Representing Financial Strength & Integrity

Claims Kit – Nevada

Contents:

BHHC Claims Kit Introductory Letter – 10/29/2013

BHHC Instructions for NV Postings – 10/10/2013

NV Form D-1 – Brief Description of Your Rights and Benefits if you are Injured on the Job or

have an Occupational Disease – 10/2007

NV Form D-2 – Brief Description of Rights and Benefits – 10/2007

NV Form D-22 – Notice to Employees – 07/1999

NV Form C-3 – Employer’s Report of Industrial Injury or Occupational Disease – 11/2005

NV Form C-1 – Notice of Injury or Occupational Disease – 10/2005

NV Form D-36 – Request for Additional Medical Information and Medical Release – 12/2007

NV Form D-8 – Employer’s Wage Verification Form – 10/2010

BHHC General Supervisor Accident Report – 10/03/2013

BHHC General Witness Accident Report – 10/03/2013

BHHC Workers’ Compensation Fraud Poster (English & Spanish) – 10/09/2013

P.O. Box 881236, San Francisco, CA 94105 | Phone: (888) 495-8949 | bhhc.com

Dear Policyholder:

Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC). We look forward to working with you to fulfill all your workers compensation needs.

Enclosed you will find documentation necessary for the processing and administration of a claim in the event of a workplace injury, as well as important information regarding workers compensation requirements for your state (i.e. posting notices, compliance laws, etc). Please utilize the documents included to collect valid information regarding the injured employee and incident, and send the documents in when reporting the claim or upon request. Any completed document should be sent directly to BHHC using mail, e-mail, or fax. The assigned claims professional will forward necessary documentation onto the appropriate state entity.

It is critical that you promptly report all new claims using one of the following methods:

Phone: (800) 661-6029 Fax: (800) 661-6984

E-mail: newclaim@bhhc.com Online: 1. Go to our website: www.bhhc.com

2. Highlight “Workers Comp” in the menu3. Highlight “Claims Center”4. Click “Report a Claim”

State law requires that employers authorize initial medical treatment within 24 hours of knowledge that an occupational injury of illness has been sustained or reported, regardless of the legitimacy of the claim. Failure to comply may result in the loss of “medical control” and a significant increase in the potential claim cost.

We will attempt to contact you and the injured worker within 24 hours of receiving the First Report of Injury. Your cooperation in allowing the injured employee to speak with one of our Claims Professionals is appreciated.

Should you have any questions regarding the contents of this kit, a claim, or claim reporting, please contact our Customer Care Center at (888) 495-8949. Questions regarding your insurance policy or coverage should be directed to your broker or agent. We thank you for choosing BHHC as your workers compensation carrier and look forward to providing you superior customer service and compassionate care for your injured workers.

BERKSHIRE HATHAWAY HOMESTATE COMPANIES

BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY BROOKWOOD INSURANCE COMPANY CONTINENTAL DIVIDE INSURANCE COMPANY CYPRESS INSURANCE COMPANY OAK RIVER INSURANCE COMPANY REDWOOD FIRE AND CASUALTY INSURANCE COMPANY

Workers’ Compensation Posting Requirements

REQUIREMENTS FOR FORM D-1 - BRIEF DESCRIPTION OF YOUR RIGHTS

AND BENEFITS IF YOU ARE INJURED ON THE JOB OR HAVE AN OCCUPATIONAL DISEASE

• Post in one or more conspicuous places readily accessible to all employees at all business

locations • Must be printed on 11” x 17” paper • Text for the form completion portion of the Poster must in at least 10-point font-size To complete the form, please enter the following information in the spaces provided:

• Name, address, contact person, and phone number for MCO/health care provider • Name of your designated insurer

For your convenience, our other contact information has been entered on the Poster. Please note, the form fields are designed to populate text meeting the statutory font-size requirement.

(Nevada Revised Statutes Annotated § 616A.490 and Nevada Administrative Code 616A.460 and 616A.480)

REQUIREMENTS FOR FORM D-2 - BRIEF DESCRIPTION OF RIGHTS AND BENEFITS

• Post next to Form D-1 – Brief Description of Your Rights and Benefits if You are Injured on the Job or Have an Occupational Disease

• Must be printed on 8.5” x 11” paper

(Nevada Administrative Code 616A.480)

REQUIREMENTS FOR FORM D-22 – NOTICE TO EMPLOYEES – TIP INFORMATION

PLEASE NOTE, FORM D-22 IS ONLY UTILIZED WHEN EMPLOYEES RECEIVE TIPS!

• When applicable, post next to Form D-1 – Brief Description of Your Rights and Benefits if You are Injured on the Job or Have an Occupational Disease and Form D-2 – Brief Description of Rights and Benefits

• Must be printed on 8.5” x 11” paper

(Nevada Administrative Code 616A.470)

State of Nevada DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS Workers’ Compensation Section

A T T E N T I O N Brief Description of Your Rights and Benefits If You Are Injured on the Job or have an Occupational Disease Notice of Injury or Occupational Disease (Incident Report Form C-1)If an injury or occupational disease (OD) arises out of and in the course ofemployment, you must provide written notice to your employer as soon aspracticable, but no later than 7 days after the accident or OD. Youremployer shall maintain a sufficient supply of the forms. Claim for Compensation (Form C-4): If medical treatment is sought, theform C-4 is available at the place of initial treatment. A completed "Claimfor Compensation" (Form C-4) must be filed within 90 days after anaccident or OD. The treating physician or chiropractor must, within 3working days after treatment, complete and mail to the employer, theemployer's insurer and third-party administrator, the Claim forCompensation. Medical Treatment: If you require medical treatment for your on-the-job injury or OD, you may be required to select a physician or chiropractorfrom a list provided by your workers’ compensation insurer, if it hascontracted with an Organization for Managed Care (MCO) or PreferredProvider Organization (PPO) or providers of health care. If your employerhas not entered into a contract with an MCO or PPO, you may select aphysician or chiropractor from the Panel of Physicians and Chiropractors.Any medical costs related to your industrial injury or OD will be paid byyour insurer. Temporary Total Disability (TTD): If your doctor has certified that youare unable to work for a period of at least 5 consecutive days, or 5cumulative days in a 20-day period, or places restrictions on you that youremployer does not accommodate, you may be entitled to TTDcompensation. Temporary Partial Disability (TPD): If the wage you receive uponreemployment is less than the compensation for TTD to which you areentitled, the insurer may be required to pay you TPD compensation tomake up the difference. TPD can only be paid for a maximum of 24months. Permanent Partial Disability (PPD): When your medical condition isstable and there is an indication of a PPD as a result of your injury or OD,within 30 days, your insurer must arrange for an evaluation by a ratingphysician or chiropractor to determine the degree of your PPD. Theamount of your PPD award depends on the date of injury, the results of thePPD evaluation and your age and wage. Permanent Total Disability (PTD): If you are medically certified by atreating physician or chiropractor as permanently and totally disabled andhave been granted a PTD status by your insurer, you are entitled to receivemonthly benefits not to exceed 66 2/3% of your average monthly wage.The amount of your PTD payments is subject to reduction if you previouslyreceived a PPD award.

Vocational Rehabilitation Services: You may be eligible for vocational rehabilitation services if you are unable to return to the job due to a permanent physical impairment or permanent restrictions as a result of your injury or occupational disease. Transportation and Per Diem Reimbursement: You may be eligible for travel expenses and per diem associated with medical treatment. Reopening: You may be able to reopen your claim if your condition worsens after claim closure. Appeal Process: If you disagree with a written determination issued by the insurer or the insurer does not respond to your request, you may appeal to the Department of Administration, Hearing Officer, by following the instructions contained in your determination letter. You must appeal the determination within 70 days from the date of the determination letter at 1050 E. William Street, Suite 400, Carson City, Nevada 89701, or 2200 S. Rancho Drive, Suite 210, Las Vegas, Nevada 89102. If you disagree with the Hearing Officer decision, you may appeal to the Department of Administration, Appeals Officer. You must file your appeal within 30 days from the date of the Hearing Officer decision letter at 1050 E. William Street, Suite 450, Carson City, Nevada 89701, or 2200 S. Rancho Drive, Suite 220, Las Vegas, Nevada 89102. If you disagree with a decision of an Appeals Officer, you may file a petition for judicial review with the District Court. You must do so within 30 days of the Appeal Officer’s decision. You may be represented by an attorney at your own expense or you may contact the NAIW for possible representation. Nevada Attorney for Injured Workers (NAIW): If you disagree with a hearing officer decision, you may request that NAIW represent you without charge at an Appeals Officer hearing. NAIW is an independent state agency and is not affiliated with any insurer. For informationregarding denial of benefits, you may contact the NAIW at: 1000 E. William Street, Suite 208, Carson City, NV 89701, (775) 684-7555, or 2200 S. Rancho Drive, Suite 230, Las Vegas, NV 89102, (702) 486-2830. To File a Complaint with the Division: If you wish to file a complaint with the Administrator of the Division of Industrial Relations (DIR), please contact Workers’ Compensation Section, 400 West King Street, Suite 400, Carson City, Nevada 89703, telephone (775)684-7270, or 1301 North Green Valley Parkway, Suite 200, Henderson, Nevada 89074, telephone (702) 486-9080. For Assistance with Workers’ Compensation Issues: You may contact the Office of the Governor Consumer Health Assistance, 555 E. Washington Avenue, Suite 4800, Las Vegas, Nevada 89101, Toll Free 1-888-333-1597, Web site: http:/govcha.state.nv.us, E-mailcha@govcha.state.nv.us

The information in this publication is derived from Chapters 616A and 617 of the Nevada Revised Statutes and is provided for informational purposes only. If you have any questions, regarding your injury or workers' compensation claim, please call the following: Insurer/Administrator: Contact Person: Address: Telephone Number:

City State Zip MCO/Health Care Provider: Contact Person: Address: Telephone Number:

City State Zip D-1 (rev. 10/07)

BRIEF DESCRIPTION OF RIGHTS AND BENEFITS (Pursuant to NRS 616C.050)

Notice of Injury or Occupational Disease (Incident Report Form C-1): If an injury or occupational disease (OD) arises out of and in the course of employment, you must provide written notice to your employer as soon as practicable, but no later than 7 days after the accident or OD. Your employer shall maintain a sufficient supply of the required forms. Claim for Compensation (Form C-4): If medical treatment is sought, the form C-4 is available at the place of initial treatment. A completed "Claim for Compensation" (Form C-4) must be filed within 90 days after an accident or OD. The treating physician or chiropractor must, within 3 working days after treatment, complete and mail to the employer, the employer's insurer and third-party administrator, the Claim for Compensation. Medical Treatment: If you require medical treatment for your on-the-job injury or OD, you may be required to select a physician or chiropractor from a list provided by your workers’ compensation insurer, if it has contracted with an Organization for Managed Care (MCO) or Preferred Provider Organization (PPO) or providers of health care. If your employer has not entered into a contract with an MCO or PPO, you may select a physician or chiropractor from the Panel of Physicians and Chiropractors. Any medical costs related to your industrial injury or OD will be paid by your insurer. Temporary Total Disability (TTD): If your doctor has certified that you are unable to work for a period of at least 5 consecutive days, or 5 cumulative days in a 20-day period, or places restrictions on you that your employer does not accommodate, you may be entitled to TTD compensation. Temporary Partial Disability (TPD): If the wage you receive upon reemployment is less than the compensation for TTD to which you are entitled, the insurer may be required to pay you TPD compensation to make up the difference. TPD can only be paid for a maximum of 24 months. Permanent Partial Disability (PPD): When your medical condition is stable and there is an indication of a PPD as a result of your injury or OD, within 30 days, your insurer must arrange for an evaluation by a rating physician or chiropractor to determine the degree of your PPD. The amount of your PPD award depends on the date of injury, the results of the PPD evaluation and your age and wage. Permanent Total Disability (PTD): If you are medically certified by a treating physician or chiropractor as permanently and totally disabled and have been granted a PTD status by your insurer, you are entitled to receive monthly benefits not to exceed 66 2/3% of your average monthly wage. The amount of your PTD payments is subject to reduction if you previously received a PPD award. Vocational Rehabilitation Services: You may be eligible for vocational rehabilitation services if you are unable to return to the job due to a permanent physical impairment or permanent restrictions as a result of your injury or occupational disease. Transportation and Per Diem Reimbursement: You may be eligible for travel expenses and per diem associated with medical treatment. Reopening: You may be able to reopen your claim if your condition worsens after claim closure. Appeal Process: If you disagree with a written determination issued by the insurer or the insurer does not respond to your request, you may appeal to the Department of Administration, Hearing Officer, by following the instructions contained in your determination letter. You must appeal the determination within 70 days from the date of the determination letter at 1050 E. William Street, Suite 400, Carson City, Nevada 89701, or 2200 S. Rancho Drive, Suite 210, Las Vegas, Nevada 89102. If you disagree with the Hearing Officer decision, you may appeal to the Department of Administration, Appeals Officer. You must file your appeal within 30 days from the date of the Hearing Officer decision letter at 1050 E. William Street, Suite 450, Carson City, Nevada 89701, or 2200 S. Rancho Drive, Suite 220, Las Vegas, Nevada 89102. If you disagree with a decision of an Appeals Officer, you may file a petition for judicial review with the District Court. You must do so within 30 days of the Appeal Officer’s decision. You may be represented by an attorney at your own expense or you may contact the NAIW for possible representation. Nevada Attorney for Injured Workers (NAIW): If you disagree with a hearing officer decision, you may request that NAIW represent you without charge at an Appeals Officer Hearing. For information regarding denial of benefits, you may contact the NAIW at: 1000 E. William Street, Suite 208, Carson City, NV 89701, (775) 684-7555, or 2200 S. Rancho Drive, Suite 230, Las Vegas, NV 89102, (702) 486-2830 To File a Complaint with the Division: If you wish to file a complaint with the Administrator of the Division of Industrial Relations (DIR), please contact the Workers’ Compensation Section, 400 West King Street, Suite 400, Carson City, Nevada 89703, telephone (775) 684-7270, or 1301 North Green Valley Parkway, Suite 200, Henderson, Nevada 89074, telephone (702) 486-9080. For assistance with Workers’ Compensation Issues: you may contact the Office of the Governor Consumer Health Assistance, 555 E. Washington Avenue, Suite 4800, Las Vegas, Nevada 89101, Toll Free 1-888-333-1597, Web site: http://govcha.state.nv.us, E-mail cha@govcha.state.nv.us

D-2 (rev. 10/07)

NOTICE TO EMPLOYEES

Pursuant to: NRS 616B.227 Election by employee to report his tips; effect; regulation.

1. For the purpose of workers' compensation, an employee may elect to report the amount he

receives as tips for the purpose of the calculation of compensation by submitting to his employer

an Employee’s Declaration of Election of Report Tips (form D-23). The employee must make

his election separately for each pay period before the end of the next pay period. The

declaration may not be amended.

2. Upon receipt of such notice the employer shall:

(a) Make a copy of each report which the employee has filed with the employer to report the

amount of his tips to the United States Internal Revenue Service or Employee's

Declaration of Election to Report Tips;

(b) Submit the copy to its workers’ compensation insurer upon request, or if the employer is

self-insured or an association of self-insured public or private employers, retain the copy

for his records; and

(c) If he is not self-insured, pay the insurer the premiums for the reported tips at the same

rate as he pays on regular wages.

3. An employee who elects to report his tips is not eligible to receive increased compensation based

on those tips until 3 months after his employer receives the Employee's Declaration of Election

to Report Tips. For the purpose of workers' compensation, tips may be reported pursuant to 26

U.S.C. §6053(a) or on form D-23. The form for reporting tips D-23 can be obtained from your

personnel office.

If the forms are not available, contact your employer or the Internal Revenue Service.

D-22 (rev. 7/99)

TO AVOID PENALTY, THIS REPORT MUST BE

COMPLETED AND MAILED TO THE INSURER WITHIN 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM

Please Type or Print

EMPLOYER’S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE

Employer’s Name

Nature of Business (mfg., etc.) FEIN OSHA Log #

Office Mail Address Location . . . If different from mailing address Telephone EM

PLO

YER

City State Zip INSURER THIRD-PARTY ADMINISTRATOR

First Name M.I. Last Name Social Security Birthdate

Age Primary Language Spoken

Home Address (Number and Street) Sex Male Female Marital Status Single Married Divorced Widowed

City State Zip Was the employee paid for the day of injury? (If applicable) Yes No

How long has this person been employed by you in Nevada?

In which state was employee hired?

Employee’s occupation (job title) when hired or disabled

Department in which regularly employed:

EM

PLO

YEE

Telephone Is the injured employee a corporate officer? . . . sole proprietor? . . . partner? Yes No Yes No Yes No

Was employee in your employ when injured or disabled by occupational disease (O/D)? Yes No

Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM) (if applicable) Date employer notified of injury or O/D

Supervisor to whom injury or O/D reported

Address or location of accident (Also provide city, county, state) (if applicable) Accident on employer’s premises? (if applicable)

Yes No

What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable)

AC

CID

ENT

OR

D

ISEA

SE

How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary.

Specify machine, tool, substance, or object most closely connected with the accident (if applicable)

Witness

Part of body injured or affected If fatal, give date of death Witness

Witness

Was there more than one person injured in this accident? (if applicable)

Yes No Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)

Did employee return to next scheduled shift after accident? (if applicable) Yes No

Will you have light duty work available if necessary? Yes No

If validity of claim is doubted, state reason Location of Initial Treatment

Treating physician/chiropractor name Emergency Room Yes No Hospitalized Yes No

IMPORTANT How many days per week does employee work? From am pm To am pm

Last day wages were earned INJU

RY

OR

DIS

EASE

Scheduled S M T W T F S Rotating days off Are you paying injured or disabled employee’s wages during disability? Yes No

Date employee was hired Last day of work after injury or disability Date of return to work Number of work days lost

Was the employee hired to If not, for how many hours a week work 40 hours per week? Yes No was the employee hired?

Did the employee receive unemployment compensation any time during the last 12 months? Yes No Do not know

For the purpose of calculation of the average monthly wage, indicate the employee’s gross earnings by pay period for 12 weeks prior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D-8). Gross earnings will include overtime, bonuses, and other remuneration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earnings from the date of hire to the date of injury or disability. IM

POR

TAN

T LO

ST T

IME

INFO

Pay period SUN TUE THUR SAT ends on: MON WED FRI

Emloyee WEEKLY MONTHLY OTHER is paid: BI-WKLY SEMI-MONTHLY

On the date of injury or disability the employee’s wage was: $ per Hr Day Wk Mo

For assistance with Workers’ Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail cha@govcha.state.nv.us

I affirm that the information provided above regarding the accident and injury or occupational disease is correct to the best of my knowledge. I further affirm the wage information provided is true and correct as taken from the payroll records of the employee in question. I also understand that providing false information is a violation of Nevada law.

Employer’s Signature and Title Date

Claim is: Accepted Denied Deferred 3rd Party Deemed Wage Account No. Class Code

Ins

urer

Use

O

nly

Claims Examiner’s Signature Date Status Clerk Date

Form C-3 (rev.11/05) ORIGINAL – EMPLOYER PAGE 2 – INSURER/TPA PAGE 3 – EMPLOYEE

"NOTICE OF INJURY OR OCCUPATIONAL DISEASE" (Incident Report) Pursuant to NRS 616C.015 Name of Employer

Name of Employee

Social Security Number

Telephone Number

Date of Accident (if applicable)

Time of Accident (if applicable)

Place where accident occurred (if applicable)

What is the nature of the injury or occupational disease?

List any body parts involved:

Briefly describe accident or circumstances of occupational disease: (Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment) Names of witnesses: Did the employee YES leave work because of the injury or NO occupational disease?

If yes, when (date and time)?

Has the employee YES returned to work? NO

If yes, when (date and time)?

Was first aid YES provided? NO

If yes, by whom?

Name and address of treating physician, if applicable or known

Did the accident happen YES in the normal course

of work? (if applicable) NO

Was anyone YES

else involved? NO

Names of others involved

MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFIED OF THESE ARRANGEMENTS.

Supervisor’s Signature Date Signature of Injured or Disabled Employee Date TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR COMPENSATION (FORM C-4). For assistance with Workers’ Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail cha@govcha.state.nv.us Employee should sign, date and retain a copy. Original to Employer, Copy to Employee C-1 (Rev. 10/05)

Request for Additional Medical Information And Medical Release

(Pursuant to NRS 616C.177 & 616C.490(4)) Injured Employee's Name: Claim Number: Social Security Number: Injured Employee's Address: Injury/Occupational Disease Date: Date this Notice Printed: Insurer's Name: Employer: Insurer's Address: Employer's Address: Please provide the information requested below, sign and date the form, and return it to your insurer. Your signature on this form also acts as a release to acquire information affecting your claim from other entities. This renews the release you signed on your C-4 form at the time your claim was submitted to your insurer. Failure to fully complete and return this form to your claims agent in a timely manner could affect your benefits or delay the resolution of your claim.

Prior History Information Please check the appropriate box below and provide the information requested.

I have no prior conditions, injuries or disabilities of which I am aware, that might affect the disposition of the claim referenced above. (If you checked this box, no further information is needed at this point)

I have a prior condition, injury or disability that could affect the disposition of the claim referenced above. This can include birth defects, prior surgeries, injuries, etc., whether work related or not. (If you checked this box, indicating a pre-existing condition, please explain in detail in the space below. Please attach additional sheets of paper to this form if necessary to fully explain the condition)

I certify that the above is true and correct to the best of my knowledge and that I have provided this information in order to obtain the benefits of Nevada’s industrial insurance and occupational diseases acts (NRS 616A to 616D, inclusive or chapter 617 of NRS). I hereby authorize any physician, chiropractor, surgeon, practitioner, or other person, any hospital, including veterans administration or governmental hospital, any medical service organization, any insurance company, or other institution or organization to release to each other, any medical or other information, including benefits paid or payable, pertinent to this injury or disease, except information relative to diagnosis, treatment and/or counseling for aids, psychological conditions, alcohol or controlled substances, for which I must give specific authorization. A photostat of this authorization shall be as valid as the original. ______________________________________________ _________________________________ Signature Date

D-36 (Rev. 12/07)

EMPLOYER'S WAGE VERIFICATION FORM (Pursuant to NRS 616C.045(2)(d)) Please provide the following information for the employee named below by completing this form. The information is needed so that the amount of disability compensation to which your employee is entitled may be calculated. Prompt completion and return of this form will ensure the timely payment of any compensation due this injured worker. Please answer all questions and sign the form where indicated. EMPLOYER: PLEASE PROVIDE THE FOLLOWING INFORMATION ANSWERING ALL QUESTIONS Date: Injured Employee's Name (Last/First/M.I.): Social Security # Claim No.: Date of Injury: Date of Hire: Was employee hired to work 40 hours per week: [ ] Yes [ ] No If no, # of hours per week: # of days per week: On the date of injury, the employee's wage was: $ per [ ] Hour [ ] Day [ ] Week [ ] Month Date the wage became effective: Was vacation paid during the applicable twelve week period? If so, during what pay period? Was sick leave paid during the applicable twelve week period? Was the injured employee paid for any holidays during the applicable twelve week period? Did employee receive payment for overtime during the applicable twelve week period? Did employee receive termination pay during the applicable twelve week period? Provide prior wage if current wage was in effect less than 12 weeks prior to date of injury: $ per [ ] Hour [ ] Day [ ] Week [ ] Month During this 12-week period did employee change to a job with different (1) duties, (2) hours of employment, (3) rate of pay? [ ] Yes [ ] No If so, date: Explain: Does the employee receive commissions? [ ] Yes [ ] No Period of commission earned to . Indicate the amount of commission received over the last 6 months, or since date of hire: $ Does the employee receive bonuses/incentive pay? [ ] Yes [ ] No Period of bonuses/incentive pay earned to . Indicate the amount of bonuses received over last 12 months, or since date of hire: $ Are the commission and bonus amounts included in GROSS EARNINGS below? [ ] Yes [ ] No Does the employee declare tips for the purpose of worker's compensation? [ ] Yes [ ] No See payroll declaration below. Attach declaration forms. Does the employee receive meals or lodging (excluding reimbursement for travel per diem)? [ ] Yes [ ] No (Do not include in gross earnings) How many meals per day?______________ Monetary value of meals $____________________per [ ] Day [ ] Week [ ] Month Lodging $_____________________per [ ] Day [ ] Week [ ] Month TWELVE WEEK VERIFICATION FROM PAYROLL RECORDS. Report GROSS EARNINGS, include overtime payment and any other remuneration (except reimbursement for expenses). (See NAC 616C.423) Give payroll information from through . If employed less than twelve weeks, give gross earnings from date of hire to date of injury.

If absent from work for the following reasons, please specify the date(s) absent and the number code for the reason of absence. 1. Certified illness or disability; 2. Institutionalized in a hospital, or other institution; 3. Enrolled as full-time student, not employed on days of attendance; 4. In military service other than training duty conducted on weekends; 5. Absent because of officially sanctioned strike; 6. Absence because of leave approved pursuant to Family and Medical Leave Act. Payroll Period Beginning Ending

Gross Salary (Excluding Tips)

Declared Tips

Payroll Period Beginning Ending

Gross Salary (Excluding Tips)

Declared Tips

Dates of Absence Reason Dates of Absence Reason Dates of Absence Reason Begin End Begin End Begin End Pay period ends on (check one) [ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Saturday Employee is paid: [ ] Weekly [ ] Bi-Weekly [ ] Semi-Monthly [ ] Monthly [ ] Other Employee scheduled day(s) off: [ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Saturday [ ] Other Explain "other": Date the employee last worked AFTER injury occurred: Date returned to work:

This information is true and correct as taken from the employee's payroll records. Print Name: Signature:

Date: Employer:

Insurer: Third-Party Administrator: D-8 (rev10/10)

SUPERVISOR’S REPORT OF EMPLOYEE ACCIDENT

Employee name Employer name Date of accident Time of accident Date accident reported Did the employee report the accident immediately? YES NO Location of accident (specify if off-site address) How did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were reported as injured? Has the employee sought any medical treatment for these injuries? If so, specify where and when.

What witnesses were present when the accident occurred (including self)? Do you have any reason to question the legitimacy of the accident? If so, please explain: Indicate working conditions present that led to accident (please check all that apply):

Unused/unavailable lifting equipment Wet/slippery floor Unused/unavailable PPE (gloves, hardhat, goggles, etc.) Poor housekeeping Unused/unavailable sharps container Interaction with co-worker Unguarded or improperly guarded equipment Interaction with patient or resident Electrical exposure Interaction with customer Obstructed view Chemical exposure Lack of training Motor vehicle accident Defective tools or equipment Other: __________________________

What changes could be made to eliminate or reduce the hazard(s) identified above? The above report is true and correct: Prepared by: Title: Date prepared:

WITNESS’ REPORT/STATEMENT OF EMPLOYEE ACCIDENT

Employee name Witness name & phone number Witness Address Date of accident Time of accident Location of accident (specify if off-site address) Did you witness the above-reported accident? If so, how did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were injured? Describe the type of injury (strain, bruise, etc.) What did the injured employee say at the time of injury? Did the injured employee complain of pain at the time of injury? If they complained of pain, please specify the body part(s).

What did the employee do after the accident occurred? Were any other witnesses present at the time of the accident? If so, please list them below. The above report is true and correct: Signature of witness: Date signed:

NOTE: Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties.

BERKSHIRE HATHAWAY HOMESTATE COMPANIES OFFERS:

REWARDREWARDWORKERS COMPENSATION

CLAIMS FRAUD

$1,000$1,000FOR INFORMATION LEADING TO THE ARREST AND CONVICTION OF ANY CO-WORKER, HEALTH CARE

PROFESSIONAL, OR ATTORNEY REPRESENTING A FRAUDULENT WORKERS’ COMPENSATION CLAIM TO BERKSHIRE HATHAWAY HOMESTATE COMPANIES*

Most states make it a FELONY to make or cause to be made a knowingly false or fraudulent material statement in order to obtain Workers’ Compensation benefits. Berkshire Hathaway Homestate Companies believes that any party engaging in such fraud should be prosecuted to the fullest extent of the law, including JAIL SENTENCES.

Please do your part to help. Putting these criminals out of operation benefits all of us, including keeping your employer’s premium rates reasonable.

Call our TOLL-FREE FRAUD HOTLINE immediately if you have information on a fraudulent claim. You, and all of us, reap the rewards of reducing Workers’ Compensation Fraud.

TOLL FREE:

1-800-300-JAIL1-800-300-JAIL*Maximum reward of $1,000 per conviction. In the event more than one individual submits information regarding the same fraudulent claim, BerkshireHathaway will equally divide the reward among those providing information used in obtaining the conviction. Berkshire Hathaway reserves the right to determine what information, if any, will be provided to the appropriate law enforcement agency. Criminal prosecutions are the sole responsibility of the authorities and may or may not be pursued at their discretion. Any issues regarding the interpretation of this policy shall be resolved by Berkshire Hathaway Homestate Companies at their sole discretion. Program subject to change or termination without prior notice.

BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY • BROOKWOOD INSURANCE COMPANY • CONTINENTAL DIVIDE INSURANCE COMPANY

CYPRESS INSURANCE COMPANY • OAK RIVER INSURANCE COMPANY • REDWOOD FIRE AND CASUALTY INSURANCE COMPANY

LA COMPAÑIA DE SEGUROS BERKSHIRE HATHAWAY OFRECE:

RECOMPENSARECOMPENSADEMANDAS FRAUDULENTAS DE

COMPENSACION DE TRABAJADORES

$1,000$1,000INFORMACIÓN QUE LLEVA AL ARRESTO Y A LA CONDENA DE CUALQUIER COMPAÑERO DE TRABAJO, PROFESIONAL DE CUIDADO MEDICO, O ABOGADO QUE REPRESENTE UN RECLAMO FRAUDULENTO

EN CONTRA DE BERKSHIRE HATHAWAY HOMESTATE COMPANIES*

En la mayoría de los estados es un delito grave hacer que se haga una declaración de material fraudulento para obtener beneficios de Compensación al Trabajador. Berkshire Hathaway Homestate Companies cree que cualquier persona que se involucre en tal fraude debe ser procesado con todo el rigor de la ley, incluyendo SER SENTENCIADO A LA CARCEL.

Ayúdenos de su parte. El poner a estos delincuentes fuera de operaciones nos beneficia a todos, incluso esto ayuda a mantener los réditos bajos de la aseguranza de su empleador.

Si usted tiene información sobre un reclamo fraudulento por favor llame de inmediato a nuestra LINEA GRATUITA DE FRAUDE. Usted y todos nosotros no beneficiamos cuando reducimos los casos fraudulentos de Compensación al Trabajador.

LLAMADA GRATIS:

1-800-300-JAIL1-800-300-JAIL*La recompensa máxima es de $1,000 por convicción. En caso de que más de una persona presente informaciones sobre la misma demando fraudulenta, Berkshire Hathaway dividirá la recompensa por partes iguales entre aquellas persones que aportaron informaciones para obtener la convicción. Berkshire Hathaway se reserva el derecho de determinar qué informacion presentará a la agencia judicial correspondiente. El proceso de crímenes es la responsibilidad exclusiva de las autoridades, que pueden decidir si el proceso debe entablarse or no. Cualquier disputa que pudiera surgir en la interpretación de esta ofreta será resuelta por la propia Compañia de Seguros Berkshire Hathaway. Este programa está sujeto a cambios a cancelación sin aviso previo.

BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY • BROOKWOOD INSURANCE COMPANY • CONTINENTAL DIVIDE INSURANCE COMPANY

CYPRESS INSURANCE COMPANY • OAK RIVER INSURANCE COMPANY • REDWOOD FIRE AND CASUALTY INSURANCE COMPANY