ARCHDIOCESE OF ST. LOUIS Risk Management Manual

Transcription

ARCHDIOCESE
OF
ST. LOUIS
Risk Management Manual
The preservation of Archdiocesan assets, both people and property, is our main objective.
This manual contains all information and forms needed to operate an efficient and cost effective
Risk Management program.
This manual available from the Archdiocesan Website at www.archstl.org. Go to the Risk
Management page. It may be found under the "Publications" listing.
Also, all of the forms contained in this manual may be found on the Risk Management page
under the "Forms" listing. These forms are in a format that allows completion on your
computer for printing and hard copy submission.
Thank you,
Bob Ryan
Director of Risk Management
Office of Risk Management
20 Archbishop May Drive
St. Louis. MO 63119-5738
Phone:
314.792.7200
Fax:
314.792.7209
Risk Management Manual Revised 01-11
1
01/11
INDEX
Pages
I
General Risk Management Contacts and Guidelines
3-6
II
Reporting Claims
7 - 10
III
Workers’ Compensation
11 - 25
IV
General Liability
26 - 31
V
Auto
32 - 37
VI
Property
38 - 41
VII
Miscellaneous Forms
42 - 49
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I.
General Risk Management
Contacts & Guidelines
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GENERAL RISK MANAGEMENT
GUIDELINES AND CONTACTS
For purposes of this manual, the term Parish/Agency includes all Parishes, Schools, Offices and
Agencies of the Archdiocese of St. Louis.
WORKERS’ COMPENSATION:
When an injury occurs to an employee of a Parish or Agency, while in the course and scope of
employment and his/her assigned job duties, please follow the claim reporting procedures under Section
II, Reporting of Claims (Page 7). (Volunteers are not covered in this program)
(For Workers’ Compensation Instruction Guidelines, see Section III, Pages 11-25)
GENERAL LIABILITY:
When an injury occurs to someone who is not an employee of a Parish or Agency, please follow the
claim reporting procedures under Section II, Reporting of Claims (Page 7)
(For General Liability Instruction Guidelines, see Section IV, Pages 26-31)
AUTO:
When a Parish/Agency vehicle is involved in a motor vehicle accident resulting in personal injury or
damage to a third-party vehicle, or to a Parish/Agency vehicle, please follow the claim reporting
procedures under Section II, Reporting of Claims (Page 7).
(For Auto Instruction Guidelines, see Section V, Pages 32-37)
To add, delete or change vehicles registered in the program please see Vehicle Change Request (Page
37). Complete all information required on form and include a copy of the title or registered ownership.
PROPERTY:
When damage occurs to Parish/Agency property (building, contents or equipment), please follow the
claim reporting procedures under Section II, Reporting of Claims (Page 7).
(For Property Instruction Guidelines, see Section VI, Pages 38-41)
To add, delete or change buildings or contents in the program please see Building Input Form (Page 41).
Complete all information required on form.
RISK MANAGEMENT BEST PRACTICES
All locations are encouraged to implement Best Practices concerning processes that will reduce or
eliminate the risk of any type of loss. The elimination or reduction of losses is most important in keeping
our future insurance premiums as low as possible.
Best Practices include establishing sound Safety practices, the continuous maintenance of property and
machinery, correcting known safety defects, adhering to Archdiocesan policies and procedures and, if a
loss does occur, timely reporting the loss to our claim administrator, Gallagher Bassett Services, Inc.
Historically, there have been a number of claims that have resulted from or made worse by the failure to
adhere to Best Practices, or, in other words, because of Poor Practices.
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Some examples of Poor Practices affecting claims would be:

Late reporting of Workers’ Compensation claims. (State law requires reporting all injuries
to our claims administrator, Gallagher Bassett, within five days of knowledge of the
injury).

Money is stolen from an “off the books” account or resulting from the use of a rubber
stamp or other methods of facsimile signatures which are practices that do not comply with
the Financial Management Control Manual for Parishes.

Injuries sustained because of a building or premises defect that should have been repaired.

Contents of building destroyed by rain leaking through a poorly maintained roof..
The following lists the insurance deductibles by line of coverage.
Please note that the Poor Practice deductible will be applied when the Poor Practice is deemed material
to a loss.
St. Louis Archdiocesan Self-Insured Program
Priests, Parishes, Agencies and Schools Deductibles
Line
of
Coverage
Best
Practice
Deductible
Poor
Practice
Deductible*
Auto, General Liability,
None
$5,000
Late Reporting of Claim, Failure to
Correct a Known Safety Hazard, All
Unlawful Activities.
Auto Comprehensive
and Collision
$500
$2,500
Late Reporting of Claim
Property Claim
$2,500
$10,000
Late Reporting of Claim. Poor
Maintenance of Damaged Building
Boiler and Machinery
$2,500
$10,000
Late Reporting of Claim, Poor
Maintenance of Boiler and Machinery
$200
$500
$10,000
$25,000
Clergy Personal
Property
Crime – Employee
Dishonesty, Forgery,
Fraud, Funds Transfer
Fraud, Computer Fraud,
Other Crime Claims
Examples
of
Poor Practices
Late Reporting of Claim
Late Reporting of Claim, Failure to
Adhere to Process and Procedures
Outlined in "Financial Management and
Control Manual for Parishes", All
Unlawful Activities
*Applied when Poor Practice is deemed material to a loss.
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DIRECTORY OF IMPORTANT RISK MANAGEMENT
TELEPHONE NUMBERS
Arthur J. Gallagher Risk Management Services. Inc. - 12444 Powerscourt Dr., Suite 500
St. Louis, MO 63131-3660
Sandy Gross (314.800.2269 or 1.800.877.8218 Fax: 1.866.201.3567) for:
 Certificates of Insurance and specific information on coverages and deductibles
 To request cards certifying coverage in our vehicle program
 General Information or Requests
 Workers’ Compensation Treatment Authorization Forms
 Risk Management Manuals
Craig Parres (314.800.2243 or 1.800.877.8218) for:




Boiler and Machinery Inspection Questions
Coverage Questions
Questions pertaining to the rental of autos
Problems or special needs
Alan Schmidt (314.800.2255 or 1.800.877,8218) for:
 Safety inspections and questions regarding safety issues
Gallagher Bassett Services, Inc. – 1630 Des Peres Rd., Suite 500 St. Louis, MO 63131-1849









Worker’s Compensation
Worker’s Compensation Supervisor
Property, Liability & Auto
Claim Manager
Fax Number
314.800.0253 – Valeri Maki
314.800.0214 – Dennis Bini
314.800.0257 – Robert Granquist, Jr.
314.800.0230 – Gary Clifton
314.800.0254 – Kim Stoff
314.800.0283 – Josh Bohrer
314.800.0255 – Sean Muldoon
314.800.0227 – Jeff Voege
1.866.947.2227
If these individuals are unavailable in an emergency, press 0 and ask the operator to assist in
obtaining someone from the department to take your claim report from the Archdiocese of St.
Louis (during office hours). For after hours emergency reporting, call 1.800.428.5428 and your
call will be re-directed to an adjuster.
St. Louis, MO 63119-5738
Phone: 314.792.7200
Fax: 314.792.7209



Changes in Pastors, or addresses;
also, questions on bills:
314.792.7201 Fred Hummel [email protected]
Vehicle & Property changes,
problems or special needs:
314.792.7203 Bob Ryan
[email protected]
Written communication is preferred. Please call only when necessary.
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II.
Reporting Claims
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Methods of Reporting Claims
1) Toll-free Phone Call
2) Internet
3) Computer Completion
4) Manual Reporting
Workers’ Compensation, General Liability, Auto and Property claims may be reported by means
of 1) a Toll-free phone call, 2) use of the Internet, 3) completing the form on your computer, print
it and submit hard copy or 4) by manually completing the appropriate claim form.
1) Telereporting – To report a claim by telephone, please see the instructions on Page 9.
2) Internet – To report claims by using the Internet, please complete the “Request for Internet Security
to Report Claims” form found on Page 10 and submit the information to Gallagher Bassett. After the
submitted information is processed, you will receive instructions for Internet reporting.
3) Computer Completion – To report using your computer you need access to the internet. Go to the
Archdiocesan Website, www.archstl.org. Next access the Risk Management page and go to the "Forms"
listing. You may download and save the forms to your computer or you may access them each time
from the internet. When you access the forms, they will open in Adobe Acrobat Reader. You can then
complete the fields on the form. When you have checked the information that you entered, you may
then print the form on your printer. The form may then be either mailed or faxed.
4) Manual Claim Reporting – To manually report claims, please complete the appropriate form found
in the specific claim category: Workers’ Compensation (Pages 18 & 19), General Liability (Page
31), Auto (Pages 34 & 35), or Property (Page 40). Note - Forms that may be completed using your
computer may be found on the Risk Management page of the Archdiocesan website.
Completed Forms Should Be Sent Directly To:
Gallagher Bassett Services, Inc.
1630 Des Peres Road, Suite 200
St. Louis, Mo. 63131-1849
Fax: 1.866.947.2227
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ARCHDIOCESE OF ST. LOUIS – 000292
Toll-free Claims Reporting Quick Reference Sheet
For Insurance Claims
1.877.263.9897
To report your Workers’ Compensation claims quickly and efficiently, please have the
following information ready when you call your toll-free claims reporting services. This is a general
listing for your quick reference. Thank you for your prompt reporting!
CLAIMANT INFORMATION
 Employee name
 Social security number
 Address and home phone number
 Spouse’s name
 Number of dependents
 Date of hire
 Gross pay per week
ACCIDENT INFORMATION
 Exact date and time of injury
 Exact location or site code where injury occurred
 Specific description of injury (i.e., employee slipped and fell on wet floor in warehouse)
 Safeguards or safety equipment provided to prevent injuries (where applicable)
 Name and address of claimant’s physician
 Name and address of hospital
To report your Liability, Auto and Property claims quickly and efficiently, please have the
following information ready when you call your toll-free claims reporting service. This is a general
listing for your quick reference. Additional information may be requested. Thank you for your prompt
reporting!
CLAIMANT INFORMATION
 Claimant Information
 Claimant Name
 Claimant address and phone number
LOSS INFORMATION
 Exact date and time of injury or damage
 Exact location where injury or damage occurred
 Specific description of injury or damage
 Witnesses or Passengers- name, address and phone numbers
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REQUEST FOR INTERNET SECURITY
TO REPORT CLAIMS
Please complete a separate form for each person who will be reporting claims
through the Internet.
Parish/Agency Information
Parish or Agency Name:
___________________________________
Address:
___________________________________
City, State, and Zip Code:
___________________________________
Risk Management Location Number or Numbers: __________________
(Note-Since security is determined by location, if you are unsure about
your location number/s please contact the Office of Risk Management.)
Individual Requesting Access
Name:
___________________________________
Email Address:
___________________________________
After you have completed this form, send it to:
20 Archbishop May Dr.
St. Louis, MO 63119-5738
After the above information is processed, you will receive instructions from
Gallagher Bassett Services, Inc. for Internet reporting.
Risk Management Manual Revised 01-11.doc
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III.
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WORKERS' COMPENSATION REPORT
The Archdiocese of St. Louis entered into agreements with various locations that provide medical
services at negotiated prices. These providers specialize in the treatment of Workers’ Compensation
injuries and will assure that Archdiocesan employees continue to receive quality care. You should use
the pre-established Archdiocesan network list.
The Division of Workers’ Compensation allows any employer in the State of Missouri to direct the
medical treatment of an employee injured on the job. Therefore it is imperative that you utilize ONLY
the Archdiocesan provider list to ensure proper medical care for a work related injury. If this procedure
is not followed, payment of bills may be denied by the Archdiocese. In that event, either the
parish/agency or the injured employee would be responsible for payment. If specialized care is required
or a provider is not within your area, contact Gallagher Bassett Services Workers’ Compensation
Specialist (See Page 6) for referrals.
When using any of the providers from the approved Archdiocesan list, you must provide the injured
employee with the treatment authorization form (Gold form on Page 25; NOTE – This form may not
be reproduced, please contact Arthur J. Gallagher Risk Management Services, Inc. for additional
copies). If an employee requires more than one treatment, physical therapy or referral to a specialist,
these locations will be contacting Gallagher Bassett Services directly to make arrangements. Should
you be contacted by one of the medical facilities asking for authorization for additional treatment or
referral to a specialist, please refer the person to Gallagher Bassett Services, Inc. for a Workers’
Compensation Specialist (See Page 6).
Select a medical provider from the list below and enter in “Physician/ Facility” space on Workers’
Compensation Treatment Authorization form (Gold page 25). Fill out this information and the
parish/agency information in advance. Make these completed forms readily available in case an
emergency. Should an emergency arise, time may be critical. NOTE - Facilities have been arranged in
Zipcode order to provide easy access to locations closest to you. These facilities are designated for
treatment of employee (workers' compensation) injuries. We have listed Medical Centers and Hospitals
at the end of the Treatment Facilities. Medical Centers and Hospitals should be only used for "after
hours" injuries or extreme emergencies.
REFERRAL FOR MEDICAL CARE
1.
Complete the Archdiocese of St. Louis Workers' Compensation Treatment Authorization form.
2.
Designate one of the pre-selected locations, insert its name on the Treatment Authorization form
(if you have not already done so), and give it to the employee. Direct the employee to the
OCCUPATIONAL HEALTH AND MEDICINE DEPARTMENT, The Emergency Room
should be used only for critical medical emergencies.
3.
Send a copy of the Treatment Authorization form to Gallagher Bassett with the Report of Injury.
4.
The Workers' Compensation Treatment Authorization form may not be duplicated.
Contact Arthur J. Gallagher Risk Management Services, Inc. (See Page 6) for additional forms.
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PRESELECTED ARCHDIOCESAN PPO NETWORK FACILITIES FOR
WORKERS’ COMPENSATION INJURIES
63010
St Anthony's Urgent Care
3619 Richardson Square Dr
Arnold, MO 63010
63011
St Luke's Urgent Care
233 Clarkson Rd
Ellisville, MO 63011
63017
St John's Mercy Corp Health
224 S Woods Mill Rd - 360 South
Chesterfield, MO 63017
63026
Concentra Medical Center
128 Matrix Commons
Fenton, MO 63026
636.717.6700
636.230.8644
314.579.9487
636.349.6850
Fenton Urgent Care
714 Gravois Rd
Fenton, MO 63026
636.326.6100
508 Old Smizer Mill Rd
Fenton, MO 63026
636.343.5223
63042
463 Lynn Haven Dr
Hazelwood, MO 63042
SSM WorkHEALTH
1 Village Square Center, Suite A
Hazelwood, MO 63042
63043
83 Progress Pky
Maryland Heights, MO 63043
63080
Sullivan Medical Office
965 Mattox Dr
Sullivan, MO 63080
63077
St. Clair Clinic
875 N Commercial Ave
St. Clair, MO 63077
63090
1701 Heritage Hill Dr
Washington, MO 63090
63104
1617 S Third St
Saint Louis, MO 63104
63110
Barnescare
5000 Manchester Ave
63122
455 S Kirkwood Rd
Big Bend Urgent Care
10296 Big Bend Blvd
314.731.0448
63125
Lemay Urgent Care
2900 Lemay Ferry Rd
636.629.7467
636.239.8844
314.421.2557
314.747.5800
314.965.6871
314.543.5970
314.543.5294
314.731.9675
63128
13303 Tesson Ferry Rd, Suite 50
314.729.9995
314.434.8174
63139
6726 Manchester Rd
314.647.0081
573.860.6000
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PRESELECTED ARCHDIOCESAN PPO NETWORK FACILITIES FOR
WORKERS’ COMPENSATION INJURIES (Continued)
63141
11700 Studt Rd
63143
SSM WorkHEALTH
2321 McCausland Ave
63146
Barnescare
11501 Page Service Dr
63147
8340 N Broadway
63303
1551 Wall St, Suite 100
Saint Charles, MO 63303
63304
SSM St Joseph Medical Park
1475 Kisker Rd
1051 Wolfrum Rd
63366
St John's Mercy Urgent Care
300 Winding Woods Dr, Suite 100
O Fallon, MO 63366
63368
5551 Winghaven Blvd, Suite 100
O Fallon, MO 63368
63376
Barnescare
1901 Trade Center Dr
Saint Peters, MO 63376
314.989.9199
314.645.9675
314.993.3014
314.385.9563
636.947.1666
636.498.7400
636.300.0370
636.379.4329
636.695.2500
636.978.1008
14
63376 - Continued
St John's Mercy Urgent Care
107 Piper Hill Dr
636.477.8757
636.928.9675
SSM WorkHEALTH
300 St. Peters Centre Blvd., Suite 150
63379
Troy Family Practice
900 E Cherry St
Troy, MO 63379
63601
Mineral Area Reg Med Ctr
1421 E Main St
Park Hills, MO 63601
63627
Bloomsdale Family Health
37 Meyer Ln
Bloomsdale, MO 63627
63628
Mineral Area Reg Med Ctr
55 Nesbit Dr
Bonne Terre, MO 63628
63664
Healthway Primary Care
200 Health Way
Potosi, MO 63664
63670
Ste Genevieve Family Health
753 Pointe Basse Dr
Sainte Genevieve, MO 63670
Ste Genevieve Family Health
930 Park Dr
63775
Perryville Family Care Clinic
212 Hospital Ln, Suite 101
Perryville, MO 63775
636.528.6755
573.431.3303
573.483.9500
573.358.1480
573.438.2977
573.883.2782
573.883.7424
573.547.7888
01/11
MEDICAL CENTERS AND HOSPITALS
These facilities should only be used for "after hours" injuries and extreme emergencies
63017
St Luke’s Hospital
232 S Woods Mill Rd
Chesterfield, MO 63017
63019
Jefferson Regional Medical Center
1400 Hwy 61 South
Crystal City, MO 63019
63026
SSM St Clare Health Center
1015 Bowles Ave
Fenton, MO 63026
63031
Northwest HealthCare
1225 Graham Rd
Florissant, MO 63031
63044
SSM Depaul Health Center
12303 Depaul Dr
Bridgeton, MO 63044
63080
Missouri Baptist Sullivan Hospital
751 Sappington Bridge Rd
Sullivan, MO 63080
63090
St John’s Mercy Hospital
901 E Fifth St
Washington, MO 63090
63110
Barnes Jewish Hospital
1 Barnes Jewish Hospital Plz
St Louis University Hospital
3635 Vista at Grand Blvd
63117
SSM St Mary’s Health Center
6420 Clayton Rd
63118
St Alexius Hospital
3933 S Broadway
314.205.6990
636.933.1111
636.496.2100
314.953.6994
314.344.6360
63122
Des Peres Hospital
2345 Dougherty Ferry Rd
63128
St Anthonys Medical Center
10010 Kennerly Rd
63131
Missouri Baptist Medical Center
3015 N Ballas Rd
63136
Christian Hospital
11133 Dunn Rd
63139
Forest Park Hospital
6150 Oakland Ave
573.468.1120
63141
Barnes Jewish West Co Hospital
12634 Olive Blvd
636.239.8011
314.362.9123
St John’s Mercy Medical Center
615 S New Ballas Rd
63301
SSM St Joseph Health Center
300 First Capital Dr
314.577.8777
63367
SSM St Joseph Hospital West
100 Medical Plz
Lake Saint Louis, MO 63367
314.768.8360
15
314.865.7955
314.966.9666
314.525.1900
314.996.5225
314.653.5994
314.768.3019
314.996.8470
314.251.6090
636.947.5111
636.625.5300
01/11
MEDICAL CENTERS AND HOSPITALS - Continued
These facilities should only be used for "after hours" injuries and extreme emergencies
63376
Barnes Jewish St Peters Hosp
10 Hospital Dr
63379
Lincoln County Medical Center
1000 E Cherry St
Troy, MO 63379
63385
SSM St Joseph Health Center
500 Medical Dr
Wentzville, MO 63385
63628
Parkland Health Center
7245 Raider Rd
Bonne Terre, MO 63628
63640
Mineral Area Regional Med Ctr
1212 Weber Rd
Farmington, MO 63640
636.916.9000
Parkland Health Center
1101 W Liberty St
Farmington, MO 63640
636.528.8551
63664
Washington County Mem Hosp
300 Health Way
Potosi, MO 63664
636.327.1100
63670
Ste Genevieve Co Mem Hosp
Highways 61 & 32
573.358.4675
63775
Perry County Mem Hosp
434 N West St
Perryville, MO 63775
573.756.4581
573.760.8475
573.438.5451
573.883.2751
573.547.2536
IMPORTANT INFORMATION CONCERNING
WORKERS’ COMPENSATION

Emergency Room Treatment - The E.R. should be used for all life threatening medical
emergencies; otherwise it should be avoided because the doctors there do not have special
training in Workers’ Compensation. When someone needs treatment after hours or on
weekends, the family physician should be contacted.

If there is no primary care center in your immediate area, (30 miles or less), contact the
Gallagher Bassett Services (See Page 6), for assistance in preselecting a medical facility.

When an employee is injured, the Risk Coordinator should be contacted immediately and
requested to notify Gallagher Bassett.

Prompt reporting will ensure more effective medical direction, thus enabling the employee
to return to work sooner, reducing costs for all of us.

It is most helpful if the Risk Coordinator is in regular contact with the injured worker,
making reports to Gallagher Bassett on the employee’s progress.
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WORKERS' COMPENSATION
CLAIMS HANDLING PROCEDURES
It is important to remember that you have several options in submitting your workers' compensation Report of
Injury. Please see page 8 before you begin processing. Only you can determine the method of reporting that
is easiest and best for you.
(The following is based upon completing a manual form or using the computer completion method.
However, the information needed for reporting under any of the options is the same. This form must be used
immediately in reporting all workers’ compensation injuries.)
REPORT OF INJURY FORM
1.
All fields that are mandatory must be completed. See field listing beginning on page 20 for
fields that are mandatory.
2.
This form also contains information that will remain constant and should be included on all
First Reports.
3.
Under section “General”, the “Location #” is your parish/agency Archdiocesan location code.
4.
Information relative to the carrier/claims administrator pertains to the Archdiocese of St. Louis
and Gallagher Bassett and has been prefilled on the sample.
5.
Use the word “alleged” on all injuries that are:
A.
B.
C.
D.
Suspicious in nature.
Not witnessed.
Reported late.
Non-visible, such as back strain.
Example: The employee alleges he twisted his back, two weeks ago, picking up a screwdriver.
6.
Mail the Report of Injury form to Gallagher Bassett Services, Inc. within 48 hours of the injury.
Do not mail the Report of Injury form to the State Division of Workers' Compensation: this is a
Gallagher Bassett Services, Inc. responsibility.
7.
Timely reporting of work-related injuries is imperative for proper control of the claim, cost
containment, and to ensure quality care for your employee.
8.
The Report of Injury (Pages 18 & 19) should be used for all work related injuries. Do not use
the Incident Report for reporting these injuries.
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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
P.O. BOX 58
JEFFERSON CITY, MO 65102-0058
REPORT OF INJURY
(SEE INSTRUCTIONS ON PAGE 2)
EMPLOYER (NAME, ADDRESS, INCL ZIP CODE)
CARRIER ADMINISTRATOR CLAIM NUMBER
REPORT PURPOSE CODE
00
JURISDICTION CLAIM NUMBER
GENERAL
JURISDICTION
MO
INSURED REPORT NUMBER
EMPLOYERS LOCATION ADDRESS (IF DIFFERENT)
SIC CODE
EMPLOYER FEIN
PHONE #
CARRIER
CARRIER (NAME, ADDRESS & PHONE NO.)
CLAIMS ADMIN
LOCATION #
POLICY PERIOD
Safety National
2443 Woodland Parkway, Ste 200
St. Louis, MO 63146
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.)
Gallagher Bassett Services
1630 Des Peres Road, Ste 200
St. Louis, MO 63131
to
CHECK IF APPROPRIATE
SELF INSURANCE
CARRIER FEIN
POLICY SELF-INSURANCE NUMBER
ADMINISTRATOR FEIN
43-0727872
36-3365500
EMPLOYEE
AGENT NAME & CODE NUMBER
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
ADDRESS
SEX
SOCIAL SECURITY #
MARITAL STATUS
MALE
EMPLOYMENT STATUS
MARRIED
UNKNOWN
PHONE #
STATE OF HIRE
OCCUPATION JOB TITLE
UNMARRIED
SINGLE DIVORCED
FEMALE
DATE HIRED
SEPARATED
# OF DEPENDENTS
NCCI CLASS CODE
WAGE
UNKNOWN
RATE
PER
TIME EMPLOYEE BEGAN WORK
DAY
MONTH
WEEK
OTHER
AM
# DAYS WORKED WEEK
DATE OF INJURY / ILLNESS
TIME OF OCCURRENCE
AM
PM
OCCURRENCE
DID INJURY ILLNESS EXPOSURE OCCUR
YES
YES
NO
DID SALARY CONTINUE?
YES
NO
LAST WORK DATE
DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN
PM
CONTACT NAME PHONE NUMBER
ON EMPLOYER’S PREMISES?
FULL PAY FOR DAY OF INJURY?
TYPE OF INJURY ILLNESS
PART OF BODY AFFE CTED
TYPE OF INUURY/ILLNESS CODE
PART OF BODY AFFECTED CODE
NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE
OCCURRED
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR
ILLNESS EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR
ILLNESS EXPOSURE OCCURRED
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE
OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED, DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR
SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL
OTHERS
TREATMENT
DATE RETURN(ED) TO WORK
IF FATAL, GIVE DATE OF DEATH
PHYSICIAN HEALTH CARE PROVIDER (NAME & ADDRESS)
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
YES
NO
WERE THEY USED?
YES
NO
HOSPITAL (NAME & ADDRESS)
INITIAL TREATMENT
0 – NO MEDICAL TREATMENT
1 – MINOR: BY EMPLOYER
2 – MINOR CLINIC HOSPITAL
3 – EMERGENCY CASE
4 – HOSPITALIZED > 24 HOURS
5 – FUTURE MAJ. MED. LOST TIME ANTICIPATED
WITNESS (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED
CAUSE OF INJURY CODE
DATE PREPARED
PREPARER’S NAME & TITLE
18
PHONE NUMBER
01/11
NOTE > This form is both the notice and report of injury as required by Section 287.380, RSMo.
Injuries that require only first aid and result in no lost time need not be reported. Please mail this
report to your WORKERS’ COMPENSATION INSURANCE CARRIER or Claims Administrator. If you
are self-insured or are not under the Law and do not have an insurance carrier, mail this form to the
Division.
PRINT QUALITY >
All reports of injury and supporting documents received by the Division will be
processed electronically. All forms submitted to the Division MUST be of clear and legible quality.
Handwritten forms will not be accepted. Computer generated forms shall use a minimum type size of
10 points. All documents not meeting the above criteria will be returned.
TO BE ANSWERED ONLY IN CASE OF DEATH
DATE OF DEATH
EMPLOYEE’S DEPENDENTS
NAME OF
DEPENDENT
ADDRESS OF DEPENDENT
RELATION TO
EMPLOYEE
ADDRESS
19
CITY
STATE
ZIP CODE
01/11
Field
Names
Employer
Carrier Administrator Claim
Number
Report Purpose Code
Jurisdiction
Jurisdiction Claim Number
Insured Report Number
Employers Location Address
Location #
Phone #
SIC Code
Employer FEIN
Carrier
Policy Period
Claims Administrator
Self-Insured Indicator
Carrier FEIN
Agent Name & Code Number
Name
Date of Birth
Social Security Number
MANDATORY FIELDS ARE IN BOLD TYPE
Definition
Of Fields
The name and address of business entity employing or
statutorily responsible for the employee.
Identifies a specific claim within a carrier administrator’s claims
processing system.
00 – Original
02 – Change/Update
The governing body, territory, who will administer the claim
and whose statues will apply to the claim adjustment process.
Example: MO
MO Division of Workers’ Compensation Injury Number
A number used by the insured to identify a specific claim.
The location where the accident occurred if different than the
employer address.
New
Field
Field
Status
Mandatory
Yes
Optional
Yes
Mandatory
Yes
Mandatory
A code defined by the employer that is used to identify the
employer’s multiple location of the accident.
The phone number of the employer.
The code which represents the nature of the employer’s business
which is contained in the Standard Industrial Classification.
Manual published by the Federal Office of Management and
Budget.
The FEIN (Federal Employer Identification Number) number
of the employee’s employer.
The name, address and phone number of the licensed business
entity issuing a contract of insurance and assuming financial
responsibility on behalf of the employer and the employee.
The date that the contract/policy under which the claim
occurred became effective and expired.
The name, address and phone number of the self-insured,
carrier or third party administrator responsible for the claim.
Check if you are self-insured.
Yes
Do not use.
Optional
Mandatory
if different
than
employer
address.
Mandatory
Yes
Mandatory
Optional
Yes
Mandatory
The FEIN (Federal Employer Identification Number) number
of the claims administrator.
Not used.
The employee’s legally recognized name, which is used on
legal documents, employment, Social Security, banking
records, etc.
The date the employee was born. (Please provide as much
information as you have.)
Yes
The Social Security number of the employees.
20
Mandatory
if applicable.
Yes
Mandatory
Yes
Mandatory
if applicable.
Mandatory
if applicable.
Mandatory
36-3365500
Not used.
Mandatory
Yes
Yes
Mandatory
Mandatory
01/11
Field
Names
Definition
Of Fields
New
Field
Field
Status
Date Hired
The date which the employee was hired. (Please provide as
much information as you have.)
Yes
Mandatory
State of Hire
The state the employee was hired.
Yes
Optional
Address
The mailing address used by the injured employee.
Mandatory
Phone #
A telephone number where the employee can be reached.
Mandatory
# of Dependents
The number of dependents as defined by the administering
jurisdiction.
Optional
Sex
Indicates the sex of the employee.
Mandatory
Marital Status
Indicates the marital status of the employee.
Mandatory
Occupational/Job Title
Identifies the primary occupation of the employee at the time
of the accident/injury exposure.
Mandatory
Employment Status
NCCI Class Code
Rate
# Days Worked/Week
Full Pay for Day of Injury
Did Salary Continue
Time Employee Began Work
Date of Injury/Illness
Time of Occurrence
Last Work Date
Date Employer Notified
Date Disability Began
Contact Name/Phone Number
Type of Injury/Illness
A code used to indicate the employee’s primary work code status
at the time of the injury with the covered employer.
FT – Full-Time
PT – Part-Time
NE – Not Employed
OS – On Strike
DS – Disabled
RT – Retired
SL – Seasonal
VO – Volunteer
PW – Piece Worker
UK – Unknown
AD – Apprenticeship Full-Time
AP – Apprenticeship Part-Time
A code corresponding to the primary occupation, which the
claimant was engaged at the time of the accident/injury
exposure.
The weekly rate at which a benefit type is being paid.
The number of the employee’s regularly scheduled workdays
per week.
Indicates whether full wages for the date of the accident/injury or
illness were paid by the employer.
Indicates whether full wages for the date of the accident/injury or
illness were paid by the employer.
The time when employee began work.
Yes
Optional
Yes
Mandatory
Mandatory
Mandatory
Yes
Optional
Yes
Optional
Optional
The date on which the accident occurred.
Mandatory
The time when the accident occurred.
The date the employee last worked. This date will not reflect
dates on which the employee was absent from work in a paid
status; vacation, comp. Time, sick day, military leave, etc.
Date employer notified of the accident/injury exposure.
The first day on which the claimant originally lost time from
work due to the occupational injury of disease or as otherwise
defined by statute.
Name/telephone number of party that can be contacted about
the injury.
Description of the type of injury/illness.
21
Mandatory
Yes
Mandatory
Yes
Mandatory
Yes
Mandatory
Mandatory
Mandatory
01/11
Field
Names
Definition
Of Fields
New
Field
Field
Status
Part of Body Affected
The part of the body the claimant sustained injury to.
Mandatory
Did Injury/Illness exposure
occur on employer’s premises?
As requested. Answer yes or no.
Optional
Type of Injury/Illness Code
Code identifying type of injury.
Yes
Mandatory
Code
Part of Body Affected Code
Code identifying part of body.
Yes
Mandatory
Code
Department or Location where
accident or illness exposure
occurred.
Description of department or location where accident occurred.
Optional
All equipment, materials or
chemicals employees was
using when accident or illness
exposure occurred.
Description of equipment, materials, chemicals, etc., employee
was using when accident occurred.
Mandatory
Specific activity the employee
was engaged in when the
accident or illness exposure
occurred.
Description of activity employee engaged in when accident
occurred.
Mandatory
Work process the employee
was engaged in when accident
or illness exposure occurred.
Description of work process employee engaged in when
accident occurred.
Mandatory
How injury or
illness/abnormal health
condition occurred. Describe
the sequence of events and
include any objects or
substances that directly
injured the employee or made
the employee ill.
Description of the sequence of events, including any objects or
substances that directly injured the employee or made the
employee ill.
Mandatory
Cause of Injury Code
Code identifying cause of injury.
Date return(ed) to work.
The date, following the most recent disability period, on which
the claimant returned to work.
Mandatory
If Fatal, give date of death
The date of employee died.
Mandatory
if applicable
Were safeguards or safety
equipment provided? Were
they used?
Answer question if application.
Physician/Health Care
Provider (Name & Address)
The name and address of the physician or health care
provider.
Mandatory
Hospital (Name & Address)
The name and address of the hospital.
Optional
Witness (Name & Address)
Name and phone number of party that witnessed accident/injury.
Yes
Optional
Date Administrator Notified
The date the claim administrator who is processing the claim
received notice of the loss or occurrence.
Yes
Optional
Date Prepared
The date that this form is completed.
Optional
Preparer’s name & Title
The name of the person filling out the form and their title.
Mandatory
Phone Number
The phone number of the preparer.
Yes
Mandatory
Initial Treatment
A code used to identify the extent of medical treatment
received by the claimant immediately following the accident.
Yes
Mandatory
22
Yes
Yes
Mandatory
Code
Optional
01/11
Field
Names
Definition
Of Fields
New
Field
Field
Status
(Check only the one that is most applicable.)
DIVISION OF WORKERS’ COMPENSATION CAUSES OF INJURY CODES
CODE
I.
01
02
11
03
04
06
07
08
09
14
CAUSE OF INJURY
BURN OR SCALD-HEAT OR COLD
Acid Chemicals
Hot Object or Substances
Cold Objects or Substances
Temperature Extremes
Fire or Flame
Dust, Gases, Fumes or Vapors
Welding Operations
Radiation
Contact with NOC
Abnormal Air Pressure
II.
10
12
20
13
CAUGHT IN OR BETWEEN
Machine or Machinery
Object Handled
Collapsing Materials (Slides of Earth)
Caught in, Under or Between, NOC
III.
15
16
17
18
19
CUT, PUNCTURE, SCRAPE INJURED BY
Broken Glass
Hand Tool, Utensil; Not Powered
Object Being Lifted or Handled
Powered Hand Tool, Appliance
Caught, Puncture, Scrape, NOC
IV.
25
26
27
28
29
30
31
32
33
FALL OR SLIP INJURY
From Different Level (Elevation)
From Ladder/Scaffolding
From Liquid or Grease Spills
Into Openings
On Same Level
Slipped, Did not Fall
Fall, Slip, Trip, NOC
On Ice or Snow
On Stairs
V.
40
41
45
46
47
48
49
MOTOR VEHICLE
Crash of Water Vehicle
Crash of Rail Vehicle
Collision or Sideswipe w/Another Vehicle
Collision with a Fixed Object
Crash of Airplane
Vehicle Upset
Motor Vehicle, NOC
CODE
VI.
52
53
54
55
56
58
59
60
61
97
23
CAUSE OF INJURY
STRAIN OR INJURY BY
Continual Noise
Twisting
Jumping
Holding or Carrying
Lifting
Reaching
Using Tool or Machine
Strain or Injury by, NOC
Wielding or Throwing
Repetitive Motion
VII.
65
66
67
68
69
70
STRIKING AGAINST OR STEPPING ON
Moving Parts of Machine
Objects Being Lifted or Handled
Sanding, Scraping, Cleaning Operations
Stationary Objects
Stepping on Sharp Object
Striking Against or Stepping on, NOC
VIII.
74
75
76
77
78
79
80
81
STRUCK OR INJURED BY
Fellow Worker, Patient
Falling or Flying Object
Hand Tool or Machine in Use
Motor Vehicle
Moving Parts of Machine
Object Being Lifted or Handled
Object Handled by Others
Struck or Injured, NOC
IX.
94
95
RUBBED OR ABRADED BY
Repetitive Motion
Rubbed or Abraded, NOC
X.
82
87
89
90
98
99
MISCELLANEOUS CAUSES
Absorption, Ingestion or Inhalation, NOC
Foreign Matter (Body) in Eye(s)
Person in Act of A Crime
Other Than Physical Cause of Injury
Cumulative, NOC
Other-Miscellaneous, NOC
01/11
DIVISION OF WORKERS’ COMPENSATION CAUSES OF INJURY CODES
CODE
PART OF BODY
CODE
PART OF BODY
I.
HEAD
IV.
TRUNK
10
Multiple Head Injury
40
Multiple Trunk
11
Skull
41
Upper Back Area (Thoracic Area)
12
Brain
42
Low Back Area (Inc. Lumbar & Lumbo-Sacral)
13
Ear(s)
43
Disc
14
Eye(s)
44
Chest (Inc. Ribs, Sternum & Soft Tissue)
15
Nose
45
Sacrum & Coccyx
16
Teeth
46
Pelvis
17
Mouth
47
Spinal Cord
18
Soft Tissue
48
Internal Organs
19
Facial Bones
49
Heart
60
Lungs
II.
NECK
61
Abdomen Including Groin
20
Multiple Injury
62
Buttocks
21
Vertebrae
63
Lumbar and/or Sacral Vertebrae
(Vertebrae NOC Trunk)
22
Disc
23
Spinal Cord
V.
LOWER EXTREMITIES
24
Larynx
50
Multiple Lower Extremities
25
Soft Tissue
51
Hip
26
Trachea
52
Upper Leg
53
Knee
54
55
56
57
58
Lower Leg
Ankle
Foot
Toe(s)
Great Toe
VI.
64
65
MULTIPLE BODY PARTS
Artificial Appliance
Insufficient Info to Properly Identify –
Unclassified
No Physical Injury
Multiple Body Parts
Body Systems & Multiple Body Systems
III.
30
31
32
33
34
35
36
37
UPPER EXTREMITIES
Multiple Upper Extremities
Upper Arm (Inc. Clavicle & Scapula)
Elbow
Lower Arm
Wrist
Hand
Finger(s)
Thumb
38
39
Shoulder(s)
Wrist(s) and Hand(s)
66
90
91
24
01/11
ARCHDIOCESE OF ST. LOUIS
WORKERS’ COMPENSATION TREATMENT AUTHORIZATION
REFER TO: OCCUPATIONAL HEALTH & MEDICINE DEPARTMENT
PARISH/AGENCY NAME:
PARISH/AGENCY ADDRESS:
PARISH/AGENCY TELEPHONE #:
EMPLOYEE INFORMATION
EMPLOYEE NAME:
EMPLOYEE ADDRESS:
EMPLOYEE TELEPHONE #:
EMPLOYEE SOC. SEC. NO.:
EMPLOYEE DATE OF BIRTH:
EMPLOYEE OCCUPATION:
DATE OF INJURY:
BODY PART:
DESCRIPTION OF ACCIDENT:
Please refer to the Archdiocesan Provider List
OR contact Valerie Maki or Nancy Pfeiffer at Gallagher Bassett for authorization and medical direction: 1-314-965-7810
Physician/Facility:
Appointment Date:
Telephone #:
TREATMENT AUTHORIZED BY:
(PARISH/AGENCY REPRESENTATIVE)
Form must be signed by a properly designated person (not injured employee)
Upon completion of medical referral, Risk Coordinator must complete a Missouri 1st Report of Injury Form and mail or fax to
Gallagher Bassett.
PROVIDER SECTION
Please complete below information and fax to Valerie Maki or Nancy Pfeiffer at 866-947-2227 OR
Mail To: Gallaher Bassett Services, 1630 Des Peres Road, Suite 200, St. Louis, MO 63131
DIAGNOSIS:
TREATMENT RECOMMENDATIONS:
RETURN TO WORK STATUS: Light Duty / Full Duty
ANTICIPATED RESTRICTIONS:
PROJECTED DATE FOR COMPLETION OF TREATMENT:
PROVIDER SIGNATURE:
DATE:
MAY NOT BE PHOTOCOPIED
Send bills to:
Gallagher Bassett Services
P.O. Box 23812
Tucson, AZ 85734
Request additional forms from Arthur J. Gallagher Risk
Management Services, Inc. at 314.800.2269 (See Page 5)
25
01/11
IV.
General Liability
26
01/11
GENERAL LIABILITY INCIDENT REPORT
General Liability: Is an accident/occurrence to a third party (non employee) that results in injury or
damage to that person or their property as a result of an actual or alleged negligent act by an employee
or volunteer of the parish/agency while performing duties, or as a result of a defective/dangerous
condition of our property.
Claim: Person (third party) that had received medical attention or sustained damage to their
person/property and is requesting or expecting payment of their expenses from the parish/agency.
Incident: When it is unknown if person (third party) will be presenting a claim. However, due to the
severity of the injury or the nature of the potential negligent act/occurrence, it is reasonable to anticipate
that a claim could arise in the future.
General Instructions: The Incident Form (page 31) should be used to report any injury on Parish, school
or agency premises or at a Parish, school or agency event off site where the injured person is not an
employee. A separate form may be used for each injured person. The Incident Form should be used to
report any injury, whether it is an incident or actual claim. However, if it is an “Incident Only”,
indicate on the top of the form “For Information Only”.
It is important to remember that you have several options in submitting your Incident Report. Please see page
8 before you begin processing . Only you can determine the method of reporting that is easiest and best for
you.
immediately in reporting all incidents.)
General Instructions:
Copies of the INCIDENT REPORT FORM should be distributed to all employees and volunteers who
have supervisory responsibility for activities of the Parish, School or Agency.
Preparer:
The INCIDENT REPORT should be completed by the Parish/Agency employee or volunteer with
supervisory responsibility for the activity at which the INCIDENT occurred at the time of the Incident
or as soon as possible.
The PREPARER should complete the top portion of the form promptly after the INCIDENT has
occurred and forward it to the RISK COORDINATOR for the Parish, School or Agency.
Risk Coordinator:
The RISK COORDINATOR should review the INCIDENT REPORT , adding his/her comments
where indicated, sign the form and forward a copy to Gallagher Bassett. If the matter is urgent,
Gallagher Bassett should be contacted by phone. Otherwise, the report should be mailed to Gallagher
Bassett within one (1) week of the occurrence.
A claim is a request for compensation for injury or damages from an “INCIDENT”. If the preparer or
any individual directly involved with the incident gives any indication that a claim will result, this
information is important and should be noted in the Comments Section.
27
01/11
Should the RISK COORDINATOR obtain additional information regarding the INCIDENT after the
REPORT has been sent to Gallagher Bassett, photocopy the report and add the additional information at
the bottom, sending it to Gallagher Bassett Services.
A RISK COORDINATOR is the representative of the Office of Risk Management on the scene in
every parish, school or agency. This is an important responsibility. It is preferred that the risk
coordinator not be the pastor/administrator. However, the pastor/administrator will always receive
copies of all material sent to the risk coordinator from our office.
Besides becoming familiar with the procedures outlined in both the Claims’ and Safety Manuals (so that
proper procedure may be followed by those involved when something happens) the RISK
COORDINATOR needs to inform others on the handling of various situations. For example,
employees need to be informed about Workers’ Compensation and, along with volunteers and those who
use buildings and facilities, they need to know how to address situations that could develop into liability
claims. Finally, they need to make information available and give proper instruction to all of the
operators of vehicles that are covered in our program.
We are all very grateful for the work that has been done thus far. If all of us face the future by joining
together to follow these procedures, we may save a great deal of money in the billings we have to pay
and, more important, help those around us avoid injuries, which, on occasion, could be serious.
Volunteers:
Volunteers are an important part of your agencies and parishes, but they are not covered under Workers’
Compensation. When a volunteer is injured on your premises, an “Incident” Report should be
completed. If the injury is severe, notify a Gallagher Bassett Property, Liability & Auto Specialist (See
Page 6) as soon as possible.
There is no medical payments coverage available to your guests or volunteers. We have no liability
unless there is negligence on our part. When a guest or volunteer is injured, always show concern for
the injured party.
If you do not believe there is negligence, the parish or agency may elect to pay whatever expenses are
incurred that are not covered by the injured person’s medical insurance, with parish and/or agency
funds. If the parish or agency makes payments, please contact the Office of Risk Management to
discuss a proper release. If the medical expenses are substantial or require a lengthy, ongoing medical
care, notify the Office of Risk Management, which may elect to provide assistance with payment or
medical management of the injury. An Incident Report should still be completed. If the parish and/or
agency elects to offer assistance, please indicate this in the Comments Section. If the injured party is
demanding payment, please also note.
It is important to remember that you have several options in submitting your workers' compensation Report of
Injury. Please see page 8 before you begin processing . Only you can determine the method of reporting that
is easiest and best for you.
immediately in reporting all workers’ compensation injuries.
28
01/11
ADDITIONAL GUIDANCE FOR RISK
COORDINATOR
General Instructions:
1.
Insert Parish/Agency name, address and telephone number on the Incident Report and
make multiple copies for distribution to persons who will have responsibility for
supervision of Parish/Agency activities. (The “PREPARERS”)
2.
Make copies of the RECOMMENDED RISK MANAGEMENT PRACTICES (page 31)
and of the Instructions (page 28-29) for distribution to the PREPARERS.
3.
Make sure the PREPARERS have your name, address, and telephone number.
4.
For times when you will be absent, make sure the Rectory or Agency office has the name,
address, and telephone number of an alternate RISK COORDINATOR.
Medical:
If any medical attention is received, indicate when and where.
Evidence:
1.
Photographs
If a camera is available, it is recommended that photographs of the INCIDENT site be
taken. The scene could be altered or changed before the INCIDENT is referred to
Gallagher Bassett for its examination.
2.
Objects
Take physical control of the object that caused the INCIDENT (banana peel, rock, etc.). If
it is liquid, attempt to identify the substance and determine its source. Also, indicate how
long present.
Prevention:
Barricade the area or take other immediate steps to prevent future incidents. Make certain
corrective measures are visible (lighting, bright paint, rope, tape).
Written Statement:
If the person intends to make a claim, the preparer should obtain a complete written statement
from the individual. This would include his or her name, address, telephone number and a
description of what happened, including the extent of the injury. The identity of any witnesses
should be obtained at that time.
Serious Injuries:
Fatalities or serious injuries that require hospitalization (other than emergency treatment) should
be reported by phone to Gallagher Bassett; so an immediate investigation may be conducted.
29
01/11
LIABILITY COVERAGE FOR
PERSONS PERFORMING
CHILD ABUSE BACKGROUND CHECKS
The policies of the Archdiocese require that a child abuse screening background check be done for each
new employee and volunteer working with or near children and that this screening be done again on the
even years thereafter. For information concerning the Archdiocesan policies and requirements, please
contact the Safe Environment Program.
Questions have been asked regarding liability insurance coverage for employees or volunteers who are
involved in the process of obtaining child abuse screenings or overseeing others in this process.
The liability insurance of the Archdiocese of St. Louis covers, with certain limitations and exclusions,
employees and volunteers for their acts or omissions which are within the course and scope of their
duties. One exclusion is for claims arising out of sexual misconduct. Thus, if an employee or volunteer
is sued for his or her acts or omissions in connection with child abuse screening and the suit is based on
a claim of sexual misconduct, there is no insurance coverage for the employee or volunteer.
In order to provide protection for employees and volunteers in the case of a claim of injury based on
sexual misconduct where an employee or volunteer is accused of negligence in the child abuse screening
process, the Archdiocese will provide indemnification and defense for employees and volunteers for
claims arising out of sexual misconduct against them based on their alleged negligent acts or omissions
in connection with child abuse screenings. This agreement to provide indemnification and defense does
not apply to claims which are covered by the insurance of the Archdiocese. The exclusion for sexual
misconduct claims became effective on July 1, 1986 and claims based on occurrences prior to that date
are covered in accordance with the provisions of the policies in effect in the respective prior years.
If any employee or volunteer receives a claim or a threat of a claim based on his or her role in the child
abuse screening process, he or she should follow the procedure for any other claim or threat of a claim,
which is to notify his or her supervisor or the pastor, in cases of a parish, who will direct the matter to
the Office of Risk Management and the Archdiocesan attorney. The claim will then be reviewed for
coverage and the employee or volunteer will be given direction.
RECOMMENDED RISK MANAGEMENT
PRACTICES GENERAL LIABILITY
1.
Check for injuries, and secure proper medical assistance if required.
2.
Obtain the name, address, and telephone number of anyone who is injured. In the case of a
minor, obtain the parent’s name and both home and business phone numbers. The parent
should be advised of the injury by phone, immediately.
3.
Obtain the names, addresses, and telephone numbers of all witnesses, even those who saw
only part of the accident.
4.
Avoid discussions of fault and responsibility.
5.
Do not discuss insurance and what you believe may or may not be covered.
6.
Do not deny or offer payment of medical bills.
30
01/11
INCIDENT REPORT, ARCHDIOCESE OF ST. LOUIS
If additional space is required use reverse side
(Please PRINT or TYPE)
A. PARISH/AGENCY:
ADDRESS:
TELEPHONE NUMBER:
B. INCIDENT DATE:
, 20
TIME:
am
pm
C. INJURED PARTY INFORMATION
NAME:
ADDRESS:
TELEPHONE:
HOME:
WORK:
PARENTS NAME:
(If injured person is a minor)
AGE:
Male
Female
D. WITNESSES: (Attach Schedule of Additional Witnesses)
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE:
E. WHERE DID INCIDENT OCCUR:
DESCRIBE WHAT OCCURRED:
F. DESCRIBE INJURY, IF ANY:
G. PLEASE INDICATE IF ANY EMERGENCY SERVICE OR MEDICAL TREATMENT
FOLLOWED:
WHERE: ______________________________
WHEN:
PREPARER INFORMATION
SIGNATURE:
TITLE:
DATE:
TELEPHONE:
MAIL TO:
GALLAGHER BASSETT SERVICES, INC.
1630 DES PERES ROAD, SUITE 200
ST. LOUIS, MO 63131-1849
31
01/11
V.
Auto
32
01/11
VEHICLE CLAIMS HANDLING PROCEDURES
Each vehicle should have an Archdiocesan Vehicle Claim Envelope in the glove compartment. In
this envelope, there should be the following documents:







Vehicle Claims Handling Procedures (this page)
Gallagher Bassett Accident Report, Auto and Truck (Pages 34 & 35)
Vehicle Accident Identification Card (Page 36)
Recommended Risk Management Practices for General Liability (Page 30)
A copy of your current Missouri Vehicle Insurance Identification Card
A few blank pieces of paper to assist you in making a sketch of the accident scene
A pencil or pen (check periodically)
It is important to remember that you have several options in submitting Automobile Accident Report. Please
see page 8 before you begin processing . Only you can determine the method of reporting that is easiest and
best for you.
However, the information needed for reporting under any of the options is the same.)
For all accidents:
1.
Exchange necessary information with the other driver to enable Gallagher Bassett to
contact that party. (Name, address, business and home phone numbers, information
pertaining to the vehicle). Identification forms are provided on page 36.
2.
Advise the other driver(s) you will report to Gallagher Bassett Services.
3.
Contact the Police Department. - Whenever possible do not move the vehicles until the
police have made their report.
4.
Obtain the police report complaint number.
5.
Obtain the name, address and telephone numbers of all witnesses.
6.
Diagram - Make a sketch of the accident scene showing measurements and placement of
vehicles.
7.
Complete all forms enclosed in your Archdiocesan Vehicle Claim Envelope, and send to
Gallagher Bassett Services, 1630 Des Peres Road, Suite 200, St. Louis, MO 63131-1849.
8.
Vehicle Damage - If minor damage is sustained and the vehicles are driveable, two (2)
estimates are usually acceptable.
A.
If damage is over $2,500, the vehicle will require an inspection by an appraiser
retained by Gallagher Bassett.
B.
If a vehicle is not driveable, report the loss by phone to Gallagher Bassett Services to
eliminate additional rental or storage charges.
C.
Rental Coverage is afforded to drivers of vehicles in our program only when a vehicle
is stolen, in an accident that renders the vehicle undriveable or while an insured
vehicle is being repaired for a covered loss.
9.
Obtain the identity of any injured parties, including names, addresses and phone numbers.
Indicate any visible injury and if anyone requires emergency treatment.
10.
Serious Injury - Fatalities or serious injuries that require a hospital admission (and therefore
emergency treatment) must be reported by phone to Gallagher Bassett (314.965.7810), so
that an immediate investigation can be conducted.
33
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34
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35
01/11
VEHICLE ACCIDENT IDENTIFICATION CARD
ARCHDIOCESE OF ST. LOUIS RISK MANAGEMENT PROGRAM
All Claims should be reported to:
Gallagher Bassett Services, Inc.
1630 Des Peres Road, Suite 200
St. Louis, MO 63131-1849
Phone: 314.965.7810
Archdiocesan Employee Name:
Parish/Agency Name:
Address:
Phone #:
Home
Work
**This form should be kept in all vehicles covered by the Archdiocese of St. Louis Risk Management Program**
Fill out this form promptly. Several copies should be kept in the glove compartment of each vehicle in
our program. In case of an accident, one should be given to each driver.
WHEN YOU ARE INVOLVED IN A MOTOR VEHICLE ACCIDENT,
OBTAIN THE FOLLOWING INFORMATION FROM THE OTHER DRIVER(S).
Name:
Address:
Phone #:
Home
Work
Drivers License #:
Insurance Carrier & Policy #:
(Copy from Insurance I.D. Card)
**This form should be kept in all vehicles covered by the Archdiocese of St. Louis Risk Management Program**
This information should be attached to the Gallagher Bassett Auto Accident Report Form.
36
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OFFICE OF RISK MANAGEMENT
VEHICLE CHANGE REQUEST
(Submit One Form For Each Vehicle Bought or Sold)
PLEASE PRINT OR TYPE
Parish/Agency Name:
Complete Address:
Person Completing Form:
Phone:
Name as it appears on title or vehicle registration form:
Name of primary operator of vehicle:
Parish or Agency # if vehicle is so titled:
Check One:
Add Vehicle
Delete Vehicle Effective Date:
Is this vehicle replacing another:
Yes
No
(Please submit separate form for deleted vehicle.)
Vehicle Information (See title or vehicle registration):
Year:
Make:
Model:
V.I.N.:
Check Type of Vehicle and Complete Required Information:
Auto
Pickup
Van (Pass. Capacity) _______
Trailer
Truck (GVW) _____
Bus (Pass. Capacity)_______
Please attach a copy of title or registered ownership after the necessary fees have
been paid to the Department of Revenue (title or registration must be in the name of
the parish, agency or priest shown above). If the vehicle is leased, a copy of the lease
must be attached (lease must be in the name of the parish, agency or priest shown
above).
Mail or fax to:
St. Louis, MO 63119-5738
Fax: 314.792.7209
If you need assistance, please call 314.792.7203
NOTE: In the event of a loan or leasing company, you must request that Arthur J. Gallagher
provide evidence of coverage to the respective loan or leasing company.
This form may be photocopied.
37
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VI.
Property
38
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PROPERTY CLAIMS HANDLING PROCEDURES
It is important to remember that you have several options in submitting Property Loss Report. Please see
page 8 before you begin processing . Only you can determine the method of reporting that is easiest and best
for you.
However, the information needed for reporting under any of the options is the same.)
The Loss Report, Property should be used to report the following:.
1.
Fire Losses - After notifying the fire department, unless minor in nature, telephone
Gallagher Bassett immediately.
2.
Boiler & Machinery - All boiler and machinery losses must be reported to Gallagher
Bassett. Complete Property Loss Notice and forward to Gallagher Bassett. On severe
losses, notify the fire department (if necessary), use reasonable means to protect property
from further damage, telephone the loss in directly to Gallagher Bassett and follow-up in
writing. To schedule inspections refer to Page 6, do not contact Gallagher Bassett.
3.
Burglary, Theft, and Robbery - Notify the police department and make a report. Complete
Property Loss Notice, and forward to Gallagher Bassett.
4.
Windstorm, Hail and etc. - Complete Property Loss Notice and forward to Gallagher
Bassett. On large or severe losses, telephone the loss in directly (314.965.7810) and
follow-up with a completed Loss Report, Property (Page 40).
On all losses it is important to remember the following:
1.
Take the necessary steps to protect property or adjacent property from further damage or
loss. Barricade, temporarily board-up, or remove to a more secure area.
2.
Evidence - If an object is suspected to have caused the fire or loss, PRESERVE IT. The
object should be secured or removed to a more secure area.
3.
Salvage - In most instances, objects that are not totally destroyed have some remaining
monetary value and can be sold as salvage, thus reducing the overall loss.
39
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40
01/11
BUILDING INPUT FORM
(Please Submit This Form for Changes
In Buildings or Contents)
PLEASE PRINT OR TYPE
Parish/Agency Name: ___________________________________________
Complete Address:
___________________________________________
Person Completing Form: __________________ Phone: _____________
Check One:
Construction of New Building
Purchase
Contents*
Addition to Existing Building
Renovation of Existing Building
Sale
Demolition
*NOTE – If the contents exceeds the cost of a building, value of contents must be declared. Also value
of contents of any building leased from any source other than an Archdiocesan entity must be declared.
Parish/Agency #: ____________________ Building #: _______________
Name of Building: _______________________________________________
Complete Address: _______________________________________________
Building or Project Cost: ________________________________________
Effective Date of Change: ________________________________________
NOTE – If new construction, addition or renovation please enter estimated date of completion above
Please complete this form and mail or fax to:
20 Archbishop May Dr.
St. Louis, MO 63119-5738
Fax: 314.792.7209
If you need assistance please call 314.792.7203
This form may be photocopied.
This form may be faxed to the Office of Risk Management
41
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VII.
Miscellaneous Forms
42
01/11
LIABILITY CONTROL AND SPECIAL EVENT
(TENANT USERS LIABILITY INSURANCE PROGRAM)
Effective July 1, 2008, the existing Special Events Program was eliminated.
After reviewing the cost and time to administer this program when compared to the actual losses
incurred, we have decided to eliminate purchasing the special events insurance policy. However, the
following practices MUST continue:
Extended Use of Facilities
(Athletic Fields, Halls, Meeting Rooms, Offices, etc.)
Whenever an OUTSIDE organization wishes to use Archdiocesan property for events or programs
that are held on a regular basis (especially when rent is paid and/or a fee is charged to the participants),
a Certificate of Insurance for Liability coverage must be obtained from the outside organization or
individual. If paid employees are involved, Workers' Compensation coverage should also be
evidenced on the Certificate of Insurance. In addition, the parties should sign a Hold Harmless
Agreement (See Page 45).
Certificate of Insurance requirements:




General Liability - $1,000,000 limit for liability
Workers' Compensation – Statutory Limit
Don't forget to attach the Hold Harmless Agreement
Maintain a copy of the Certificate of Insurance and Hold Harmless Agreement on file for
a period of five (5) years from the event date.
If courtesy is extended to a group by allowing it to meet on the premises where there is no financial
consideration involved, liability coverage is not required. However, a hold harmless agreement must
be obtained. All blank forms and material concerning special events should be destroyed.
Short Term Event
Similar to Extended Use arrangements, a certificate of insurance and hold harmless agreement must be
obtained from all organizations using the parish/agency premises for a single event. Individuals using
the parish/agency premises most likely will not be able to provide a certificate of insurance; therefore,
you MUST have them sign a hold harmless agreement prior to the facility usage.
Note: Failure to comply with Best Practices will result in the an increased deductible per the Risk
Management Policy.
43
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HOLD HARMLESS AGREEMENT
The undersigned party or parties (“User”), in consideration of the use of the below
described facility (“Facility”) of
[name of
parish or organization] (the “Organization”), hereby agrees to hold harmless and
indemnify the Organization, the Archdiocese of St. Louis, and affiliates, and their
respective officers, directors, employees, agents and volunteers from all claims,
including all loss, cost, damage, and expense, including the cost of defense and
reasonable attorneys’ fees related thereto, for damages arising out of the use of the
Facility by the undersigned, its or their employees, volunteers or invitees. The
Undersigned User understands that no insurance is provided by the Archdiocese of
St. Louis.
Facility:
Usage:
Date and Time:
Begin:
End:
Name
of Users:
(Organization)
Name of Representative
Title
___________________________________________________________________
Signature
Date
44
01/11
CONSENT TO EMPLOYMENT
The undersigned being the parent, legal custodian or guardian of
______________________________ (“Child), a child between the ages of 14 and 18,
(Name of Child)
hereby consents to child performing occasional yard work which may involve the use of
power driven lawn and garden machinery for __________________________________
(Name of Parish or Agency)
provided that appropriate instruction and supervision are provided.
Date: ____________________
______________________________________
Parent, Legal Custodian or Guardian
45
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CONTRACTORS AND CONTRACTED SERVICES
Certificates of Liability and Workers' Compensation Insurance must be obtained from any contractor
hired to perform work for any parish or agency. Possibilities include: transportation or day care service,
maintenance or construction firms, providers of services like extermination or grass mowing, cafeteria
or day care service, picnic rides, and security. The requirements for the Certificate of Insurance are
outlined on Page 43.
Note on Security Services:
Firms hired to furnish security services for fundraisers should be handled in the manner described above.
If off-duty police officers are desired, they may not be hired directly (because of the absence of proper
coverage). They may, however, be hired through one of the firms listed below.
If a company providing security services for an event does not have a service agreement, the one found
on Pages 47 & 48 should be used.
SECURITY AGENCIES USING OFF DUTY POLICE OFFICERS
Midwest Security, Inc.
P.O. Box 510176
St. Louis, Missouri 63151-0176
Telephone: 314.845.2330
Special Services
1309 Convention Plaza
Telephone: 314.421.1800
Sentry Security Agency, Inc.
9021 Riverview Drive
Telephone: 314.867.1125
Hi-Tech Security, Inc.
1210 S. Vandeventer Avenue
Telephone: 314.531.1500
We have been informed that these are the only firms that hire “off-duty” police that have proper liability
and workers’ compensation coverage. If you know the name of another, phone the Risk Management
Office to pass on the information.
46
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SECURITY SERVICES AGREEMENT
THIS AGREEMENT is made and entered into as of the
Day of
, 20
(the “Client”) and
by and between
[name of parish or agency]
(the “Contractor”).
[name of security firm]
WHEREAS, the Contractor is engaged in the business of providing security services, and
WHEREAS, the Client requires the services of a security firm for an event which it plans
to hold.
NOW, THEREFORE, in consideration of the mutual promises contained herein, the Client
engages the Contractor to provide security services under the following terms and conditions:
1.
The Contractor shall furnish security guard(s) ( the “Guard(s)”) at the premises
located at
[address of event]
(the “Premises”). The Guard(s) will be in uniform and armed. They will provide security to
persons and property at the Premises. All services shall be performed in accordance with
applicable laws and ordinances.
2.
The event for which security services will be provided by the Contractor pursuant
to this Agreement will be
[describe event]
for which security services will be provided from
to
[date and time]
.
[date and time]
3.
The Contractors shall provide
set forth in paragraph 2 above.
Guard(s) during the time period
4.
The Client shall compensate the Contractor at the rate of
Dollars ($
) per hour for each Guard on duty. Invoices shall be
mailed to the Client at the following address: (Please print)
An interest rate of one and one-half percent (1 1/2%) per month, or such lower maximum percentage as
may be allowed by law, will be added to all invoices not paid within thirty (30) days of receipt.
5. The Guard(s) shall be employees of the Contractor. The Contractor shall be responsible for the
hiring, supervision, scheduling and compensation of the Guard(s). The Guard(s) shall not for any
purpose be deemed to be employees of the Client.
Page 1 of 2
47
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6. The Contractor agrees to indemnify and hold harmless the Client, its affiliates, officers,
directors, employees and agents from all liability and damages, including cost of defense and reasonable
attorneys fees, which it or they may incur as a result of injury or damages sustained by any person
arising out of the negligence or misconduct of the Contractor, its employees or agents. The liability of
the Contractor to the Client, its affiliates, officers, directors, employees and agents shall be limited to
One Million Dollars ($1,000,000.00) per occurrence, with a Two Million Dollar ($2,000,000.00) annual
aggregate.
7. The Contractor shall maintain comprehensive general liability insurance on an occurrence
basis, covering itself and its employees performing services pursuant to this Agreement in the minimum
amounts of One Million Dollars ($1,000,000.00) per occurrence, with a Two Million Dollar
($2,000,000.00) annual aggregate, with coverage for contractual liability. The Contractor shall also
maintain workers’ compensation insurance for its employees. Prior to the performance of services
pursuant to this Agreement, the Contractor or its insurer will provide the Client with a Certificate of
Insurance showing that such coverages are in effect.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
first above written.
CLIENT:
CONTRACTOR:
By: ________________________________
By:
Date: _______________________________
Date:
Page 2 of 2
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RISK COORDINATOR
HAVE YOU KEPT US INFORMED?
Materials sent out by our office are intended primarily for risk coordinators. Therefore, it is very important that each
parish and agency have one, and that the person be someone other than the pastor or administrator. Please complete
a new form each time there is a change of risk coordinators. Also, each location is not limited to only one risk coordinator.
Date:
PARISH/AGENCY INFORMATION
Name:
Address:
City:
State:
Zip Code:
(Please include all nine digits)
Telephone #:
Location #:
(Please include Area Code for all telephone numbers)
RISK COORDINATOR INFORMATION
Name:
Address:
City:
State:
Zip Code:
(Please include all nine digits)
Day Telephone #:
Evening Telephone #:
Please check one:
Add the above individual to our location
Delete the above individual from our location
The above individual replaces an individual at our location
Name of individual to be replaced _______________________
Information has changed from previously submitted
(such as address, telephone number)
Please return this form to:
St. Louis, MO 63119-5738
FAX: 314.792.7209
49
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ARCHDIOCESE OF ST. LOUIS Risk Management Manual

Transcription

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