensation Division 1915 North Stiles Avenue Oklahoma City, OK 73105 Toll free: 800.522.8210, Phone: 405.522.8760 OREGON Workers’ Compensation Division 350 Winter Street NE, Room 27 Salem, OR 97301-3879 Workers’ Comp Info-line: 800.452.0288 Phone: 503.947.7810, Fax: 503.947.7581 Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com List of State Contacts Workers’ Compensation Information Page 4 of 4 PENNSYLVANIA Bureau of Workers’ Compensation 1171 South Cameron Street, Room 324 Harrisburg, PA 17104-2501 Toll free (inside Pennsylvania): 800.482.2383 Phone: 717.772.4447 VERMONT Workers’ Compensation Division 5 Green Mountain Drive P.O. Box 488 Montpelier, VT 05601-0488 Phone: 802.828.2286, Fax: 802.828.2195 RHODE ISLAND State of Rhode Island Workers’ Compensation Court J. Joseph Garrahy Judicial Complex 1 Dorrance Plaza Providence, RI 02903-3973 Phone: 401.458.5000 VIRGINIA Virginia Workers’ Compensation Commission 1000 DMV Drive Richmond, VA 23220 Toll free: 877.664.2566, Fax: 804.367.9740 SOUTH CAROLINA Workers’ Compensation Commission Street Address: 1612 Marion Street Columbia, SC 29201 Mailing Address: P.O. Box 1715 Columbia, SC 29202-1715 Phone: 803.737.5700, Fax: 803.737.5768 SOUTH DAKOTA Division of Labor and Management Kneip Building, Third Floor 700 Governors Drive Pierre, SD 57501-2291 Phone: 605.773.3681, Fax: 605.773.4211 TENNESSEE Workers’ Compensation Division 220 French Landing Drive Nashville, TN 37243-1002 Toll free (within Tennessee) 800.332.2667 Phone: 615.532.4812, Fax: 615.532.1468 TEXAS Texas Workers’ Compensation Commission (TWCC) Southfield Building MS-3 4000 South IH-35 Austin, TX 78704-7491 Phone: 512.804.4000, Fax: 512.804.4001 WASHINGTON Workers’ Compensation Information Labor and Industries Building P.O. Box 44000 Olympia, WA 98504-4000 Phone: 360.902.4213, Fax: 360.902.4565 WEST VIRGINIA Workers’ Compensation Division P.O. Box 2628 Charleston, WV 25329-2628 Phone: 304.558.5230, Fax: 304.558.1322 WISCONSIN Workers’ Compensation Division Street Address: 201 East Washington Avenue, Room C100 Madison, WI 53703 Mailing Address: P.O. Box 7901 Madison, WI 53707-7901 Phone: 608.266.1340, Fax: 608.267.0394 WYOMING Workers’ Safety and Compensation Division 1510 East Pershing Boulevard Cheyenne, WY 82002 Phone: 307.777.7441, Fax: 307.777.6552 UTAH Labor Commission of Utah 160 East 300 South, 3rd Floor P.O. Box 146610 Salt Lake City, UT 84114-6610 Phone: 801.530.6800, Fax: 801.530.6390 Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com Personal Health Benefits Are you looking for personal health insurance with benefits that will follow you no matter where you work—even if you are not working at all? First, check with your production company to see if you are eligible for EP Cares™. For more information on the program, visit ep.com/epcares or call 855.339.7350 and select Option 2. If you are not eligible for EP Cares™, please keep reading to learn more about gaining access to individual coverage. Call 866.206.8493 today to learn more about an innovative Self-Pay program which is designed specifically for production workers and other temporary employees who may be unable to qualify for union benefits or employer-sponsored programs. Licensed benefit counselors are available to help you determine the benefits you need at a price you can afford. Highlights Include: • No waiting period and no eligibility requirements. • There are options to keep your own doctor. • Coverage is portable—so it follows you even when you work for other employers or are unemployed (provided you continue to pay the monthly premium). EP Production Worker Employees now have access to Personal Health Benefits! Call 866.206.8493 today for a quote or more information. • Premiums vary depending on your needs; rates are guaranteed for one year. • The Plan Provider bills the premium directly to you. • You may opt-out or cancel coverage at any time. • The Call Center provides licensed benefit counselors to help you decide what’s best for you and/or your family. • The Call Center is bilingual (Spanish) and open from 6:00 am to 6:00 pm (Pacific). • The enrollment process is quick and easy—no forms to complete! • Coverage is available in all 50 states. • You will receive a 30-Day Welcome Call to make sure your policy has arrived and that you feel comfortable about how to use the benefits. • You will receive an 11-Month Pre-Renewal Call from the counselor to help you evaluate how your personalized benefits worked for you and if any changes are desired. ep.com Whistleblowers Are Protected It is the public policy of the State of California to encourage employees to notify an appropriate government or law enforcement agency when they have reason to believe their employer is violating a state or federal statute, or violating or not complying with a state or federal rule or regulation. Who is protected? Pursuant to California Labor Code Section 1102.5, employees are the protected class of individuals. “Employee” means any person employed by an employer, private or public, including, but not limited to, individuals employed by the state or any subdivision thereof, any county, city, city and county, including any charter city or county, and any school district, community college district, municipal or public corporation, political subdivision, or the University of California. [California Labor Code Section 1106] What is a whistleblower? A “whistleblower” is an employee who discloses information to a government or law enforcement agency where the employee has reasonable cause to believe that the information discloses: 1. A violation of a state or federal statute, 2. A violation or noncompliance with a state or federal rule or regulation, or 3. With reference to employee safety or health, unsafe working conditions or work practices in the employee’s employment or place of employment. What protections are afforded to whistleblowers? 1. An employer may not make, adopt, or enforce any rule, regulation, or policy preventing an employee from being a whistleblower. 2. An employer may not retaliate against an employee who is a whistleblower. 3. An employer may not retaliate against an employee for refusing to participate in an activity that would result in a violation of a state or federal statute, or a violation or noncompliance with a state or federal rule or regulation. 4. An employer may not retaliate against an employee for having exercised his or her rights as a whistleblower in any former employment. Under California Labor Code Section 98.6, if an employer retaliates against a whistleblower, the employer may be required to reinstate the employee’s employment and work benefits, pay lost wages, and take other steps necessary to comply with the law. How to report improper acts If you have information regarding possible violations of state or federal statutes, rules, or regulations, or violations of fiduciary responsibility by a corporation or limited liability company to its shareholders, investors, or employees, call the California State Attorney General’s Whistleblower Hotline at 1-800-952-5225. The Attorney General will refer your call to the appropriate government authority for review and possible investigation. Sample Injury and Illness Prevention Program Re: Sample Injury and Illness Prevention Program Every California employer must establish, implement, and maintain a written Injury and Illness Prevention (IIP) Program. A copy must be maintained at each worksite or at a central work site if the employer has non-fixed work sites. The requirements for establishing, implementing and maintaining an effective written injury and illness prevention program are contained in Title 8 of the California Code of Regulations, Section 3203 (T8 CCR 3203), and consist of the following eight elements: • Responsibility • Compliance • Communication • Hazard Assessment • Accident • Exposure Investigation • Hazard Correction • Training and Instruction • Recordkeeping This model program was written for a broad spectrum of employers, and it may not match your establishment’s exact needs. However, it does provide the essential framework required for an Injury and Illness Prevention Program. Proper use of this model program requires that your establishment’s IIP Program administrator carefully review the requirements for each of the eight included IIP Program elements. Fill in the appropriate blank spaces and check those items that are applicable to your workplace. The Recordkeeping section requires that the IIP Program Administrator select and implement the category appropriate for your establishment. Sample forms for hazard assessment and correction, accident/exposure investigation, and employee training/instruction are all provided with this model program. This model program must be maintained by the site employer (The Production) in order to be effective. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com Revised 7/2014 Production Injury and Illness Prevention Program Page 1 of 7 Responsibility The Injury and Illness Prevention Program (IIP Program) Administrator is: _______________________________________________ The Program Administrator has the authority and responsibility for implementing the provisions of this program for the filming of: ________________________________ All managers and supervisors are responsible for implementing and maintaining the IIP Program in their work areas and for answering worker questions about the IIP Program. A copy of this IIP Program should be available to each manager and supervisor. Compliance Management is responsible for ensuring that all safety and health policies and procedures are clearly communicated and understood by all employees. Managers and supervisors are expected to enforce the rules fairly and uniformly. All employees are responsible for using safe work practices; for following all directives, policies and procedures; and for assisting in maintaining a safe work environment. Our system of ensuring that all employees comply with the rules and maintain a safe work environment include: 1. Informing employees of the provisions of our IIP Program 2. Evaluating the safety performance of all employees 3. Recognizing employees who perform safe and healthful work practices 4. Providing training to employees whose safety performance is deficient 5. Disciplining employees for failure to comply with safe and healthful work practices 6. The following practices: ________________________________________________ Production Injury and Illness Prevention Program Page 2 of 7 Communication We recognize that open, two-way communication between management and staff on health and safety issues is essential to ensuring an injury-free, productive workplace. The following system of communication is designed to facilitate a continuous flow of safety and health information between management and staff in a form that is readily understandable and consists of one or more of the following items: • New employee orientation including a discussion of safety and health policies and procedures. • Review of our lIP Program. • Workplace safety and health training programs. • Regularly scheduled safety meetings. • Effective communication of safety and health concerns between employees and supervisors, including translation when appropriate. • Posted or distributed safety information. • A system for employees to anonymously inform management about workplace hazards. If our establishment has less than ten employees, we communicate with and instruct employees orally about general safe work practices and hazards unique to each job assignment. • A labor/management safety and health committee which: meets regularly; prepares written records of its meetings; reviews results of the periodic scheduled inspections; reviews investigations of accidents and exposures and makes suggestions to management for the prevention of future incidents; reviews investigations of alleged hazardous conditions; and submits recommendations to assist in the evaluation of employee safety suggestions. • A plan to address emergencies at each worksite. Depending on the location and number of employees involved, the plan may be in writing. • Other: _____________________________________________________ Production Injury and Illness Prevention Program Page 3 of 7 Hazard Assessment Periodic inspections to identify and evaluate workplace hazards shall be performed by the following competent observer(s) in the following areas of our workplace: Competent Observer Area Periodic inspections are to be performed according to the following schedule: 1. Frequency: _________________________________ (Daily, weekly, monthly, etc.) 2. When we initially established our lIP Program 3. When new substances, processes, procedures or equipment that present potential new hazards are introduced into our workplace 4. When new, previously unidentified hazards are recognized 5. When occupational injuries and/or illnesses occur 6. When we hire and/or reassign permanent or intermittent employees to processes, operations, or tasks for which a hazard evaluation has not been previously conducted 7. Whenever workplace conditions warrant an inspection. Periodic inspections consist of identification and evaluation of workplace hazards utilizing applicable sections of the attached Hazard Assessment Checklist and any other effective methods to identify and evaluate any workplace hazards. Accident/Exposure Investigations Procedures for investigating workplace accidents and hazardous substance exposures include: 1. Visiting the accident scene as soon as possible 2. Interviewing injured workers and witnesses 3. Examining the workplace for factors associated with the accident/exposure 4. Determining the cause of the accident/exposure 5. Taking corrective action to prevent the accident/exposure from recurring 6. Recording the findings and corrective actions taken Production Injury and Illness Prevention Program Page 4 of 7 Hazard Correction Unsafe or unhealthy work conditions, practices, or procedures shall be corrected in a timely manner based on the severity of the hazards. Hazards shall be corrected according to the following procedures: 1. Whenever possible, a hazard shall be corrected immediately upon observation/discovery. 2. When an imminent hazard exists which cannot be immediately abated without endangering employee(s) and/or property, we will remove all exposed workers from the area except those necessary to correct the existing condition. Workers necessary to correct the hazardous condition shall be provided with the necessary protection. 3. All such actions taken and dates they are completed shall be documented on the appropriate forms. Training and Instruction All employees, including managers and supervisors, shall have training and instruction on general and job-specific safety and health practices. Training and instruction shall be provided as follows: 1. When the IIP Program is first established 2. To all new employees, except for those in construction who are provided training through a Cal/OSHA approved construction industry occupational safety and health training program 3. To all employees given new job assignments for which training has not been previously provided 4. Whenever new substances, processes procedures or equipment are introduced to the workplace and represent a new hazard 5. Whenever the employer is made aware of a new or previously unrecognized hazard 6. To supervisors to familiarize them with the safety and health hazards to which workers under their immediate direction and control may be exposed 7. To all employees with respect to hazards specific to each employee’s job assignment Workplace safety and health training practices for all industries include, but are not limited to, the following: 1. Explanation of the employer’s IIP Program, emergency action plan, and fire prevention plan; and measures for reporting any unsafe conditions, work practices, and injuries. 2. Use of appropriate clothing, including gloves, footwear, and personal protective equipment. 3. Information about chemical hazards to which employees could be exposed, and other hazard communication program information. 4. Availability of toilet, hand-washing, and drinking water facilities. 5. Provisions for medical services and first aid, including emergency procedures. 6. In addition, we provide specific instructions to all employees regarding hazards unique to their job assignment, to the extent that such information was not already covered in other training. Production Injury and Illness Prevention Program Page 5 of 7 Recordkeeping We have taken the following steps to implement and maintain our IIP Program: 1. Records of hazard assessment inspections – including the person(s) conducting the inspection, the unsafe conditions and work practices that have been identified, and the action taken to correct the identified unsafe conditions and work practices – are recorded on a hazard assessment and correction form. 2. Documentation of safety and health training for each employee – including the employee’s name or other identifier, training dates, type(s) of training, and training providers – are recorded on an employee training and instruction form. We also include the records relating to employee training provided by a construction industry occupational safety and health training program approved by Cal/OSHA. Inspection records and training documentation will be maintained according to the following schedule: • For one year, except for training records of employees who have worked for less than one year which are provided to the employee upon termination of employment; or • Since we have less than ten workers, including managers and supervisors, we maintain inspection records only until the hazard is corrected and only maintain a log of instructions to employees with respect to employee job assignments when they are first hired or assigned new duties. Production Injury and Illness Prevention Program Page 6 of 7 List of Training Subjects Depending on the particular worksite and job activities involved, we train our workers about safety topics that include: • The employer’s Code of Safe Practices • Confined spaces • Safe procedures for operations, cleaning, repairing, servicing, storing, and adjusting equipment and machinery • Safe access to working areas • Protection from falls • Electrical hazards, including working around high voltage lines • Crane operations • Trenching and excavation work • Proper use of powered tools • Guarding of belts and pulleys, gears and sprockets, and conveyor nip points • Machine, machine parts, and prime movers guarding • Lock-out/tag-out procedures • Materials handling • Chainsaw and other power tool operation • Tree falling/bucking procedures and precautions, including procedures for recognizing and working with hazard trees, snags, lodged trees, and unsafe weather conditions • Yarding operations including skidding, running lines, unstable logs, rigging and communication • Landing and loading areas, including release of rigging, landing layout, moving vehicles and equipment, and log truck locating, loading and wrapping • Fall protection from elevated locations • Use of elevated platforms, including condors and scissor lifts • Safe use of explosives • Driver safety • Slips, falls, and back injuries • Ergonomic hazards, including proper lifting techniques and working on ladders or in a stooped posture for prolonged periods at one time • Personal protective equipment • Respiratory equipment • Hazardous chemical exposures • Hazard communication • Physical hazards, such as heat/cold stress, noise, and ionizing and non-ionizing radiation • Blood-borne pathogens and other biological hazards • Other job-specific hazards, such as ____________________ Page 7 of 7 Production Injury and Illness Prevention Program HAZARD ASSESSMENT AND CORRECTION RECORD Date of Inspection: Person Conducting: Unsafe Condition or Work Practice: Corrective Action Taken: Date of Inspection: Person Conducting: Unsafe Condition or Work Practice: Unsafe Condition or Work Practice: Corrective Action Taken: Corrective Action Taken: Date of Inspection: Person Conducting: Unsafe Condition or Work Practice: Unsafe Condition or Work Practice: Corrective Action Taken: Corrective Action Taken: Print Form Production Injury and Illness Prevention Program Appendix C Appendix C: Code of Safe Practices This is a suggested code. It is general in nature and intended as a basis for preparation by the contractor of a code that fits his operations more exactly. GENERAL 1. All persons shall follow these safe practice rules, render every possible aid to safe operations, and report all unsafe conditions or practices to the foreman or superintendent. 2. Foremen shall insist on employees observing and obeying every rule, regulation, and order as is necessary to the safe conduct of the work, and shall take such action as is necessary to obtain observance. 3. All employees shall be given frequent accident prevention instructions. Instructions shall be given at least every 10 working days. 4. Anyone known to be under the influence of drugs or intoxicating substances that impair the employee’s ability to safely perform the assigned duties shall not be allowed on the job while in that condition. 5. Horseplay, scuffling, and other acts that tend to have an adverse influence on the safety or wellbeing of the employees shall be prohibited. 6. Work shall be well planned and supervised to prevent injuries in the handling of materials and in working together with equipment. 7. No one shall knowingly be permitted or required to work while the employee’s ability or alertness is so impaired by fatigue, illness, or other causes that it might unnecessarily expose the employee or others to injury. 8. Employees shall not enter manholes, underground vaults, chambers, tanks, silos, or other similar places that receive little ventilation, unless it has been determined that is safe to enter. 9. Employees shall be instructed to ensure that all guards and other protective devices are in proper places and adjusted, and shall report deficiencies promptly to the foreman or superintendent. 10. Crowding or pushing when boarding or leaving any vehicle or other conveyance shall be prohibited. 11. Workers shall not handle or tamper with any electrical equipment, machinery, or air or water lines in a manner not within the scope of their duties, unless they have received instructions from their foreman. 12. All injuries shall be reported promptly to the foreman or superintendent so that arrangements can be made for medical or first aid treatment. 13. When lifting heavy objects, the large muscles of the leg instead of the smaller muscles of the back shall be used. 14. Inappropriate footwear or shoes with thin or badly worn soles shall not be worn. 15. Materials, tools, or other objects shall not be thrown from buildings or structures until proper precautions are taken to protect others from the falling objects. Safety Management Bulletin Most accidents can be prevented, but sooner or later some workers may be injured on the job. You should be ready to take care of those injuries. You can minimize the extent of the disability and dollar loss to both the employee and your company through pre-planning. Before the Injury Inform all employees on the date of hire that all injuries MUST be reported to their supervisor immediately (same day). Have a definite plan for the prompt implementation of: • First aid • Treatment by a physician (Designate an occupational health facility near the assignment location. Send all injured workers to designated facility.) • Ambulance • Emergency hospital Accident Occurrences Key accident occurrence guidelines that should be taken are: • All employee injuries should be investigated. Investigate to get facts, not to place blame. • Assign responsibility and accountability for the accident investigation to a supervisor/foreman. • Provide immediate care to the injured person(s) and protect property from further damage. • Provide timely accident investigation, accident reporting, and preservation of evidence. Take pictures if possible. • Talk with the injured person at the scene of the injury. Get a statement if possible. • Answer the following key questions as part of your accident investigation: 1. How did the accident occur? (Describe what happened – who was involved, where, when, why, how) 2. What was the nature of the injury? (Accident type – fall from, struck by, slip/fall, lifting) o o o Source of injury – scaffold, ladder, machinery Nature of injury – strain, burn, bruise, laceration Body part affected – back, foot, hand, right or left 3. What was the cause of the accident? (Identify unsafe acts or conditions – contributory factors, lack of planning, lack of control, equipment malfunction, weather conditions) 4. Were there any witnesses? (Talk with witnesses and other employees to obtain the facts of the accident. Get name, address and telephone number of all witnesses and supervisors.) 5. What follow-up steps were taken to prevent reoccurrence of a similar accident? (Describe steps taken to prevent reoccurrence of a similar type accident.) Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com Revised 07/2014 Safety Tips from EP The health and safety of our employees is of paramount concern to all of us. Our collective goals are to prevent accidents, reduce personal injury and occupational illness, and to comply with all safety and health standards. Safety is a cooperative undertaking requiring participation by every employee. Supervisors should ensure that employees observe all applicable Company, State, and Federal safety rules and practices and take action as is necessary to obtain compliance. All work should be carefully planned so that proper and safe methods are used. The following are general tips that we feel will assist us in meeting our collective safety goals: General • Report all unsafe conditions and equipment to your supervisor. • Report all accidents, injuries, and illnesses to your supervisor. • Anyone known to be under the influence of intoxicating liquor or drugs should not be allowed on the job while in that condition. • Observe all warning signs. • Horseplay, scuffling, and other acts which tend to have an adverse influence on the safety or well being of the employees should not be condoned. Lifting • Always use the correct lifting technique. Never attempt to lift an object that is more than 50 pounds even with a team lift. • Get help with heavy or clumsy loads. Housekeeping • Aisles should be kept clear at all times. • Work areas should be maintained in a neat, orderly manner. • All spills should be wiped promptly. Personal • Protective equipment should be worn as the job requires. • Hard hats should be worn as job requires. Tools • All tools and equipment should be maintained in good condition. • Only appropriate tools should be used for a specific job. Ladders and Scaffolds • There should be no climbing on ladders. If asked to do so, please call your Account Representative. • Any damage to scaffolds, false work, or other supporting structures should be reported immediately. Machinery and Equipment • Only authorized persons should operate machinery or equipment. • Do not make repairs on engines or equipment without contacting your supervisor. • You should not operate a forklift unless licensed to do so and approved by EP. • Gasoline should not be used for cleaning purposes or used to prime carburetors. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2011 Entertainment Partners. All Rights Reserved. www.ep.com Revised 07/2014 Page 1 of 2 Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers’ compensation benefits. Use the attached form to file a workers’ compensation claim with your employer. You should read all of the information below. Keep this sheet and all other papers for your records. You may be eligible for some or all of the benefits listed depending on the nature of your claim. If you file a claim, the claims administrator, who is responsible for handling your claim, must notify you within 14 days whether your claim is accepted or whether additional investigation is needed. To file a claim, complete the “Employee” section of the form, keep one copy and give the rest to your employer. Do this right away to avoid problems with your claim. In some cases, benefits will not start until you inform your employer about your injury by filing a claim form. Describe your injury completely. Include every part of your body affected by the injury. If you mail the form to your employer, use first-class or certified mail. If you buy a return receipt, you will be able to prove that the claim form was mailed and when it was delivered. Within one working day after you file the claim form, your employer must complete the “Employer” section, give you a dated copy, keep one copy, and send one to the claims administrator. Medical Care: Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness. Medical benefits are subject to approval and may include treatment by a doctor, hospital services, physical therapy, lab tests, x-rays, medicines, equipment and travel costs. Your claims administrator will pay the costs of approved medical services directly so you should never see a bill. There are limits on chiropractic, physical therapy, and other occupational therapy visits. The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness. If you previously designated your personal physician or a medical group, you may see your personal physician or the medical group after you are injured. If your employer is using a medical provider network (MPN) or Health Care Organization (HCO), in most cases, you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group. An MPN is a group of health care providers who provide treatment to workers injured on the job. You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. If your employer is not using an MPN or HCO, in most cases, the claims administrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group. If your employer has not put up a poster describing your rights to workers’ compensation, you may be able to be treated by your personal physician right after you are injured. Within one working day after you file a claim form, your employer or the claims administrator must authorize up to $10,000 in treatment for your injury, consistent with the applicable treating guidelines until the claim is accepted or rejected. If the employer or claims administrator does not authorize treatment right away, talk to your supervisor, someone else in management, or the claims administrator. Ask for treatment to be authorized right now, while waiting for a decision on your claim. If the employer or claims administrator will not authorize treatment, use your own health insurance to get medical care. Your health insurer will seek reimbursement from the claims administrator. If you do not have health insurance, there are doctors, clinics or hospitals that will treat you without immediate payment. They will seek reimbursement from the claims administrator. Switching to a Different Doctor as Your PTP: If you are being treated in a Medical Provider Network (MPN), you may switch to other doctors within the MPN after the first visit. If you are being treated in a Health Care Organization (HCO), you may switch at least one time to another doctor within the HCO. You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employerprovided health insurance). If you are not being treated in an MPN or HCO and did not predesignate, you may switch to a new doctor one time during the first 30 days after your injury is reported to your employer. Contact the claims administrator to switch doctors. After 30 days, you may switch to a doctor of your choice if Rev. 1/1/2016 Si Ud. se lesiona o se enferma, ya sea físicamente o mentalmente, debido a su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es posible que Ud. tenga derecho a beneficios de compensación de trabajadores. Utilice el formulario adjunto para presentar un reclamo de compensación de trabajadores con su empleador. Ud. debe leer toda la información a continuación. Guarde esta hoja y todos los demás documentos para sus archivos. Es posible que usted reúna los requisitos para todos los beneficios, o parte de éstos, que se enumeran dependiendo de la índole de su reclamo. Si usted presenta un reclamo, l administrador de reclamos, quien es responsable por el manejo de su reclamo, debe notificarle dentro de 14 días si se acepta su reclamo o si se necesita investigación adicional. Para presentar un reclamo, llene la sección del formulario designada para el “Empleado,” guarde una copia, y déle el resto a su empleador. Haga esto de inmediato para evitar problemas con su reclamo. En algunos casos, los beneficios no se iniciarán hasta que usted le informe a su empleador acerca de su lesión mediante la presentación de un formulario de reclamo. Describa su lesión por completo. Incluya cada parte de su cuerpo afectada por la lesión. Si usted le envía por correo el formulario a su empleador, utilice primera clase o correo certificado. Si usted compra un acuse de recibo, usted podrá demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado. Dentro de un día laboral después de presentar el formulario de reclamo, su empleador debe completar la sección designada para el “Empleador,” le dará a Ud. una copia fechada, guardará una copia, y enviará una al administrador de reclamos. Atención Médica: Su administrador de reclamos pagará por toda la atención médica razonable y necesaria para su lesión o enfermedad relacionada con el trabajo. Los beneficios médicos están sujetos a la aprobación y pueden incluir tratamiento por parte de un médico, los servicios de hospital, la terapia física, los análisis de laboratorio, las medicinas, equipos y gastos de viaje. Su administrador de reclamos pagará directamente los costos de los servicios médicos aprobados de manera que usted nunca verá una factura. Hay límites en terapia quiropráctica, física y otras visitas de terapia ocupacional. El Médico Primario que le Atiende (Primary Treating Physician- PTP) es el médico con la responsabilidad total para tratar su lesión o enfermedad. Si usted designó previamente a su médico personal o a un grupo médico, usted podrá ver a su médico personal o grupo médico después de lesionarse. Si su empleador está utilizando una red de proveedores médicos (Medical Provider Network- MPN) o una Organización de Cuidado Médico (Health Care Organization- HCO), en la mayoría de los casos, usted será tratado en la MPN o HCO a menos que usted hizo una designación previa de su médico personal o grupo médico. Una MPN es un grupo de proveedores de asistencia médica quien da tratamiento a los trabajadores lesionados en el trabajo. Usted debe recibir información de su empleador si su tratamiento es cubierto por una HCO o una MPN. Hable con su empleador para más información. Si su empleador no está utilizando una MPN o HCO, en la mayoría de los casos, el administrador de reclamos puede elegir el médico que lo atiende primero a menos de que usted hizo una designación previa de su médico personal o grupo médico. Si su empleador no ha colocado un cartel describiendo sus derechos para la compensación de trabajadores, Ud. puede ser tratado por su médico personal inmediatamente después de lesionarse. Dentro de un día laboral después de que Ud. Presente un formulario de reclamo, su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesión, de acuerdo con las pautas de tratamiento aplicables, hasta que el reclamo sea aceptado o rechazado. Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato, hable con su supervisor, alguien más en la gerencia, o con el administrador de reclamos. Pida que el tratamiento sea autorizado ya mismo, mientras espera una decisión sobre su reclamo. Si el empleador o administrador de reclamos no autoriza el tratamiento, utilice su propio seguro médico para recibir atención médica. Su compañía de seguro médico buscará reembolso del administrador de reclamos. Si usted no tiene seguro médico, hay médicos, clínicas u hospitales que lo tratarán sin pago inmediato. Ellos buscarán reembolso del administrador de reclamos. Cambiando a otro Médico Primario o PTP: Si usted está recibiendo tratamiento en una Red de Proveedores Médicos Page 1 of 3 your employer or the claims administrator has not created or selected an MPN. Disclosure of Medical Records: After you make a claim for workers' compensation benefits, your medical records will not have the same level of privacy that you usually expect. If you don’t agree to voluntarily release medical records, a workers’ compensation judge may decide what records will be released. If you request privacy, the judge may "seal" (keep private) certain medical records. Problems with Medical Care and Medical Reports: At some point during your claim, you might disagree with your PTP about what treatment is necessary. If this happens, you can switch to other doctors as described above. If you cannot reach agreement with another doctor, the steps to take depend on whether you are receiving care in an MPN, HCO, or neither. For more information, see “Learn More About Workers’ Compensation,” below. If the claims administrator denies treatment recommended by your PTP, you may request independent medical review (IMR) using the request form included with the claims administrator’s written decision to deny treatment. The IMR process is similar to the group health IMR process, and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given. Your attorney or your physician may assist you in the IMR process. IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician. If you disagree with your PTP on matters other than treatment, such as the cause of your injury or how severe the injury is, you can switch to other doctors as described above. If you cannot reach agreement with another doctor, notify the claims administrator in writing as soon as possible. In some cases, you risk losing the right to challenge your PTP’s opinion unless you do this promptly. If you do not have an attorney, the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute. If you have an attorney, the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME). If the claims administrator disagrees with your PTP on matters other than treatment, the claims administrator can require you to be seen by a QME or AME. Payment for Temporary Disability (Lost Wages): If you can't work while you are recovering from a job injury or illness, you may receive temporary disability payments for a limited period. These payments may change or stop when your doctor says you are able to return to work. These benefits are tax-free. Temporary disability payments are two-thirds of your average weekly pay, within minimums and maximums set by state law. Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days. Stay at Work or Return to Work: Being injured does not mean you must stop working. If you can continue working, you should. If not, it is important to go back to work with your current employer as soon as you are medically able. Studies show that the longer you are off work, the harder it is to get back to your original job and wages. While you are recovering, your PTP, your employer (supervisors or others in management), the claims administrator, and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do. Actively communicate with your PTP, your employer, and the claims administrator about the work you did before you were injured, your medical condition and the kinds of work you can do now, and the kinds of work that your employer could make available to you. Payment for Permanent Disability: If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do, you may receive additional payments. The amount will depend on the type of injury, extent of impairment, your age, occupation, date of injury, and your wages before you were injured. Supplemental Job Displacement Benefit (SJDB): If you were injured on or after 1/1/04, and your injury results in a permanent disability and your employer does not offer regular, modified, or alternative work, you may qualify for a nontransferable voucher payable for retraining and/or skill enhancement. If you qualify, the claims administrator will pay the costs up to the maximum set by state law. Death Benefits: If the injury or illness causes death, payments may be made to a Rev. 1/1/2016 (Medical Provider Network- MPN), usted puede cambiar a otros médicos dentro de la MPN después de la primera visita. Si usted está recibiendo tratamiento en un Organización de Cuidado Médico (Healthcare Organization- HCO), es posible cambiar al menos una vez a otro médico dentro de la HCO. Usted puede cambiar a un médico fuera de la HCO 90 o 180 días después de que su lesión es reportada a su empleador (dependiendo de si usted está cubierto por un seguro médico proporcionado por su empleador). Si usted no está recibiendo tratamiento en una MPN o HCO y no hizo una designación previa, usted puede cambiar a un nuevo médico una vez durante los primeros 30 días después de que su lesión es reportada a su empleador. Póngase en contacto con el administrador de reclamos para cambiar de médico. Después de 30 días, puede cambiar a un médico de su elección si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN. Divulgación de Expedientes Médicos: Después de que Ud. presente un reclamo para beneficios de compensación de trabajadores, sus expedientes médicos no tendrán el mismo nivel de privacidad que usted normalmente espera. Si Ud. no está de acuerdo en divulgar voluntariamente los expedientes médicos, un juez de compensación de trabajadores posiblemente decida qué expedientes serán revelados. Si usted solicita privacidad, es posible que el juez “selle” (mantenga privados) ciertos expedientes médicos. Problemas con la Atención Médica y los Informes Médicos: En algún momento durante su reclamo, podría estar en desacuerdo con su PTP sobre qué tratamiento es necesario. Si esto sucede, usted puede cambiar a otros médicos como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico, los pasos a seguir dependen de si usted está recibiendo atención en una MPN, HCO o ninguna de las dos. Para más información, consulte la sección “Aprenda Más Sobre la Compensación de Trabajadores,” a continuación. Si el administrador de reclamos niega el tratamiento recomendado por su PTP, puede solicitar una revisión médica independiente (Independent Medical ReviewIMR), utilizando el formulario de solicitud que se incluye con la decisión por escrito del administrador de reclamos negando el tratamiento. El proceso de la IMR es parecido al proceso de la IMR de un seguro médico colectivo, y tarda aproximadamente 40 (o menos) días para llegar a una determinación de manera que se pueda dar un tratamiento apropiado. Su abogado o su médico le pueden ayudar en el proceso de la IMR. La IMR no está disponible para resolver disputas sobre cuestiones aparte de la necesidad médica de un tratamiento particular solicitado por su médico. Si no está de acuerdo con su PTP en cuestiones aparte del tratamiento, como la causa de su lesión o la gravedad de la lesión, usted puede cambiar a otros médicos como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico, notifique al administrador de reclamos por escrito tan pronto como sea posible. En algunos casos, usted arriesg perder el derecho a objetar a la opinión de su PTP a menos que hace esto de inmediato. Si usted no tiene un abogado, el administrador de reclamos debe enviarle instrucciones para ser evaluado por un médico llamado un evaluador médico calificado (Qualified Medical EvaluatorQME) para ayudar a resolver la disputa. Si usted tiene un abogado, el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un médico llamado un evaluador médico acordado (Agreed Medical Evaluator- AME). Si el administrador de reclamos no está de acuerdo con su PTP sobre asuntos aparte del tratamiento, el administrador de reclamos puede exigirle que sea atendido por un QME o AME. Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede trabajar, mientras se está recuperando de una lesión o enfermedad relacionada con el trabajo, Ud. puede recibir pagos por incapacidad temporal por un periodo limitado. Estos pagos pueden cambiar o parar cuando su médico diga que Ud. está en condiciones de regresar a trabajar. Estos beneficios son libres de impuestos. Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio, con cantidades mínimas y máximas establecidas por las leyes estales. Los pagos no se hacen durante los primeros tres días en que Ud. no trabaje, a menos que Ud. sea hospitalizado una noche o no puede trabajar durante más de 14 días. Permanezca en el Trabajo o Regreso al Trabajo: Estar lesionado no significa que usted debe dejar de trabajar. Si usted puede seguir trabajando, usted debe hacerlo. Si no es así, es importante regresar a trabajar con su empleador actual tan Page 2 of 3 spouse and other relatives or household members who were financially dependent on the deceased worker. It is illegal for your employer to punish or fire you for having a job injury or illness, for filing a claim, or testifying in another person's workers' compensation case (Labor Code 132a). If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Resolving Problems or Disputes: You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact your employer or claims administrator first to see if you can resolve it. If you are not receiving benefits, you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits. Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606, or go to their website at www.edd.ca.gov. You Can Contact an Information & Assistance (I&A) Officer: State I&A officers answer questions, help injured workers, provide forms, and help resolve problems. Some I&A officers hold workshops for injured workers. To obtain important information about the workers’ compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an I&A officer of the state Division of Workers’ Compensation. You can also hear recorded information and a list of local I&A offices by calling (800) 736-7401. You can consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee will be taken out of some of your benefits. For names of workers' compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www. californiaspecialist.org. Learn More About Workers’ Compensation: For more information about the workers’ compensation claims process, go to www.dwc.ca.gov. At the website, you can access a useful booklet, “Workers’ Compensation in California: A Guidebook for Injured Workers.” You can also contact an Information & Assistance Officer (above), or hear recorded information by calling 1-800-7367401. pronto como usted pueda medicamente hacerlo. Los estudios demuestran que entre más tiempo esté fuera del trabajo, más difícil es regresar a su trabajo original y a sus salarios. Mientras se está recuperando, su PTP, su empleador (supervisores u otras personas en la gerencia), el administrador de reclamos, y su abogado (si tiene uno) trabajarán con usted para decidir cómo va a permanecer en el trabajo o regresar al trabajo y qué trabajo hará. Comuníquese de manera activa con su PTP, su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse, su condición médica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podría poner a su disposición. Pago por Incapacidad Permanente: Si un médico dice que no se ha recuperado completamente de su lesión y siempre será limitado en el trabajo que puede hacer, es posible que Ud. reciba pagos adicionales. La cantidad dependerá de la clase de lesión, grado de deterioro, su edad, ocupación, fecha de la lesión y sus salarios antes de lesionarse. Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB): Si Ud. se lesionó en o después del 1/1/04, y su lesión resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular, modificado, o alternativo, usted podría cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento y/o mejorar su habilidad. Si Ud. cumple los requisios, el administrador de reclamos pagará los gastos hasta un máximo establecido por las leyes estatales. Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, es posible que los pagos se hagan a un cónyuge y otros parientes o a las personas que viven en el hogar que dependían económicamente del trabajador difunto. Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad laboral, por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona. (Código Laboral, sección 132a.) De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los límites establecidos por el estado. Resolviendo problemas o disputas: Ud. tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo. Si Ud. tiene un desacuerdo, primero comuníquese con su empleador o administrador de reclamos para ver si usted puede resolverlo. Si usted no está recibiendo beneficios, es posible que Ud. pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability InsuranceSDI) o beneficios del desempleo (Unemployment Insurance- UI). Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 3334606, o visite su página Web en www.edd.ca.gov. Puede Contactar a un Oficial de Información y Asistencia (Information & Assistance- I&A): Los Oficiales de Información y Asistencia (I&A) estatal contestan preguntas, ayudan a los trabajadores lesionados, proporcionan formularios y ayudan a resolver problemas. Algunos oficiales de I&A tienen talleres para trabajadores lesionados. Para obtener información importante sobre el proceso de la compensación de trabajadores y sus derechos y obligaciones, vaya a www.dwc.ca.gov o comuníquese con un oficial de información y asistencia de la División Estatal de Compensación de Trabajadores. También puede escuchar información grabada y una lista de las oficinas de I&A locales llamando al (800) 736-7401. Ud. puede consultar con un abogado. La mayoría de los abogados ofrecen una consulta gratis. Si Ud. decide contratar a un abogado, los honorarios serán tomados de algunos de sus beneficios. Para obtener nombres de abogados de compensación de trabajadores, llame a la Asociación Estatal de Abogados de California (State Bar) al (415) 538-2120, o consulte su página Web en www.californiaspecialist.org. Aprenda Más Sobre la Compensación de Trabajadores: Para obtener más información sobre el proceso de reclamos del programa de compensación de trabajadores, vaya a www.dwc.ca.gov. En la página Web, podrá acceder a un folleto útil, “Compensación del Trabajador de California: Una Guía para Trabajadores Lesionados.” También puede contactar a un oficial de Información y Asistencia (arriba), o escuchar información grabada llamando al 1-800-7367401. Rev. 1/1/2016 Page 3 of 3 . State of California Department of Industrial Relations DIVISION OF WORKERS’ COMPENSATION WORKERS’ COMPENSATION CLAIM FORM (DWC 1) Employee: Complete the “Employee” section and give the form to your employer. Keep a copy and mark it “Employee’s Temporary Receipt” until you receive the signed and dated copy from your employer. You may call the Division of Workers’ Compensation and hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included in the Notice of Potential Eligibility, which is the cover sheet of this form. Detach and save this notice for future reference. You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain them. You may receive written notices from your employer or its claims administrator about your claim. If your claims administrator offers to send you notices electronically, and you agree to receive these notices only by email, please provide your email address below and check the appropriate box. If you later decide you want to receive the notices by mail, you must inform your employer in writing. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony. Estado de California Departamento de Relaciones Industriales DIVISION DE COMPENSACIÓN AL TRABAJADOR PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL TRABAJADOR (DWC 1) Empleado: Complete la sección “Empleado” y entregue la forma a su empleador. Quédese con la copia designada “Recibo Temporal del Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador. Ud. puede llamar a la Division de Compensación al Trabajador al (800) 7367401 para oir información gravada. Una explicación de los beneficios de compensación de trabajadores está incluido en la Notificación de Posible Elegibilidad, que es la hoja de portada de esta forma. Separe y guarde esta notificación como referencia para el futuro. Ud. también debería haber recibido de su empleador un folleto describiendo los benficios de compensación al trabajador lesionado y los procedimientos para obtenerlos. Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo. Si su administrador de reclamos ofrece enviarle notificaciones electrónicamente, y usted acepta recibir estas notificaciones solo por correo electrónico, por favor proporcione su dirección de correo electrónico abajo y marque la caja apropiada. Si usted decide después que quiere recibir las notificaciones por correo, usted debe de informar a su empleador por escrito. Toda aquella persona que a propósito haga o cause que se produzca cualquier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores lesionados es culpable de un crimen mayor “felonia”. Employee—complete this section and see note above Empleado—complete esta sección y note la notación arriba. 1. Name. Nombre. ___________________________________________________ Today’s Date. Fecha de Hoy. ____________________________________________ 2. Home Address. Dirección Residencial. _____________________________________________________________________________________________________ 3. City. Ciudad. _______________________________________ State. Estado. _____________________ Zip. Código Postal. ______________________________ 4. Date of Injury. Fecha de la lesión (accidente). ________________________________ Time of Injury. Hora en que ocurrió. ____________a.m. ___________p.m. 5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _______________________________________________________ _______________________________________________________________________________________________________________________________________ 6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. ____________________________________________________________ _______________________________________________________________________________________________________________________________________ 7. Social Security Number. Número de Seguro Social del Empleado. _______________________________________________________________________________ 8. Check if you agree to receive notices about your claim by email only. Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electrónico. Employee’s e-mail. _____________________________________ Correo electrónico del empleado. __________________________________________. You will receive benefit notices by regular mail if you do not choose, or your claims administrator does not offer, an electronic service option. Usted recibirá notificaciones de beneficios por correo ordinario si usted no escoge, o su administrador de reclamos no le ofrece, una opción de servicio electrónico. 9. Signature of employee. Firma del empleado. ________________________________________________________________________________________________ Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo. 10. Name of employer. Nombre del empleador. ________________________________________________________________________________________________ Entertainment Partners 11. Address. Dirección. __________________________________________________________________________________________________________________ 2835 N. Naomi Street, Burbank, CA 91504 12. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. ___________________________________________ 13. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. ______________________________________________________ 14. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador._____________________________________________________ 15. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros. _______________ _______________________________________________________________________________________________________________________________________ AIG, P.O. Box 25978, Shawnee Mission, KS 66225 16. Insurance Policy Number. El número de la póliza de Seguro.___________________________________________________________________________________ WC 066830141 17. Signature of employer representative. Firma del representante del empleador. ____________________________________________________________________ 18. Title. Título. _________________________________________ 19. Telephone. Teléfono. ___________________________________________________________ Workers' Compensation Coordinator 800-955-4878 Employer: You are required to date this form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the claim within one working day of receipt of the form from the employee. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día hábil desde el momento de haber sido recibida la forma del empleado. EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD Employer copy/Copia del Empleador Employee copy/Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado Clear / Vacie Rev. 1/1/2016 Print / Iprima California Specific Requirements Differences Between Cal/OSHA and Fed/OSHA Recordkeeping and Reporting Requirements There are two substantial differences between the Cal/OSHA and Federal OSHA recordkeeping and reporting requirements: 1. The following industries in the private sector, which are covered by the Federal Low Hazard Industry Exemption, are required to maintain records in California: • SIC 55: Automotive dealers and service stations • SIC 57: Furniture and home furnishing stores • SIC 781: Motion picture production and allied services 2. California’s requirement for reporting serious injuries/illnesses and fatalities is different from that of Fed/OSHA. California requires employers to report EVERY case involving a serious injury/illness or death immediately by telephone or telegraph to the nearest California Division of Occupational Safety and Health (DOSH) district office. Telephone numbers of all district offices are listed on the Cal/OSHA poster. A “serious injury/illness” is one in which: • An employee is hospitalized for more than 24 hours for other than medical observation. • An employee suffers loss of any member of the body (feet, nose, arms, etc.) or any serious degree of permanent disfigurement. “Immediately” means as soon as practically possible but not longer than EIGHT hours from the employer’s receipt of knowledge of the death or serious injury/illness. Although the Labor Code definition of “serious injury or illness” excludes those caused by the commission of a Penal Code violation, Cal/OSHA actively encourages employers to report all deaths and serious injuries/illnesses resulting from a workplace assault or other type of violent act to the nearest Cal/OSHA District Office so that a fuller understanding of the scope and nature of workplace violence can be acquired by conducting an investigation of the circumstances surrounding the event. For any questions on recordkeeping, please write or call: California Division of Labor Statistics and Research P.O. Box 420603 San Francisco, CA 94142-9488 Phone: 415.703.4780 Simplified, clearer definitions also make it easier for employers to determine which cases must be recorded. Posting an annual summary of workplace injuries and illnesses for a longer period of time improves employee access to information, and as employees learn how to report workplace injuries and illnesses, their involvement and participation increase. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com Revised 07/2014 Page 1 of 4 California Specific Requirements Revised July 2014 Page 2 of 4 Which Record Keeping Requirements Apply? Reporting fatalities and catastrophes: All employers covered by the Occupational Safety and Health Act of 1970 (P.L. 91–596) must report to OSHA any workplace incident resulting in a fatality or the inpatient hospitalization of three or more employees within 8 hours. Keeping injury and illness records: If you had 10 or fewer employees during all of the last calendar year or your business is classified in a specific low-hazard retail, service, finance, insurance, or real estate industry, you do not have to keep injury and illness records unless the Bureau of Labor Statistics or OSHA informs you in writing that you must do so. OSHA 300 Log Reminders • Recordable incidents have to be recorded on the OSHA 300 log within 7 calendar days of incident becoming recordable. • Count the number of calendar days the employee was on restricted work activity or days away from work (weekend days, holidays, vacation days, or other days off are included), regardless of whether or not the employee was scheduled to work. • Begin counting restricted work days or days away from work on the day after the injury or illness began. Days away from work or restricted days may be capped at 180 days. • Only post a copy of the Summary (OSHA 300A form) from February 1 to April 30 for the preceding year (e.g., post February 1, 2003 for 2002 log). • If you have no recordable injuries or illnesses, you must still complete log and post copy of summary, putting 0 in the appropriate places. • Keep original 300 log and summary for 5 years. • A company executive must review and sign the 300A form summary. • Be very specific in listing diagnosis (e.g., foreign body left eye, needle stick tip right index finger, lower back strain, and contusion right knee). • For every recordable incident, a copy of the OSHA Form 301 or any equivalent state form must be completed. Criteria for Recording per 29 CFR Subpart C 1904.4 • Is incident work related (1904.5)? • Is incident a new case (1904.6)? • Does incident meet one or more of the general recording criteria or the application to specific cases? • General Recording Criteria (1904.7): o Death o Days away from work o Restricted work or transfer to another job o Medical treatment beyond first aid o Loss of consciousness Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com California Specific Requirements Revised July 2014 o Page 3 of 4 A significant injury or illness diagnosed by a physician or other licensed health care professional (e.g., punctured eardrum, fractured toe or rib, silicosis, some types of cancer). Criteria for Medical Treatment per 29 CFR 1904.7(b)(5) • Managing and caring for a patient for the purpose of combating disease or disorder • The following are not considered medical treatments and are not recordable: o Visiting a doctor or health care professional solely for observation or counseling o Use of diagnostic procedures (e.g., x-rays, blood test, etc.) and or the administration of prescription medications used solely for diagnostic purposes (e.g., eye drops to dilate pupils) o Any incident which meets the criteria for first aid Criteria for First Aid per 29 CFR Part 1904(b)(5)(ii) • Use of non-prescription medications at non-prescription strength • Administration of tetanus immunizations • Cleaning, flushing, or soaking wounds on the skin surface • Use of wound coverings (e.g., band aids, gauze pads, steri-strips, or butterfly bandages) • Use of hot or cold therapy • Use of totally non-rigid means of support (e.g., elastic bandages, wraps, non-rigid back belts) • Use of temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, or backboards) • Drilling a fingernail or toenail to relieve pressure or draining fluids from blisters • Using eye patches • Use of simple irrigation or a cotton swab to remove foreign bodies not embedded in or adhered to the eye • Use of irrigation, tweezers, cotton swab, or other simple means to remove splinters or foreign material from areas other than the eye • Use of finger guards • Use of massages • Drinking fluids to relieve heat stress There are no other procedures included in first aid. Criteria for specific cases per 29 CFR 1904.8.–.12 • Any needle sticks injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com California Specific Requirements Revised July 2014 Page 4 of 4 • Any incident requiring an employee to be medically removed under the requirements of an OSHA health standard • Any incident resulting in a Standard Threshold Shift (STS) in hearing • Any incident resulting in tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician or other licensed health care professional after exposure to a known case of active tuberculosis Criteria for Privacy Concern Cases The following incidents are recordable. The employee’s name should not be entered on the OSHA 300 form: • Any incident which results in injury or illness to an intimate body part or to the reproductive system • Any incident resulting in injury or illness from a sexual assault • Any incident where mental illness is a factor • Any incident resulting in my infection, hepatitis, or tuberculosis • Any incident resulting from a needle stick injury or cut from a sharp object that is contaminated with blood or other potentially infectious material • Other illnesses if the employee independently and voluntarily requests that her or his name not be entered on the log Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 Copyright © 2014 Entertainment Partners. All Rights Reserved. www.ep.com STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation Notice to Employees--Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: • Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. There is a limit on some medical services. • Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury. • Permanent Disability (PD) Benefits: Payments if your injury causes a permanent disability. • Supplemental Job Displacement Benefit: A nontransferable voucher payable to a state approved school if your injury arises on or after 1/1/04 and results in a permanent disability that prevents you from returning to work within 60 days after TD ends, and your employer does not offer you modified or alternative work. • Death Benefits: Paid to dependents of a worker who dies from a work-related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured and your physician must agree to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees. If You Get Hurt: 1. Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department. If you need first aid, contact your employer. 2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after you file a claim form, your employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for your alleged injury and shall be liable for up to ten thousand dollars ($10,000) in treatment until the claim is accepted or rejected. 3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you predesignated by naming your personal physician or medical group before injury (see above), you may see him or her for treatment in certain circumstances. Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. You may be able to switch to a doctor of your choice after 30 days. Different rules apply if your employer offers a Health Care Organization (HCO) or has a Medical Provider Network (MPN). You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. 4. Medical Provider Networks. Your employer may be using a MPN, which is a selected network of health care providers to provide treatment to workers injured on the job. If your employer is using a MPN, a MPN notice should be posted next to this poster to explain how to use the MPN. You can request a copy of this notice by calling the MPN number below. If you have predesignated a personal physician prior to your work injury, then you may receive treatment from your predesignated doctor. If you have not predesignated and your employer is using a MPN, you are free to choose an appropriate provider from the MPN list after the first medical visit directed by your employer. If you are treating with a non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below: talispoint.com/aig/EP (877) 802-5246 Current MPN’s toll free number: __________________MPN website: _______________________________________________________ P.O. Box 25977, Shawnee Mission, KS 66225-5977 1/1/2016 MPN Effective Date_____________ Current MPN’s address: ______________________________________________________________ Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): 877.802.5246 AIG Insurance _______________________ Claims Administrator ________________________________________________________________Phone Insurance Company State of Pennsylvania Workers’ compensation insurer _______________________________________________________ (Enter “self-insured” if appropriate) 1/1/2017 Policy Expiration Date ____________________ If the workers’ compensation policy has expired, contact a Labor Commissioner at the Division of Labor Standards Enforcement (DLSE). You can also get free information from a State Division of Workers' Compensation Information & Assistance Officer. The nearest Information & Assistance Officer can be found at location: ________________________________________________________________ or by calling toll-free (800) 736-7401. Learn more information about DWC and DLSE online: www.dwc.ca.gov or www.dir.ca.gov/dlse. False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned. Your employer may not be liable for the payment of workers' compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties. DWC 7 (6/10) Print Form ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES División de Compensación de Trabajadores Aviso a los Empleados—Lesiones Causadas por el Trabajo Es posible que usted tenga derecho a beneficios de compensación de trabajadores si usted se lesiona o se enferma a causa de su trabajo. La compensación de trabajadores cubre la mayoría de las lesiones y enfermedades físicas o mentales relacionadas con el trabajo. Una lesión o enfermedad puede ser causada por un evento (como por ejemplo el lastimarse la espalda en una caída) o por acciones repetidas (como por ejemplo lastimarse la muñeca por hacer el mismo movimiento una y otra vez). Beneficios. Los beneficios de compensación de trabajadores incluyen: • Atención Médica: Consultas médicas, servicios de hospital, terapia física, análisis de laboratorio, radiografías y medicinas que son razonablemente necesarias para tratar su lesión. Usted nunca deberá ver un cobro. Hay un límite para ciertos servicios médicos. • Beneficios por Incapacidad Temporal (TD): Pagos si usted pierde sueldo mientras se recupera. Para la mayoría de las lesiones, beneficios de TD no se pagarán por mas de 104 semanas dentro de cinco años después de la fecha de la lesión. • Beneficios por Incapacidad Permanente (PD): Pagos si su lesión le causa una incapacidad permanente. • Beneficio Suplementario por Desplazamiento de Trabajo: Un vale no-transferible pagadero a una escuela aprobada por el estado si su lesión surge en o después del 1/1/04, y le ocasiona una incapacidad permanente que le impida regresar al trabajo dentro de 60 días después de que los pagos por TD terminen y su empleador no le ofrece a usted un trabajo modificado o alternativo. • Beneficios por Muerte: Pagados a los dependientes de un(a) trabajador(a) que muere a causa de una lesión o enfermedad relacionada con el trabajo. Designación de su Propio Médico Antes de una Lesión o Enfermedad (Designación previa). Es posible que usted pueda elegir al médico que le atenderá en una lesión o enfermedad relacionada con el trabajo. Si elegible, usted debe informarle al empleador, por escrito, el nombre y la dirección de su médico personal o grupo médico, antes de que usted se lesione y su médico debe estar de acuerdo de atenderle la lesión causada por el trabajo. Para instrucciones, vea la información escrita sobre la compensación de trabajadores que se le exige a su empleador darle a los empleados nuevos. Si Usted se Lastima: 1. Obtenga Atención Médica. Si usted necesita atención de emergencia, llame al 911 para ayuda inmediata de un hospital, una ambulancia, el departamento de bomberos o departamento de policía. Si usted necesita primeros auxilios, comuníquese con su empleador. 2. Reporte su Lesión. Reporte la lesión inmediatamente a su supervisor(a) o a un representante del empleador. No se demore. Hay límites de tiempo. Si usted espera demasiado, es posible que usted pierda su derecho a beneficios. Su empleador está obligado a proporcionarle un formulario de reclamo dentro de un día laboral después de saber de su lesión. Dentro de un día después de que usted presente un formulario de reclamo, el empleador autorizará todo tratamiento médico de acuerdo con las pautas de tratamiento aplicables a su presunta lesión y será responsable por diez mil dolares ($10,000) en tratamiento hasta que el reclamo sea aceptado o rechazado. 3. Consulte al Médico que le está Atendiendo (PTP). Este es el médico con la responsabilidad total de tratar su lesión o enfermedad. Si usted designó previamente a su médico personal o grupo médico antes lesionarse (vea uno de los párrafos anteriores), en ciertas circunstancias, usted puede consultarlo para el tratamiento. De otra forma, su empleador tiene el derecho de seleccionar al médico que le atenderá durante los primeros 30 días. Es posible que usted pueda cambiar a un médico de su preferencia después de 30 días. Hay reglas diferentes que se aplican cuando su empleador ofrece una Organización de Cuidado Médico (HCO) o si tiene una Red de Proveedores Médicos (MPN). Usted debe recibir información de su empleador si está cubierto por una HCO o una MPN. Hable con su empleador para más información. 4. Red de Proveedores Médicos (MPN): Es posible que su empleador use una MPN, lo cual es una red de proveedores de asistencia médica seleccionados para dar tratamiento a los trabajadores lesionados en el trabajo. Si su empleador usa una MPN, una notificación de la MPN debe estar al lado de este cartel para explicar como usar la MPN. Usted puede pedir una copia de esta notificación hablando al número de la MPN debajo descrito. Si usted ha hecho una designación previa de un médico personal antes de lesionarse en el trabajo, entonces usted puede recibir tratamiento de su medico previamente designado. Si usted no ha hecho una designación previa y su empleador está usando una MPN, usted puede escoger un proveedor apropiado de la lista de la MPN después de la primera visita médica dirigida por su empleador. Si usted está recibiendo tratamiento de parte de un médico que no pertenece a la MPN para una lesión existente, puede requerirse que usted se cambie a un médico dentro de la MPN. Para más información, vea la siguente información del contacto de la MPN : talispoint.com/aig/EP (877) 802-5246 Número gratuito de la MPN vigente:_______________Página web de la MPN:______________________________________________________ de la MPN vigente _________________________________________________________ Fecha de vigencia de la MPN ______________Dirección 1/1/2016 P.O. Box 25977, Shawnee Mission, KS 66225-5977 Discriminación. Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad en el trabajo, por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona. De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los límites establecidos por el estado. ¿Preguntas? Aprenda más sobre la compensación de trabajadores leyendo la información que se requiere que su empleador le dé cuando es contratado. Si usted tiene preguntas, vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de compensación de trabajadores de su empleador): AIG Insurance 877.802.5246 Administrador de Reclamos _____________________________________________________________________Teléfono _______________ Insurance Company State of Pennsylvania (Anote “autoasegurado” si es apropiado) Asegurador del Seguro de Compensación de trabajador ___________________________________________ Fecha de Vencimiento de la Póliza _______________________ 1/1/2017 Si la póliza de compensación de trabajadores se ha vencido, comuníquese con el Comisionado Laboral, en la División para el Cumplimiento de las Normas Laborales (Division of Labor Standards Enforcement- DLSE). Usted también puede obtener información gratuita de un Oficial de Información y Asistencia de la División Estatal de Compensación de Trabajadores. El Oficial de Información y Asistencia más cercano se localiza en ___________________________________________________________________ o llamando al número gratuito (800) 736-7401. Usted puede obtener más información sobre de la DWC y DLSE en el Internet en: www.dwc.ca.gov o www.dir.ca.gov/dlse. Los reclamos falsos y rechazos falsos del reclamo. Cualquier persona que haga o que ocasione que se haga una declaración o una representación material intencionalmente falsa o fraudulenta, con el fin de obtener o negar beneficios o pagos de compensación de trabajadores, es culpable de un delito grave y puede ser multado y encarcelado. Es posible que su empleador no sea responsable por el pago de beneficios de compensación de trabajadores para ninguna lesión que proviene de su participación voluntaria en cualquier actividad fuera del trabajo, recreativa, social, o atlética que no sea parte de sus deberes laborales. DWC 7 (6/10) Iprima Forma California Entertainment Partners Medical Provider Network (Chartis/EP MPN 2418) Employee Notification © 2015 American International Group, Inc. All rights reserved. SP 677T (Rev. 11/15) Contents What is an MPN?............................................................................................................... 2 What MPN is used by my employer?.............................................................................. 2 Who can I contact if I have questions about my MPN?............................................... 2 What if I need help finding and making an appointment with a doctor?.................... 3 How do I find out which doctors are in my MPN?......................................................... 3 What happens if I get injured at work?............................................................................ 3 How do I choose a provider?........................................................................................... 3 Can I change providers?................................................................................................... 4 What standards does the MPN have to meet?............................................................... 4 What if there are no MPN providers where I am located?........................................... 5 What if I need a specialist not in the MPN?.................................................................... 5 What if I disagree with my doctor about medical treatment?........................................ 5 What if I am already being treated for a work-related injury before the MPN begins?................................................................................................... 6 Can I Continue Being Treated By My Doctor?............................................................... 6 What if I am being treated by an MPN doctor who decides to leave the MPN?...... 7 What if I have questions or need help?........................................................................... 8 Important Information about Medical Care if you have a Work-Related Injury or Illness Entertainment Partners Medical Provider Network: Employee Notification (Title 8, California Code of Regulations, section 9767.12) California law requires your employer to provide and pay for medical treatment if you are injured at work. Your employer has chosen to provide this medical care by using a workers’ compensation physician network called a Medical Provider Network (MPN). This MPN is administered by AIG Claims, Inc. This notification tells you what you need to know about the MPN program, and describes your rights in choosing medical care for work-related injuries and illnesses. What is an MPN? A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job. MPNs must allow employees to have a choice of provider(s). Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. What MPN is used by my employer? Your employer is using the Entertainment Partners MPN with the identification number 2418. You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN. Who can I contact if I have questions about my MPN? The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN. The contact for your MPN is: Contact: Pre-Injury Consultants Address: California Telephone Number: (877) 802-5246 Email address: [email protected] General information regarding the MPN can also be found at the following website: www.talispoint.com/aig/EP 2 What if I need help finding and making an appointment with a doctor? The MPN’s Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments. The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctors’ normal business hours. Assistance is available in English and in Spanish. The contact information for the Medical Access Assistant is: Toll Free Telephone Number: (855) 803-0363 FAX Number: (866) 841-5375 Email Address: [email protected] How do I find out which doctors are in my MPN? You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at www.talispoint.com/aig/EP. At minimum, the regional list must include a list of all MPN providers within 15 miles of your workplace and/or residence or a list of all MPN providers within the county where you live and/or work. You may choose which list you wish to receive. You also have the right to obtain a list of all the MPN providers upon request. You can access the roster of all treating physicians in the MPN by going to the website at www.talispoint.com/aig/EP. What happens if I get injured at work? In case of an emergency, you should call 911 or go to the closest emergency room. If you are injured at work, notify your employer as soon as possible. Your employer will provide you with a claim form. When you notify your employer that you have had a work-related injury, your employer or insurer will make an initial appointment with a doctor in the MPN. How do I choose a provider? Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician. After the first medical visit, you may continue to be treated by that doctor, or you may choose another doctor from the MPN. You may continue to choose doctors within the MPN for all of your medical care for this injury. 3 If appropriate, you may choose a specialist or ask your treating doctor for a referral to a specialist. Some specialists will only accept appointments with a referral from the treating doctor. Such specialist might be listed as “by referral only” in your MPN directory. If you need help in finding a doctor or scheduling a medical appointment, you may call the Medical Access Assistant. Can I change providers? Yes. You can change providers within the MPN for any reason, but the providers you choose should be appropriate to treat your injury. Contact the MPN Contact or your claims adjuster if you want to change your treating physician. What standards does the MPN have to meet? The MPN has providers for the following counties in California except Alpine. The MPN has providers throughout the state, but may not have full MPN specialty coverage in your area. Please utilize the MPN directory or your MPN Contact for a listing of MPN providers in your area. The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuries/illnesses in your industry. The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live. If you live in a rural area or an area where there is a health care shortage, there may be a different standard. After you have notified your employer of your injury, the MPN must provide initial treatment within 3 business days. If treatment with a specialist has been authorized, the appointment with the specialist must be provided to you within 20 business days of your request. If you have trouble getting an appointment with a provider in the MPN, contact the Medical Access Assistant. If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements, then you will be allowed to seek the necessary treatment outside of the MPN. 4 What if there are no MPN providers where I am located? If you are a current employee living in a rural area or temporarily working or living outside the MPN service area, or you are a former employee permanently living outside the MPN service area, the MPN or your treating doctor will give you a list of at least three physicians who can treat you. The MPN may also allow you to choose your own doctor outside of the MPN network. Contact your MPN Contact for assistance in finding a physician or for additional information. What if I need a specialist not in the MPN? If you need to see a type of specialist that is not available in the MPN, you have the right to see a specialist outside of the MPN. What if I disagree with my doctor about medical treatment? If you disagree with your doctor or wish to change your doctor for any reason, you may choose another doctor within the MPN. If you disagree with either the diagnosis or treatment prescribed by your doctor, you may ask for a second opinion from another doctor within the MPN. If you want a second opinion, you must contact the MPN contact or your claims adjuster and tell them you want a second opinion. The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor. To get a second opinion, you must choose a doctor from the MPN list and make an appointment within 60 days. You must tell the MPN Contact of your appointment date, and the MPN will send the doctor a copy of your medical records. You can request a copy of your medical records that will be sent to the doctor. If you do not make an appointment within 60 days of receiving the regional provider list, you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician. If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats, the doctor’s office will notify your employer or insurer and you. You will get another list of MPN doctors or specialists so you can make another selection. If you disagree with the second opinion, you may ask for a third opinion. If you request a third opinion, you will go through the same process you went through for the second opinion. Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list, then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician. 5 If you disagree with the third-opinion doctor, you may ask for an MPN Independent Medical Review (IMR). Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician. If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test, you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment, you may choose a physician outside the MPN within a reasonable geographic area. What if I am already being treated for a work-related injury before the MPN begins? Your employer or insurer has a “Transfer of Care” policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN. If your current doctor is not or does not become a member of the MPN, then you may be required to see a MPN physician. However, if you have properly predesignated a primary treating physician, you cannot be transferred into the MPN. (If you have questions about predesignation, ask your supervisor.) If your employer decides to transfer you into the MPN, you and your primary treating physician must receive a letter notifying you of the transfer. If you meet certain conditions, you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN. The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below. Can I continue being treated by my doctor? You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions: •(Acute) The treatment for your injury or illness will be completed in less than 90 days; •(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment. You may be allowed to be treated by your current treating doctor for up to one year, until a safe transfer of care can be made. 6 •(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less. •(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date, or the termination of contract date between the MPN and your doctor. You can disagree with your employer’s decision to transfer your care into the MPN. If you don’t want to be transferred into the MPN, ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN. Your primary treating physician has 20 days from the date of your request to give you a copy of his/her report on your condition. If your primary treating physician does not give you the report within 20 days of your request, the employer can transfer your care into the MPN and you will be required to use an MPN physician. You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care. If you or your employer disagrees with your doctor’s report on your condition, you or your employer can dispute it. See the complete Transfer of Care policy for more details on the dispute resolution process. For a copy of the Transfer of Care policy, in English or Spanish, ask your MPN Contact. What if I am being treated by an MPN doctor who decides to leave the MPN? Your employer or insurer has a written “Continuity of Care” policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN. If your employer decides that you do not qualify to continue your care with the non-MPN provider, you and your primary treating physician must receive a letter notifying you of this decision. If you meet certain conditions, you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician. These conditions are set forth in the “Can I Continue Being Treated By My Doctor?” box above. You can disagree with your employer’s decision to deny you Continuity of Care with the terminated MPN provider. If you want to continue treating with the terminated doctor, ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily. 7 Your primary treating physician has 20 days from the date of your request to give you a copy of his/her medical report on your condition. If your primary treating physician does not give you the report within 20 days of your request, your employer’s decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply, and you will be required to choose a MPN physician. You will need to give a copy of the report to your employer if you wish to postpone the selection of another MPN doctor for your continued treatment. If you or your employer disagrees with your doctor’s report on your condition, you or your employer can dispute it. See the complete Continuity of Care policy for more details on the dispute resolution process. For a copy of the Continuity of Care policy, in English or Spanish, ask your MPN Contact. What if I have questions or need help? • MPN Contact: You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN. •Medical Access Assistants: You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments. •Division of Workers’ Compensation (DWC): If you have concerns, complaints or questions regarding the MPN, the notification process, or your medical treatment after a work-related injury or illness, you can call the DWC’s Information and Assistance office at 1-800-7367401. You can also go to the DWC’s website at www.dir.ca.gov/dwc and click on “medical provider networks” for more information about MPNs. •Independent Medical Review: If you have questions about the MPN Independent Medical Review process contact the Division of Workers’ Compensation’s Medical Unit at: DWC Medical Unit P.O. Box 71010 Oakland, CA 94612 510-286-3700 or 800-794-6900 Keep this information in case you have a work-related injury or illness. 8 Entertainment Partners Red de Proveedores Médicos de California (Chartis/EP MPN 2418) Notificación del Empleado © 2015 American International Group, Inc. All rights reserved. SP 679T (Rev. 11/15) Contents ¿Qué es una MPN?....................................................................................................................2 ¿ Qué MPN es utilizado por mi empleador?..........................................................................2 ¿Con quién me puedo poner en contacto si tengo una pregunta sobre mi MPN?...........2 ¿Qué debo hacer si necesito ayuda para encontrar y hacer una cita con un médico....3 ¿Cómo puedo averiguar cuáles médicos pertenecen a mi MPN? ......................................3 ¿Qué pasa si me lastimo en el trabajo?...................................................................................3 ¿Cómo escojo a un proveedor?................................................................................................3 ¿Qué requisitos debe reunir la MPN?......................................................................................4 ¿Qué tal si no hay proveedores de la MPN en el área donde estoy localizado?.............4 ¿Qué tal si necesito a un especialista que no está dentro de la MPN?...............................4 ¿Qué tal si no estoy de acuerdo con mi médico sobre el tratamiento médico?..................5 ¿Que tal si ya estoy siendo atendido por otro proveedor medico antes que empiece la MPN?...........................................................................................................................................6 ¿Puedo seguir siendo tratado por mi médico?........................................................................6 ¿Qué tal si estoy bajo tratamiento con un médico de la MPN y decido salirme de ella?.....7 ¿Qué tal si tengo preguntas o necesito ayuda?......................................................................8 Información Importante sobre Cuidado Médico si tiene una Lesión o Enfermedad de Trabajo. Entertainment Partners Red de Proveedores Médicos de California Notificación Inicial Escrita del Empleado sobre la Red de Proveedores Médicos (Título 8, Código de Regulaciones de California, sección 9767.12) La Ley de California requiere que su empleador le proporcione y pague el tratamiento médico si se lesiona en el trabajo. Su empleador ha elegido proporcionarle este cuidado médico por medio de una red de médicos de Compensación de Trabajadores llamada Red de Proveedores Médicos ó MPN (Medical Provider Network siglas en Inglés). Esta MPN está administrada por AIG Claims,Inc. Esta documentación le informará lo que necesita saber sobre el programa de la MPN y le describirá sus derechos en elegir su cuidado médico para sus lesiones o enfermedades de trabajo. ¿Qué es una MPN? Una Red de Proveedores Médicos (MPN) es un grupo de proveedores de asistencia médica (médicos y otros proveedores) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo. MPN debe permitir que los empleados tienen la opción de los proveedore(s). Cada MPN debe incluir una combinación de médicos que se especializan en lesiones de trabajo y médicos expertos en áreas de medicina general. ¿Qué MPN es utilizado por mi empleador? Su empleador está usando el Entertainment Partners Médicos de California MPN con el número 2418 de identificación. Debe consultar el nombre MPN y el número de identificación del MPN siempre que usted tenga preguntas o solicitudes acerca de la MPN. ¿A quién puedo contactar si tengo preguntas sobre mi MPN? El contacto del MPN en esta notificación será capaz de responder a sus preguntas sobre el uso del MPN y atenderá las quejas respecto a la MPN. El contacto de la MPN es: Contacto: Pre-Injury Consultores Dirección: California Número de Teléfono: (877) 802-5246 Dirección de correo electrónico: [email protected] Información general sobre el MPN también se puede encontrar en el siguiente sitio web: www.talispoint.com/aig/EP 2 ¿Qué debo hacer si necesito ayuda para encontrar y hacer una cita con un médico? Asistente de acceso médico del MPN le ayudará encontrar médicos disponibles de la MPN de su elección y pueden ayudarle a programar y confirmar citas de médico. El médico asistente de acceso está disponible para ayudarle del lunes al sábado de 7:00AM hasta las 8:00PM (Pacífico) y calendario de citas médicas en horario normal de los médicos. Asistencia está disponible en inglés y en español. La información de contacto para el acceso a médicos Assistant es: Número de teléfono gratuito: (855) 803-0363 FAX: (866) 841-5375 Dirección de Correo Electrónico: pic [email protected] ¿Cómo puedo averiguar cuáles médicos pertenecen a mi MPN? Usted puede obtener una lista regional de todos los proveedores en su área llamando al contacto de la MPN o visitando nuestro sitio web en: www.talispoint.com/aig/EP. Como mínimo, la lista regional debe incluir una lista de todos los proveedores de la MPN dentro de 15 millas de su lugar de trabajo o residencia o una lista de todos los proveedores de la MPN en el condado donde usted vive o trabaja. Usted puede elegir que lista para recibir. También tienes el derecho a obtener una lista de todos los proveedores de la MPN bajo petición. Para acceder a la lista de todos los médicos tratante de la MPN, puede ir a la página web www.talispoint.com/aig/EP. ¿Qué pasa si me lastimo en el trabajo? En caso de emergencia, debe llamar al 911 o vaya a la sala de emergencias más cercana. Si usted se lesiona en el trabajo, notifique a su empleador tan pronto como sea posible. Su empleador le proporcionará un formulario de reclamación. Cuando usted notificar a su empleador que usted ha tenido un accidente de trabajo, su empleador o asegurador hará una cita inicial con un doctor en el MPN. ¿Cómo escojo un proveedor? Su empleador o la aseguradora de su empleador se encargará de la evaluación médica inicial con un médico de la MPN. Después de la primera visita médica, puede continuar tratamiento con ese doctor, o puede escogoer a otro doctor de la MPN. Usted puede continuar a escoger a médicos dentro de la MPN para todos de su cuidado médico por esta lesión. Si es necesario, puede elegir a un especialista o pregunte a su médico tratante para una remisión a un especialista. Algunos especialistas sólo aceptará citas con una remisión del médico tratante. Tal especialista puede aparecer como “por derivación sólo” en el directorio de la MPN. Si usted necesita ayuda para encontrar a un médico o programar una cita médica, puede llamar el Asistente de acceso médico. 3 ¿Puedo cambiar de proveedor? Sí. Puede cambiar los proveedores de la MPN por cualquier razón, pero los proveedores que usted elija deben ser adecuados tratar su lesión. Comunicarse con el contacto del MPN o su Ajustador de reclamos si usted quiere cambiar a su médico tratante. Póngase en contacto con el Contacto de MPN o sus ajustadores de la reclamación si quiere cambiar a su medico trantante. ¿Qué requisitos debe reunir la MPN? El MPN tiene los proveedores en los siguientes condados de California excepto Alpine. El MPN tiene los proveedores en todo el estado, pero no puede tener plena cobertura MPN especialidad en su área. Por favor, utilice el directorio del MPN o en su MPN Contacto para obtener una lista de proveedores MPN en su zona. La MPN debe darle acceso a una lista de los proveedores regionales que incluye al menos a tres médicos de cada especialidad comúnmente se utiliza para tratar lesiones en el trabajo o enfermedades en su industria. La MPN debe proporcionar acceso a médicos primarios dentro de los 30 minutos o 15 millas y especialistas dentro de los 60 minutos o 30 millas de donde usted vive o trabaja. Si usted vive en una zona rural o en una zona donde hay una atención de la salud insuficiente, puede ser un criterio diferente. Después de haber notificado a su empleador de su lesión, el MPN debe proporcionar tratamiento inicial dentro de los 3 días hábiles siguientes. Si el tratamiento con un especialista ha sido autorizada, la cita con el especialista debe ser proporcionado a usted dentro de los 20 días hábiles de su solicitud. Si tiene problemas para obtener una cita con un proveedor en el MPN, póngase en contacto con el médico asistente Acceso. Si no hay MPN proveedores adecuados en la especialidad para tratar su lesión dentro de la distancia y el plazo, entonces lo que se le permitirá a buscar el tratamiento necesario fuera de la MPN ¿Qué tal si no hay proveedores de la MPN en el área donde estoy localizado? Si usted es un empleado actual, viviendo en una zona rural o trabajan o viven temporalmente fuera del área de servicio MPN, o si usted es un ex empleado viven permanentemente fuera del área de servicio MPN, el MPN o su doctor le dará una lista de por lo menos tres médicos que te puedan tratar. El MPN también le permitirá escoger su propio médico fuera de la MPN red. Póngase en contacto con el MPN Contacto para obtener asistencia en la búsqueda de un médico o para obtener información adicional. ¿Qué tal si necesito a un especialista que no está dentro de la MPN? Si necesita ver un especialista que no está disponible dentro de la MPN, usted tiene el derecho de ver a un especialista fuera de la MPN. 4 ¿Qué tal si no estoy de acuerdo con mi médico sobre el tratamiento médico? Si usted no está de acuerdo con su médico o si desea cambiar su médico por cualquier razón, usted puede elegir otro médico dentro de la MPN. Si usted no está de acuerdo con el diagnóstico o el tratamiento prescrito por su médico, usted puede pedir una segunda opinión a otro médico en el MPN Si desea una segunda opinión, usted debe ponerse en contacto con el contacto MPN o el ajustador de reclamos y decirles que usted desea una segunda opinión. La MPN debe darle por lo menos a nivel regional o completa lista de proveedores de MPN que usted puede elegir un segundo dictamen médico. A fin de obtener una segunda opinión, debe elegir un médico de la MPN lista y hacer una cita en un plazo de 60 días. Usted debe decirle al MPN contacto de su cita, y el MPN le enviará al médico una copia de su historial médico. Usted puede solicitar una copia de su historial médico que se enviará al médico. Si usted no hace una cita dentro de 60 días de la recepción de la lista de proveedores regionales, no se le permitirá tener una segunda o tercera opinión con respecto a este controvertido diagnóstico o tratamiento médico de este tratamiento. Si el segundo médico siente que su lesión se encuentra fuera del tipo de lesión que él o ella normalmente trata, el doctor notificará a su empleador o aseguradora y usted. Usted recibirá una lista de médicos o especialistas MPN para que usted pueda hacer otra selección. Si usted no está de acuerdo con la segunda opinión, puede solicitar una tercera opinión. Si usted solicita una tercera opinión, usted pasará a través del mismo proceso que se fue a través de una segunda opinión. Recuerde que si no hace una cita dentro de 60 días de obtener otro proveedor de la lista MPN, a continuación, no se le permitirá tener una tercera opinión con respecto a este controvertido diagnóstico o tratamiento de este tratamiento médico. Si usted no está de acuerdo con la tercera opinión médico, usted puede pedir una revisión médica independiente MPN (TMI). Su empleador o Contacto MPN le dará toda aquella información sobre cómo solicitar una revisión médica independiente y un formulario en el momento en que seleccione un tercer dictamen médico. Si la segunda o tercera opinión médica o Revisor Independiente coincide con la necesidad de un tratamiento o una prueba, es posible que le permitan recibir el servicio médico de un proveedor dentro de la MPN o si el MPN no contiene un médico que pueda proporcionar el tratamiento recomendado, usted puede elegir un médico fuera de la MPN dentro de un plazo razonable área geográfica. 5 ¿Que tal si ya estoy siendo atendido por otro proveedor medico antes que empiece la MPN? Su empleador o aseguradora tiene una “Transferencia de cuidado” política que determinará si usted puede seguir siendo tratada de una forma temporal existente lesiones relacionadas con el trabajo por un médico fuera de la MPN antes de que su atención se transfiere en el MPN. Si su médico actual no es, o no es miembro de la MPN, entonces usted puede ser necesario para ver un médico MPN. Sin embargo, si usted tiene un principal prefijados correctamente el tratamiento médico, no puede ser transferida a la MPN (Si usted tiene preguntas sobre predesignation, pregúntele a su supervisor.) Si su empleador decide que le transfiera a la MPN, usted y su médico deben recibir una carta en la que se notifique de la transferencia. Si usted cumple con ciertas condiciones, usted puede calificar para continuar el tratamiento con un médico que no es del MPN hasta por un año antes de que usted se transfieren a la MPN. Las condiciones para acogerse a aplazar el traslado de su cuidado en el MPN se exponen en el cuadro siguiente. ¿Puedo seguir siendo tratado por mi médico? Usted puede calificar para continuar el tratamiento con su médico MPN (a través de la transferencia de la atención o la continuidad de la atención) hasta un máximo de un año si la lesión o enfermedad cumple con cualquiera de las siguientes condiciones: • (Aguda) El tratamiento de su lesión o enfermedad se completó en menos de 90 días • (Seria o crónica) su lesión o enfermedad es uno que es grave y continúa por lo menos durante 90 días sin curación total o empeora y requiere tratamiento continuo. Es posible que le permitan ser tratadas por su médico tratante actual por un período de hasta un año, hasta que un traslado seguro de atención médica puede ser hecho. •(Terminal) tiene una enfermedad incurable o condición irreversible que es probable que cause muerte dentro de un año o menos • (A la espera cirugía) ya tiene una cirugía u otro procedimiento que ha sido autorizado por el empleador o aseguradora que se producen dentro de los 180 días siguientes a la fecha efectiva MPN, o la rescisión del contrato entre el MPN y el médico. 6 Usted puede estar en desacuerdo con la decisión del empleador de transferir su cuidado en el MPN. Si usted no desea que se va a transferir en el MPN, pregunte a su médico primario para un informe médico sobre si usted tiene una de las cuatro condiciones antes mencionadas para poder beneficiarse de un aplazamiento de la transferencia en el MPN. Su médico primario tiene un plazo de 20 días desde la fecha de su solicitud de una copia de su informe de su condición. Si su médico tratante primario no te da el informe en un plazo de 20 días de su solicitud, el empleador puede transferir su cuidado en el MPN y usted necesitará usar un médico MPN. Usted tendrá que darle una copia del informe a su empleador si desea posponer la transferencia de su atención médica. Si usted o su empleador no concuerda con su informe médico sobre su condición, usted o su empleador puede poner en duda. Consulte la Transferencia completa de la atención política para obtener más detalles sobre el proceso de solución de controversias. Para obtener una copia de la transferencia de la tutela política, ya sea en español o en inglés, pregunte al MPN Contacto. ¿Qué tal si estoy bajo tratamiento con un médico de la MPN y decido salirme de ella? Su empleador o asegurador tiene un escrito de “continuidad de la atención” que determinará si usted puede continuar con el tratamiento temporalmente de una lesión en el trabajo con su médico si su médico ya no participa en el MPN. Si su empleador decide que usted no puede optar a continuar su cuidado con el medico que no es MPN, usted y su médico tratante primario debe recibir una carta que le notifica de la presente decisión. Si usted cumple con ciertas condiciones, puede optar por continuar el tratamiento con este doctor hasta por un año antes de que usted debe elegir un médico MPN. Estas condiciones se establecen en el “ ¿puedo seguir siendo tratadas por Mi Doctor?”. Usted puede estar en desacuerdo con la decisión del empleador de negar continuidad de la atención con la terminación medico de MPN. Si usted desea continuar el tratamiento médico con el fin primario, pregúntele a su médico tratante para un informe médico sobre si usted tiene una de las cuatro condiciones establecidas en el cuadro anterior para ver si usted califica para continuar con el tratamiento médico actual temporalmente. Su médico primario tiene 20 días desde la fecha de su solicitud de una copia de su informe médico sobre su condición. Si su médico tratante primario no te da el informe en un plazo de 20 días a partir de su solicitud, la decisión del empleador de negarle a usted continuidad de la atención con el médico que ya no participa en el MPN se aplicará, y se le pedirá que elija un médico MPN. 7 Tendrá que darle una copia del informe a su empleador si desea posponer la selección de otro MPN médico para su tratamiento continuado. Si usted o su empleador no concuerda con su informe médico sobre su condición, usted o su empleador puede poner en duda. Ver el completo de la continuidad de la atención política para obtener más detalles sobre el proceso de solución de controversias. Para obtener una copia de la continuidad de la atención política, ya sea en español o en inglés, pregunte al MPN Contacto. ¿Qué puedo hacer si tengo preguntas o necesita ayuda? • MPN Contacto: Siempre podrá ponerse en contacto con el MPN contacto si tiene preguntas acerca de la utilización de la MPN y hacer frente a cualquier reclamación relativa al MPN. • Acceso a Médicos Asistentes: Puede ponerse en contacto con el Asistente acceso a médicos si usted necesita ayuda para encontrar médicos MPN y programación y confirmar las citas. • División de Compensación de Trabajadores (DWC): Si usted tiene inquietudes, quejas o preguntas sobre el MPN, el proceso de notificación, o su tratamiento médico después de una lesión o enfermedad relacionada con el trabajo, se puede llamar a los de la DWC Información y oficina de ayuda al 1-800-736-7401. También puede ir a la página web de la DWC www.dir.ca.gov/dwc y haga clic en “médico redes” para obtener más información sobre la MPN. • Revisión Médica Independiente: Si usted tiene preguntas acerca de la revisión médica independiente MPN proceso, conectarse con la División de Compensación para Trabajadores: DWC Medical Unit P.O. Box 71010 Oakland, CA 94612 510-286-3700 or 800-794-6900 Guarde esta información en caso tenga una lesión o enfermedad de trabajo. 8 Time of Hire Pamphlet PLEASE RETAIN FOR YOUR RECORDS Source: State of California, Department of Industrial Relations, Division of Workers’ Compensation What Is Workers’ Compensation? If you get hurt on the job, your employer is required by law to pay for workers’ compensation benefits. You could get hurt by: One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries. —or— five years from your date of injury. Temporary disability (TD) stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it’s going to. Permanent disability benefits: Payments if you don’t recover completely. You will be paid every two weeks if you are eligible. There are minimum and maximum weekly payment rates established by state law. The amount of payment is based on: • Your doctor’s medical reports Repeated exposures at work. Examples: hurting your wrist from using vibrating tools, losing your hearing because of constant loud noise. —or— Workplace crime. Examples: you get hurt in a store robbery, physically attacked by an unhappy customer. Discrimination Is Illegal It is illegal under Labor Code section 132a for your employer to punish or fire you because you: • File a workers’ compensation claim • Intend to file a workers’ compensation claim • Settle a workers’ compensation claim • Testify or intend to testify for another injured worker. If it is found that your employer discriminated against you, he or she may be ordered to return you to your job. Your employer may also be made to pay for lost wages, increased workers’ compensation benefits, and costs and expenses set by state law. What Are the Benefits? Medical care: Paid for by your employer to help you recover from an injury or illness caused by work. Doctor visits, hospital services, physical therapy, lab tests, and x-rays are some of the medical services that may be provided. These services should be necessary to treat your injury. There are limits on some services such as physical and occupational therapy and chiropractic care. Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering. The amount you may get is up to two-thirds of your wages. There are minimum and maximum payment limits set by state law. You will be paid every two weeks if you are eligible. For most injuries, payments may not exceed 104 weeks within • Your age • Your occupation Supplemental job displacement benefits: This is a voucher for up to $6,000 that you can use for retraining or skill enhancement at an approved school, books, tools, licenses or certification fees, or other resources to help you find a new job. You are eligible for this voucher if: • You have a permanent disability. • Your employer does not offer regular, modified, or alternative work, within 60 days after the claims administrator receives a doctor’s report saying you have made a maximum medical recovery. Death benefits: Payments to your spouse, children, or other dependents if you die from a job injury or illness. The amount of payment is based on the number of dependents. The benefit is paid every two weeks at a rate of at least $224 per week. In addition, workers’ compensation provides a burial allowance. Other Benefits You may file a claim with the Employment Development Department (EDD) to get state disability benefits when workers’ compensation benefits are delayed, denied, or have ended. There are time restrictions, so for more information contact the local office of EDD or go to their web site, www.edd.ca.gov. If your injury results in a permanent disability (PD) and the state determines that your PD benefit is disproportionately low compared to your earning loss, you may qualify for additional money from the Department of Industrial Relation’s special earnings loss supplement program also known as the return to work program. If you have questions or think you qualify, contact the Information & Assistance Unit by going to www.dwc.ca.gov and looking under “Workers’ Compensation programs and units” for the “Information & Assistance Unit” link or visit the DIR web site at www.dir.ca.gov. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91505-2024 | www.ep.com Revised July 2014 Page 1 of 3 Time of Hire Pamphlet Revised July 2014 Workers’ Compensation Fraud Is a Crime Any person who makes or causes to be made any knowingly false statement in order to obtain or deny workers’ compensation benefits or payments is guilty of a felony. If convicted, the person will have to pay fines up to $150,000 and/or serve up to five years in jail. What Should I Do if I Have an Injury? Report your injury to your employer. Tell your supervisor right away no matter how slight the injury may be. Don’t delay – there are time limits. You could lose your right to benefits if your employer does not learn of your injury within 30 days. If your injury or illness is one that develops over time, report it as soon as you learn it was caused by your job. If you cannot report to the employer or don’t hear from the claims administrator after you have reported your injury, contact the claims administrator yourself. Workers’ compensation claims administrator, or if employer is self-insured, person responsible for handling the claim is: AIG Insurance P.O. Box 25977 Shawnee Mission, KS 66225-5977 Phone: 877.802.5246 You may be able to find the name of your employer’s workers’ compensation insurer at www.caworkcompcoverage.com. If no coverage exists or coverage has expired, contact the Division of Labor Standards Enforcement at www.dir.ca.gov/DLSE, as all employees must be covered by law. Get emergency treatment if needed. If it’s a medical emergency, go to an emergency room right away. Tell the medical provider who treats you that your injury is job related. Your employer may tell you where to go for follow up treatment. Emergency telephone number: Call 911 for an ambulance, fire department, or police. For non-emergency medical care, contact your employer, the workers’ compensation claims administrator, or go to this facility: Page 2 of 3 Fill out DWC 1 claim form and give it to your employer. Your employer must give you a DWC 1 claim form within one working day after learning about your injury or illness. Complete the employee portion, sign and give it back to your employer. Your employer will then file your claim with the claims administrator. Your employer must authorize treatment within one working day of receiving the DWC 1 claim form. If the injury is from repeated exposures, you have one year from when you realized your injury was job related to file a claim. In either case, you may receive up to $10,000 in employer-paid medical care until your claim is either accepted or denied. The claims administrator has up to 90 days to decide whether to accept or deny your claim. Otherwise, your case is presumed payable. Your employer or the claims administrator will send you “benefit notices” that will advise you of the status of your claim. More About Medical Care What is a Primary Treating Physician (PTP)? This is the doctor with overall responsibility for treating your injury or illness. He or she may be: • The doctor you name in writing before you get hurt on the job • A doctor from the medical provider network (MPN) • The doctor chosen by your employer during the first 30 days of injury if your employer does not have an MPN or • The doctor you chose after the first 30 days if your employer does not have an MPN. What is a Medical Provider Network (MPN)? An MPN is a select group of health care providers who treat injured workers. Check with your employer to see if they are using an MPN. If you have not named a doctor before you get hurt and your employer is using an MPN, you will see an MPN doctor. After your first visit, you are free to choose another doctor from the MPN list. What is Predesignation? Predesignation is when you name your regular doctor to treat you if you get hurt on the job. The doctor must be a medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or a medical group with an M.D. or D.O. You must name your doctor in writing before you get hurt or become ill. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91505-2024 | www.ep.com Time of Hire Pamphlet Revised July 2014 You may predesignate a doctor if you have health care coverage for non-work injuries and illnesses. The doctor must have: • Treated you • Maintained your medical history and records before your injury and • Agreed to treat you for a work-related injury or illness before you get hurt or become ill You may use the “predesignation of personal physician” form included with this pamphlet. After you fill in the form, be sure to give it to your employer. If your employer does not have an approved MPN, you may name your chiropractor or acupuncturist to treat you for work related injuries. The notice of personal chiropractor or acupuncturist must be in writing before you get hurt. You may use the form included in this pamphlet. After you fill in the form, be sure to give it to your employer. With some exceptions, state law does not allow a chiropractor to continue as your treating physician after 24 visits. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. The term “chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. Exceptions to the prohibition on a chiropractor continuing as your treating physician after 24 visits include postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule, or if your employer has authorized additional visits in writing. What if There Is a Problem? Page 3 of 3 To contact the nearest I&A Unit, go to www.dwc.ca.gov and under “Workers’ Compensation programs and units”, click on “Information & Assistance Unit.” At this site you will find fact sheets, guides, and information to help you. The nearest I&A Unit is located at: 6150 Van Nuys Blvd., Room 105 Van Nuys, CA 91401-3370 Phone: 800.736.7401 Consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fees may be taken out of some of your benefits. For names of workers’ compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www.californiaspecialist.org. You may get a list of attorneys from your local I&A Unit or look in the yellow pages. Warning! Your employer may not pay workers’ compensation benefits if you get hurt in a voluntary off-duty recreational, social or athletic activity that is not part of your work-related duties. Additional Rights You may also have other rights under the Americans with Disabilities Act (ADA) or the Fair Employment and Housing Act (FEHA). For additional information, contact FEHA at (800) 884-1684 or the Equal Employment Opportunity Commission (EEOC) at (800) 669-4000. The information contained in this pamphlet conforms to the informational requirements found in Labor Code sections 3551 and 3553 and California Code of Regulation, Title 8, sections 9880 and 9883. This document is approved by the Division of Workers’ Compensation administrative director. Revised 6/17/14 and effective for dates of injuries on or after 1/1/13. If you have a concern, speak up. Talk to your employer or the claims administrator handling your claim and try to solve the problem. If this doesn’t work, get help by trying the following: Contact the Division of Workers’ Compensation (DWC) Information and Assistance (I&A) Unit. All 24 DWC offices throughout the state provide information and assistance on rights, benefits, and obligations under California’s workers’ compensation laws. I&A officers help resolve disputes without formal proceedings. Their goal is to get you full and timely benefits. Their services are free. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91505-2024 | www.ep.com Predesignation of Personal Physician In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.), or medical group if: • On the date of your work injury, you have health care coverage for injuries or illnesses that are not work related; • The doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetriciangynecologist, or family practitioner, and has previously directed your medical treatment and retains your medical records; • Your “personal physician” may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; • Prior to the injury your doctor agrees to treat you for work injuries or illnesses; • Prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met. Notice of Predesignation of Personal Physician Employee: Complete this Section To: (Name of Employer) Physician Information If I have a work-related injury or illness, I choose to be treated by: Name: name of doctor (M.D., D.O.) or medical group Address: City: State: ZIP: Phone: Employee Information Employee Name: Address: SSN: City: State: - ZIP: Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses: Employee Signature: Date: Physician: Complete this Section I agree to this predesignation. Physician Signature: Date: The physician is not required to sign this form; however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician’s agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). Print Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com 2014-07 Notice of Personal Chiropractor or Personal Acupuncturist (Optional) If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. NOTE: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term “chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon or physician designated by the surgeon under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule. You may use this form to notify your employer of your personal chiropractor or acupuncturist. Your Chiropractor or Acupuncturist’s Information: Name: Address: City: State: ZIP: Phone: Employee Information Employee Name: Address: SSN: City: Employee Signature: State: - ZIP: Date: Print Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com 2014-07 Un Folleto para el Nuevo Empleado CONSERVE PARA SUS RÉCORDS Source: State of California, Department of Industrial Relations, Division of Workers’ Compensation ¿Qué Es la Compensación de Trabajadores? Si usted se lesiona en el trabajo, su empleador por ley está obligado a pagarle los beneficios de compensación de trabajadores. Usted podría lesionarse por: Un incidente en el trabajo. Ejemplos: lastimarse la espalda al caerse, quemarse con un producto químico que le salpique la piel, lesionarse en un accidente de tránsito mientras hace entregas. — o— Exposiciones repetidas en el trabajo. Ejemplos: lastimarse la muñeca por hacer movimientos repetitivos, perder la audición debido a la presencia de ruidos fuertes y constantes. — o— Crimen en el lugar de trabajo. Ejemplos: se lesiona en un robo de una tienda, físicamente atacado por un cliente disgustado. La Discriminación Es Ilegal Es ilegal bajo el Código Laboral sección 132a que su empleador lo castigue o despida porque: • Presenta un reclamo de compensación de trabajadores • Tiene la intención de presentar un reclamo de compensación de trabajadores • Finaliza un reclamo de compensación de trabajadores • Testifica o tiene la intención de testificar para otro trabajador lesionado. Si se determina que su empleador discriminó contra usted, él o ella pueden ser ordenados a regresarlo a su trabajo. Su empleador también puede ser obligado a pagar por salarios perdidos, aumentos en beneficios de compensación de trabajadores además de costos y gastos establecidos por la ley estatal. ¿Cuáles Son los Beneficios? Atención médica: Pagado por su empleador para ayudarle a recuperarse de una lesión o enfermedad causada por el trabajo. Visitas al médico, servicios de hospital, terapia física, exámenes de laboratorio, y rayos X son algunos servicios médicos que pueden ser proporcionados. Estos servicios deben ser necesarios para tratar su lesión. Hay límites en algunos servicios como terapia física y ocupacional y cuidado quiropráctico. Beneficios por incapacidad temporal: Pagos que usted recibe por los salarios perdidos si su lesión le impide hacer su trabajo usual mientras se recupera. La cantidad que puede recibir es hasta dos tercios de su salario. Hay límites de pagos mínimos y máximos establecidos por la ley estatal. Será pagado cada dos semanas si es elegible. Para la mayoría de las lesiones, los pagos no pueden exceder más de 104 semanas dentro de cinco anos después de su lesión. La Incapacidad Temporal (Temporary Disability- TD) termina cuando usted regresa a trabajar o cuando su médico le permite regresar a trabajar o indica que su lesión ha mejorado lo mejor posible. Beneficios por incapacidad permanente: Pagos si no se recupera completamente. Se le pagará cada dos semanas si es elegible. Hay tasas de pago semanales mínimas y máximas establecidas por la ley estatal. La cantidad de pago está basada en: • El informe médico de su doctor • Su edad • Su ocupación Beneficios suplementarios por la pérdida de trabajo: Este es un vale de hasta $6,000 que usted puede utilizar para pagar por reentrenamiento/capacitación o mejoramiento de habilidades en una escuela aprobada por el estado, libros, herramientas, honorarios de certificación o licenciatura u otros recursos para ayudarle a encontrar un nuevo trabajo. Usted es elegible para este vale si: • Usted tiene una incapacidad permanente • Su empleador no le ofrece trabajo regular, modificado o alternativo dentro de 60 días después de que el administrador de reclamos recibe un informe médico indicando que ha llegado a una máxima recuperación médica. Beneficios por Muerte: Pagos a su cónyuge, hijos, u otros dependientes si usted muere debido a una lesión o enfermedad de trabajo. La cantidad del pago está basada en el número de dependientes. El beneficio es pagado cada dos semanas a una tasa de por lo menos $224 por semana. Adicionalmente, el seguro de compensación de trabajadores proporciona una cantidad para el entierro. Otros Beneficios Usted puede presentar un reclamo con el Departamento del Desarrollo de Empleo (Employment Development DepartmentEDD) para obtener beneficios de incapacidad estatal cuando los beneficios del programa de compensación de trabajadores son demorados, negados o han terminado. Hay plazos específicos así que para más información comuníquese con la oficina local del EDD o vaya a su sitio web en www.edd.ca.gov. Si su lesión resulta en una incapacidad permanente y el estado determina que su beneficio de PD es desproporcionadamente bajo comparado a su pérdida de ingresos, usted puede calificar para dinero adicional del programa de Pérdida de Ingresos Especiales Suplementarios del Departamento de Relaciones Industriales (Department of Industrial Relations- DIR) que también es conocido como el Programa del Regreso al Trabajo. Si tiene preguntas o piensa que califica, comuníquese con la Unidad de Información y Asistencia yendo a www.dwc.ca.gov y busque el enlace “Information & Assistance Unit” bajo la sección Workers’ compensation programs & units” o visite la página web del DIR en www.dir.ca.gov. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91505-2024 | www.ep.com Revisado Julio 2014 Pagina 1 de 3 Un Folleto para el Nuevo Empleado Revisado Julio 2014 El Fraude de Compensación de Trabajadores Es un Crimen Cualquier persona que hace o causa que se haga una declaración intencionadamente falsa para obtener o negar beneficios o pagos de compensación de trabajadores es culpable de una felonía. Si condenado, la persona tendrá que pagar multas de hasta $150,000 y/o cumplir hasta cinco años de cárcel. ¿Qué Debo Hacer si Me Lesiono en el Trabajo? Informe a su empleador sobre la lesión que ha sufrido. Dígale inmediatamente a su supervisor no importa que tan leve sea la lesión. No demore – hay plazos específicos. Usted puede perder su derecho a beneficios si su empleador no se entera de su lesión dentro de 30 días. Si su lesión o enfermedad se desarrolló gradualmente, infórmelo tan pronto como se entere que fue causada por su trabajo. Si usted no puede informarle al empleador o no ha escuchado del administrador de reclamos después de haber reportado su lesión, comuníquese con el administrador de reclamos usted mismo. La compañía del seguro de compensación de trabajadores, o si el empleador está auto asegurado, la persona responsable por la administración del reclamo es: AIG Insurance P.O. Box 25977 Shawnee Mission, KS 66225-5977 Phone: 877.802.5246 Puede poder encontrar el nombre de la compañía del seguro de compensación de trabajadores en www.caworkcompcoverage.com. Si no hay cobertura o si la cobertura ha expirado, comuníquese con la División para el Cumplimiento de las Normas Laborales en www.dir.ca.gov/DLSE ya que por ley, todos los empleados deben ser cubiertos. Obtenga tratamiento de emergencia si es necesario. Si es una emergencia médica, vaya a una sala de emergencia inmediatamente. Dígale al proveedor médico que le atiende que su lesión está relacionada con su trabajo. Su empleador le puede decir dónde ir para continuar con su tratamiento. Número de teléfono de emergencia: Llame al 911 para una ambulancia, el departamento de bomberos, o la policía. Para cuidado médico que no es urgente, contacte a su empleador, administrador de reclamos de compensación de trabajadores o vaya a esta instalación: Pagina 2 de 3 Llene el formulario de reclamo DWC 1 y déselo a su empleador. Su empleador debe darle un Formulario de reclamo DWC 1 dentro de un día laboral después de enterarse de su lesión o enfermedad. Complete la sección del empleado, fírmelo y regréselo a su empleador. Su empleador entonces presentará su reclamo al administrador de reclamos. Su empleador debe autorizar tratamiento dentro de un día laboral después de recibir el formulario DWC 1. Si la lesión es debida a exposiciones repetidas, usted tiene un año de cuando usted se da cuenta que su lesión está relacionada con su trabajo para presentar un reclamo. En cualquier caso, puede recibir hasta $10,000 en cuidado médico pagado por su empleador hasta que su reclamo sea aceptado o negado. El administrador de reclamos tiene hasta 90 días para decidir si acepta o niega su reclamo. De otra manera, se supondrá que su caso es pagadero. Su empleador o administrador de reclamos le enviará “Avisos de beneficios” que le informarán sobre el estado de su reclamo. Más Acerca de Atención Médica ¿Qué es un médico primario (Primary Treating PhysicianPTP)? Es el médico que tiene la responsabilidad total sobre el tratamiento para su lesión o enfermedad. Él o ella pueden ser: • El médico que usted denomina por escrito antes de que se lesione en el trabajo • Un médico de la red de proveedores médicos (Medical Provider Network- MPN) • El médico escogido por su empleador durante los primeros 30 días después de su lesión si su empleador no tiene una MPN o • El médico que usted escogió después de los primeros 30 días después de su lesión si su empleador no tiene una MPN. ¿Qué es una red de proveedores médicos (Medical Provider Network- MPN)? Una MPN es un grupo selecto de proveedores de cuidado médico que dan tratamiento médico a trabajadores lesionados. Consulte con su empleador para ver si están usando una MPN. Si usted no ha denominado a un médico antes de lesionarse y su empleador está usando una MPN, usted verá a un médico de la MPN. Después de su primera visita, está libre para escoger otro médico de la lista de la MPN. ¿Qué es la designación previa? La designación previa es cuando usted denomina a su médico particular para que lo atienda si usted se lastima en el trabajo. El médico debe ser un doctor en medicina (M.D.), doctor en medicina osteopatía (D.O.) o un grupo médico con un M.D. o D.O. Debe denominar a su médico por escrito antes de que usted se lastime o enferme. Shawnee Mission, KS 66225-5977 877.802.5246 Chartis Insurance P.O. Box 25977 Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91505-2024 | www.ep.com Un Folleto para el Nuevo Empleado Revisado Julio 2014 Usted puede designar de antemano a un médico si usted tiene plan de seguro médico para enfermedades y lesiones no relacionadas con el trabajo. El médico debe haberle: • Atendido • Mantenido su expediente/historial médico antes de su lesión y • Indicado que está de acuerdo en atenderlo para una lesión o enfermedad de trabajo antes de que usted se lastime o enferme Usted puede usar el formulario “Designación previa de médico particular” incluido con este folleto para denominar a su médico. Después de llenar el formulario, asegúrese de dárselo a su empleador. Si su empleador no tiene una MPN aprobada, usted puede denominar a su quiropráctico o acupunturista para que lo atienda para sus lesiones de trabajo. El aviso de quiropráctico o acupunturista personal debe ser por escrito antes de lastimarse. Puede utilizar el formulario incluido en este folleto. Después de llenar el formulario, asegúrese de dárselo a su empleador. Con algunas excepciones, la ley estatal no permite que un quiropráctico siga siendo su médico que lo atiende después de 24 consultas. Una vez que haya recibido 24 consultas quiroprácticas, si aún necesita tratamiento médico, usted tendrá que escoger un nuevo médico que no sea quiropráctico. El término “consulta quiropráctica” significa cualquier consulta en un consultorio quiropráctica, sin importar si los servicios cumplidos conllevan manipulación quiropráctica o se limitan a evaluación y manejo. Las excepciones a la prohibición a que un quiropráctico siga siendo su médico que lo atiende incluyen consultas por medicina física pos-quirúrgica prescrita por el cirujano o médico designado por el cirujano, bajo el componente pos-quirúrgico del Catálogo de Utilización de Tratamientos Médicos o MTUS de la División de Compensación de Trabajadores, o si su empleador ha autorizado consultas adicionales por escrito. ¿Qué si Hay Algún Problema? Si tiene alguna inquietud, diga algo. Hable con su empleador o con el administrador de reclamos encargado de su reclamo para tratar de resolver el problema. Si esto no funciona, consiga ayuda intentando lo siguiente: Pagina 3 de 3 Para comunicarse con la más cercana Unidad de I&A, vaya a www.dwc.ca.gov y bajo la sección “Workers’ compensation programs and units.” haga clic en el enlace “Information & Assistance Unit.” En este sitio encontrará hojas de información, guías e información para ayudarle. La más cercana unidad de I&A está ubicada en: 6150 Van Nuys Blvd., Room 105 Van Nuys, CA 91401-3370 Phone: 818.901.536 Consulte con un abogado. La mayoría de los abogados ofrecen una consulta gratis. Si decide retener a un abogado, sus honorarios pueden ser tomados de algunos de sus beneficios. Para nombres de abogados de compensación de trabajadores, llame al Colegio de Abogados (State Bar Association) de California al 415.538.2120 o vaya a la página web en www.californiaspecialist.org. Puede conseguir una lista de abogados de su Unidad de I&A local o consulte las páginas amarillas. Advertencia: Es posible que su empleador no pague beneficios de compensación de trabajadores si se lastima en una actividad voluntaria fuera de su trabajo, recreativa, social o atlética que no sea parte de sus deberes laborales. Derechos Adicionales: Usted también puede tener otros derechos bajo la Ley de Estadounidenses con Discapacidades (Americans with Disabilities Act - ADA) o la Ley de Igualdad en el Empleo y la Vivienda (Fair Employment and Housing Act - FEHA). Para información adicional, comuníquese con FEHA al 800.884.1684 o la Comisión para la Igualdad de Oportunidades en el Empleo (Equal Employment Opportunity Commission - EEOC) al 800.669.4000. La información contenida en este folleto se conforma a los requisitos de información encontrados en las secciones 3551 y 3553 del Código Laboral y las secciones 9880 y 9883 del Título 8, Código de Regulaciones de California. Este documento está aprobado por el director administrativo de la División de Compensación de Trabajadores. Revisado 12/20/12 y efectivo para fecha de lesiones en o después del 1/1/13. Comuníquese con la Unidad de Información y Asistencia (Information & Assistance- I&A) de la División de Compensación de Trabajadores (Division of Workers’ Compensation- DWC) Todas de las 24 oficinas de la DWC alrededor del estado proporcionan información y asistencia sobre derechos, beneficios, y obligaciones de acuerdo a las leyes de compensación de trabajadores en California. Los oficiales de I&A ayudan a resolver disputas sin entablar juicio. Su meta es de conseguirle beneficios completos y a tiempo. Los servicios son gratis. Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91505-2024 | www.ep.com Designación Previa de Médico Particular (Opcional) En caso de que usted sufra una lesión o enfermedad relacionada con su empleo, usted puede recibir tratamiento médico por esa lesión o enfermedad de su médico particular (M.D.), médico osteópata (D.O.) o grupo médico si: • Su empleador le ofrece un plan de salud grupal; • El médico es su médico familiar o de cabecera, que será un médico que ha limitado su práctica médica a medicina general o que es un internista certificado o elegible para certificación, pediátra, gineco-obstreta, o médico de medicina familiar y que previamente ha estado a cargo de su tratamiento médico y tiene su expediente médico; • Su “médico particular” puede ser un grupo médico si es una corporación o sociedad o asociación compuesta de doctores certificados en medicina u osteopatía, que opera un integrado grupo médico multidisciplinario que predominantemente proporciona amplios servicios médicos para lesiones y enfermedades no relacionadas con el trabajo; • Antes de la lesión su médico está de acuerdo a proporcionarle tratamiento médico para su lesión o enfermedad de trabajo; • Antes de la lesión usted le proporcionó a su empleador por escrito lo siguente: (1) notificación de que quiere que su médico particular le brinde tratamiento para una lesión o enfermedad de trabajo y (2) el nombre y dirección comercial de su médico particular. Puede usar este formulario para notificarle a su empleador que desea que su médico particular o médico osteópata le proporcione tratamiento médico para una lesión o enfermedad de trabajo y que los requisitos mencionados arriba han sido cumplidos. Noticia de Designación Previa de Médico Particular Empleado: Rellene Esta Sección. A: (Nombre del Empleador) Información sobre su Médico Si sufro una lesión o enfermedad de trabajo, yo elijo recibir tratamiento médico de: Nombre: M.D., D.O., o grupo médico Dirección: Ciudad: Estado: Código Postal: Teléfono: Información sobre el Empleado Número de Seguro Social: Nombre del Empleado: Dirección: Ciudad: Firma del Empleado: Estado: - Código Postal: Fecha: Médico: Rellene Esta Sección. Estoy de acuerdo con esta designación previa. Firma: Fecha: Médico o empleado designado por el médico o grupo médico El médico no está obligado a firmar este formulario, sin embargo, si el médico o empleado designado por el médico o grupo médico no firma, será necesario presentar documentación sobre el consentimiento del médico de ser designado previamente de acuerdo al Código de Reglamentos de California, Título 8, sección 9780.1(a)(3). Imprima Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com 2014-09 Noticia de Quiropráctico Personal o Acupuntor Personal (Opcional) Si su empleador o la compañía de seguros de su empleador no tiene una Red de Proveedores Médicos establecida, puede cambiar su médico que le esté proporcionando tratamiento médico a su quiropráctico o acupuntor personal después de una lesión o enfermedad de trabajo. Para ser elegible a hacer este cambio, usted debe antes de la lesión o enfermedad darle por escrito a su empleador el nombre y la dirección comercial de un quiropráctico o acupuntor personal. Generalmente, su administrador de reclamos tiene el derecho de elegir al médico que le proporcionará el tratamiento dentro de los primeros 30 días después de que su empleador sabe de su lesión o enfermedad. Después de que su administrador de reclamos haya iniciado su tratamiento con otro médico durante este tiempo, usted puede, bajo petición, transferir su tratamiento a su quiropráctico o acupuntor personal. Puede usar este formulario para notificarle a su empleador sobre su quiropráctico o acupuntor personal. La ley estatal no permite que un quiropráctico siga como su médico después de 24 visitas. Información Sobre su Quiropráctico o Acupuntor: Nombre: Dirección: Ciudad: Estado: Código Postal: Teléfono: Información Sobre el Empleado: Número de Seguro Social: Nombre: Dirección: Ciudad: Firma del Empleado: Estado: Código Postal: Fecha: Imprima Entertainment Partners | 2835 N. Naomi Street, Burbank, CA 91504-2024 | www.ep.com 2014-09
