MISSOURI INTERGOVERNMENTAL RISK MANAGEMENT ASSOCIATION

CLAIMS HANDLING PROCEDURES

TABLE OF CONTENTS

PAGE

SECTION I: INTRODUCTION 2

SECTION II: CLAIMS REPORTING 2

A. TIME REQUIREMENTS 2

B. CLAIMS HANDLING AND SETTLEMENT AUTHORITY 2

C. WHERE TO REPORT 3

D. FORMS TO USE 4

SECTION III: SENDING ADDITIONAL INFORMATION 6

SECTION IV: CLAIMS MANAGEMENT 6

A. INTRODUCTION 6

B. WORKER'S COMPENSATION 6

C. AUTOMOBILE & GENERAL LIABILITY 8

D. AUTO PHYSICAL DAMAGE & PROPERTY 9

SECTION V: GETTING STATUS INFORMATION 10

SECTION VI: WHERE TO GET FORMS 10

SECTION VII: CLAIMS STAFF 11

REFERENCE: LOCATION CODES 12DEPARTMENT CODES 13FIRST REPORT OF INJURY INSTRUCTIONS 14WORKERS’ COMPENSATION WAGE STATEMENT 17NCCI CLASSIFCATION CODES 18TYPE OF INJURY CODES 21CAUSE OF INJURY CODES 22PART OF BODY CODES 23SIC CODES 24

Revised January, 2017 1

SECTION I: INTRODUCTION

MIRMA is not an insurance company, but rather a non-profit, self-insurance pool wholly owned by our members. MIRMA not only provides a comprehensive coverage package, but also works closely with each member through our loss control services to provide an organized approach for the management of municipal risks.

MIRMA is contracted with Corporate Claims Management, Inc. (CCMI) out of Chesterfield, MO to handle the administration of all claims, except for workers' compensation and employment practices liability (EPL) claims. MIRMA is contracted with Transitional Claims Solutions (TCS) out of Dallas, TX to administer EPL claims. MIRMA handles all workers' compensation claims out of our office in Columbia, MO with our staff adjuster.

SECTION II: CLAIMS REPORTING

A. TIME REQUIREMENTS

All claims, or any incident likely to give rise to a claim, should be reported to MIRMA within two (2) business days of the member’s first knowledge of any such claim or incident. This would include a notice of an EEOC complaint, attorney representation letter or a lawsuit. MIRMA does allow a grace period of 30 calendar days to report a new claim/incident; however, after 30 calendar days, a Late Notice Deductible will be assessed against the member for 25% of all claim costs.

If any employee, official or representative is aware of a claim or incident, that is considered knowledge by the member. It is each member’s responsibility to provide all employees, officials and representatives with the necessary instruction for reporting claims.

It is not necessary to obtain all the details of a claim/incident before reporting it to MIRMA. Simply having the basic facts, such as the date of the occurrence, location and claimant’s name, is sufficient to make the initial claim report. The adjuster assigned to the claim may follow up to ask for assistance in gathering additional information, such as taking photographs or getting damage estimates, but please do not delay reporting a claim to MIRMA once you are aware of it.

In the event of a serious claim, such as a fatality, head injury, amputation, tornado, large fire, widespread wind or hail storm, shooting incident, significant sewer backup(s) with property damage, or multiple vehicle accident, please call MIRMA immediately.

If you are aware of a serious claim after-hours or on a weekend or holiday, please call CCMI (except for workers' compensation claims). Do not call CCMI to report a serious workers' compensation injury – please call MIRMA the next business day. Please only call CCMI about a new claim if the MIRMA office is closed, and then only if it is a very serious, non-workers’ compensation claim.

B. CLAIMS HANDLING AND SETTLEMENT AUTHORITY

While a member may be asked to assist in obtaining information and/or documentation for a claim, please be careful not to actually get involved in the handling of a claim. The decision to settle, defend or otherwise establish strategy for the handling of a claim is the sole right and responsibility of MIRMA. This means the member should never make any commitment to pay or to deny responsibility for any claim. For example, if an injured worker presents a claim, you must report that to MIRMA without any comment about whether or not you think the claim is compensable.

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Please note that Section XI of the MIRMA By-Laws specifically prohibits a member from handling any claim or lawsuit or acting independently from or contrary to MIRMA with respect to any claim or lawsuit that falls within MIRMA’s coverage. Should this occur, the member forfeits all coverage with MIRMA for that particular claim or lawsuit.

For example: If MIRMA denies liability to a homeowner for a sewer backup claim, and that homeowner then files a lawsuit, MIRMA’s coverage would provide a legal defense for the member and pay any settlement or judgment. If, however, the member decided to make a settlement with the homeowner, contrary to MIRMA ‘s liability denial, the member would lose all coverage for that claim. If the homeowner were to later file a lawsuit for additional damage or injury, the member would have no coverage at all with MIRMA for that lawsuit since the member acted independently and contrary to MIRMA.

C. REPORTING A CLAIM OR INCIDENT

All claims should be reported to MIRMA. You can report a claim by fax, email or online. MIRMA prefers that all claims be reported online using Spectrum – the web based online claims access provided by our claims administrator, CCMI. Member employees that are responsible for reporting claims to MIRMA should have a user ID and password assigned to them by CCMI to login to Spectrum. Spectrum not only allows for a member to report claims online, but also provides information about that member’s claims. Some basic loss run reporting is also available on Spectrum.

There are two different forms used to report claims, one for workers’ compensation claims and one for all other claims. The First Report of Injury form – Form WC-1 – is the state required form that must be used for all workers’ compensation claims. For all other claims use the Notice of Occurrence/Claim Form.

If you report claims using Spectrum, the system completes the form for you. Just select whether you are reporting a workers’ compensation claim or other occurrence, and then navigate through the tabs to fill in the necessary information. Please also select whether you are reporting it as a claim or a ‘record only’.

Another benefit of reporting claims using Spectrum is that all of the codes, including all of the required workers’ compensation codes, are in drop down menus. Just follow through the tabs and be sure to complete all required fields.

If you do wish to report a new claim by sending us the physical form, please either fax it to 573-441-0515 or scan and email to newclaim@mirma.org. Please do not send new claim reports to us by mail as that will cause an unnecessary delay.

MIRMA office contact information:

MIRMA3002 Falling Leaf CourtColumbia, MO 65201

(573) 817-2554 or 877-562-1125Claims Fax: (573) 441-0515

www.mirma.org

Office Hours: 8:00 a.m. to 4:30 p.m.newclaim@mirma.org

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The contact information for our third party administrators is:

CCMI782 Spirit 40 Park DriveChesterfield, MO 63005

636-519-0330 or 800-449-2264636-519-0227 (fax)

TransEleven Claims ManagersKathy Weber, Esq.

Executive Vice President - TCM5900 S. Lake Forest Dr. Suite 300

McKinney, Texas 75070844-281-2811 ext. 707

kathyw@trans11claims.com

To report an emergency/serious claim after-hours (not a workers' compensation claim), you may contact CCMI at the phone number provided above. Please do not have a claimant contact CCMI direct after hours. CCMI does have extended office hours, but when their office is closed they use an answering service. If you reach the answering service simply advise that you are trying to reach the CCMI on-call adjuster. An adjuster should be back in touch within the hour.

D. FORMS

We strongly encourage all members to report claims online using Spectrum. It is the easiest and fastest way to report your claims. If you need a user ID and password please contact the MIRMA office and we will request one from CCMI.

If you need to submit a physical claim form, please do not complete the forms by hand. Electronic versions of all claim forms are available on the MIRMA website, www.mirma.org. Please also do not give the claim form to an injured worker or claimant to complete.

1. WORKERS COMPENSATION

a. REPORT OF INJURY – FORM WC-1: This is a state form and must be used to report all work related injuries. Do not send this form to the Division of Workers Compensation, send it to MIRMA and we will file it with the Division.

(1) “Employer (Name, Address, incl. Zip code)” should include the name and address of the Member City.

(2) “Location #” is the three letter abbreviation for the Member, plus the three number Department Code found in the DEPARTMENT CODES list found in the following coding section of these procedures.

(3) “Phone #”, immediately under “Location #”, should be the phone number of the department where the employee can be reached. In the Section titled “Employee”, “Phone #” under the employee’s name and address should be the employee’s home phone.

(4) “Carrier (name, address & phone no.)” should read: MIRMA, 3002 Falling Leaf Ct., Columbia, MO 65201.

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(5) “Carrier FEIN” should read: 43-1232810.

(6) “NCCI Class Code” is a four digit code corresponding to the employee’s primary occupation. These codes can be found in Appendix B under NCCI Worker’s Compensation Classification Codes.

(7) “Type of injury/illness” - Please be as specific as you can.

(8) “Type of injury/Illness Code” - Two digit code can be found in Appendix B

(9) “Part of Body Affected” - Again, please be as specific as you can.

(10) “Part of Body Code” - Two digit code can be found in Appendix B.

(11) “Cause of Injury Code”- Two digit code can be found in Appendix B.

(12) “How Injury or Illness/Abnormal Health Condition Occurred ...” should include the word “alleged” on all injuries that are:

(a) Suspicious in nature.(b) Not witnessed.(c) Reported late.(d) Non-visible injury such as back strain.

Example: The employee alleges he twisted his back two weeks ago while picking up a screwdriver.

(13) “Physician/Health Care Provider (Name & Address)” should include the doctor or clinic’s name and address if any treatment was rendered to the employee.

b. Keep copies of all forms and written statements for your file.

2. ALL OTHER CLAIMS

All other claims and losses must be reported on the Notice of Occurrence/Claim Form. Please complete the information in the top box of the form, and please be sure to indicate what city department the claim is for.

The Member Property section is to be used if you are reporting a claim for a damaged city automobile or damage to a city building(s). If you are reporting damage to a city building, please indicate the location number for that property as it is on the property schedule you submitted.

The Claimants section is to be completed when you are reporting a liability claim. The claimant is the person that is alleging the city has caused them harm or damage. Please provide whatever contact information you have for all claimants.

Please report any claim just as soon as you are aware of it. Do not wait to obtain estimates, photographs, police reports, etc. before reporting the claim. As long as you have the basic facts, please report the claim to MIRMA. The adjuster assigned will follow up with you to get whatever additional details are needed.

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1SECTION III:SENDING ADDITIONAL INFORMATION

All information and documentation, such as police reports, inspection reports or internal investigations, may not be immediately available when you need to report the claim. As mentioned above, please do not wait to report a claim in order to gather additional information.

As a claim develops and you receive additional information, including damage estimates, photographs, reports, or even suit papers, please forward it immediately to the handling adjuster. Please be sure to include the claim number when sending information or in any correspondence to the adjuster.

SECTION IV: CLAIMS MANAGEMENT

A. INTRODUCTION

The timely and proper reporting of a claim is one of the most important steps in the overall claims process. The more quickly an adjuster is involved, the better the adjuster can determine what steps are needed to effectively handle the claim.

There are also some other things the member can do to help ensure proper claims management.

1. PRE-OCCURRENCE: Pre-occurrence handling procedures deal with those things the member can do before a claim occurs in order to be prepared for when a claim is reported. This includes such things as informing all employees to report all incidents, no matter how minor, and establishing procedures such as who is to submit claim reports to MIRMA.

2. OCCURRENCE: Occurrence handling procedures deal with those things the member must do once a claim occurs. This will include such things as using proper forms, taking photographs, obtaining police reports, and supervisory investigations.

3. POST-OCCURRENCE: Post-Occurrence handling procedures deal with those things the member should do after the claim has been reported, such as providing the adjuster with new or additional information

B. WORKER'S COMPENSATION

1. PRE-OCCURRENCE

a. Files should be maintained on every employee to include:

(1) Employment Application(2) Pre-Placement physicals(3) Group Health and disability claims(4) Prior workers' compensation claims(5) Violations of safety rules(6) Attendance information(7) Performance evaluations

b. Pre-select a local medical facility for proper treatment and diagnosis. In Missouri, the workers' compensation statute says the employer has the right to direct medical treatment.

c. During the employee's orientation, he or she should be informed to report all incidents to their supervisor, no matter how minor, immediately.

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2. OCCURRENCE

a. Medical Treatment(1) First aid on site(2) Refer to your pre-selected doctor or medical facility. If critical or

emergency care is needed a hospital ER may be appropriate.

b. Reporting of the Claim

(1) Complete the state required First Report of Injury Form, WC-1 online using Spectrum, or e/mail or fax the physical form to MIRMA within two business days.

(2) Call MIRMA immediately on serious injuries that involve:

(a) Death(b) Amputation(c) Heart attacks or strokes(d) Multiple injuries or (e) Head injuries resulting in loss of consciousness(f) Serious burns(g) Mental disorders(h) Questionable compensability

c. Never accuse employee of malingering or faking.

d. Never tell an employee a claim is not covered or that they cannot file a workers' compensation claim. MIRMA will make all determinations of compensability.

e. Ask the employee to write out a statement describing how the injury happened and identify any witnesses to the injury.

f. Notify family on serious injuries.

g. Preserve evidence. If there is any question about whether evidence must be retained, please contact MIRMA.

h. Complete the Supervisor’s Accident Investigation Report Form and submit to MIRMA.

3. POST-OCCURRENCE

a. Discuss with the employee:

(1) Present condition or progress(2) Return-to-work date(3) Complaints on treatment(4) Bills received or not paid

b. Discuss with the doctor:

(1) Status(2) Return-to-work date(3) Employee's job description(4) Light duty and/or work restrictions

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c. Communication with MIRMA:

(1) All of the above information(2) Return-to-work notification(3) Any additional claim investigation facts

d. Do not submit any forms direct to the Division of Workers' Compensation – all forms will be submitted by MIRMA.

C. AUTOMOBILE & GENERAL LIABILITY

1. PRE-OCCURRENCE

a. Inform all employees to report any accident or incident that could likely give rise to a claim immediately.

b. Inform all employees on what to do in the event of an auto accident.

c. Document all maintenance, inspections and repairs to city streets, sidewalks, sewer lines, water lines, gas lines, utility lines and poles, tree trimming and removal, city equipment, and any facilities used by the public.

d. Document all city vehicle maintenance.

2. OCCURRENCE

a. Do Not

(1) Admit liability or fault(2) Commit to pay for anything or say that the City will take care of it.(3) Discuss settlement or compensation(4) Authorize any work to be done on a claimant’s property(5) Arrange or authorize a rental vehicle, hotel room, or contractor for a

claimant

b. Do

(1) Call for emergency medical assistance if necessary.(2) Obtain the name, address, telephone number, etc., of all parties involved –

including witnesses.(3) Tell the claimant(s) that the claim will be reported to MIRMA and that an

adjuster will be in touch within 24-hours. If this is a serious incident the Member should contact MIRMA immediately.

(4) Auto accidents- always call the police and make a report.(5) Preserve evidence- Auto accidents, if possible, do not move vehicles until

the police have made their report. (6) Photographs - Take photos whenever possible. Take several – preferably

digital. Take overview shots showing all directions as well as close-up shots of damages or alleged defects.

(7) Diagram- Make a sketch of the accident scene showing measurements and placement of objects.

(8) Take physical control of any object that caused the accident (banana peel, rock, etc,). If that is physically impossible, be sure to take several photos

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and properly identify the item/object. If it is a liquid, try to determine the type of substance, where it came from, and how long it was present.

c. IN THE EVENT OF A SEWER BACKUP - the homeowner has a duty to protect their property against further loss or damage – regardless of fault or liability. Just because there is a sewer backup it does not mean the city is automatically at fault. Please do not commit to pay for anything or directly arrange for a cleaning contractor. Please do take pictures and try to determine the cause of the backup.

MIRMA strongly encourages the city to notify MIRMA immediately of any sewer backup. You may also advise the homeowner of the following, but please be clear the city is not authorizing or guaranteeing payment for any repairs or damage:

(1) All water and sewage should be immediately removed and the area ventilated. The homeowner may elect to contact a water damage restoration company – but the city should not authorize work or commit to pay for anything . Floor fans and dehumidifiers can be rented from a local rental shop.

(2) Contents should be removed from the affected area, however, it is better not to discard anything until the adjuster can inspect the loss.

(3) Carpet and pad that comes in direct contact with the sewer backup will need to be removed. Do not advise the homeowner to attempt to clean carpet that has come in direct contact with the sewer backup.

(4) If the backup was high enough to involve a motor on a furnace, or electrical appliance, the homeowner should contact a reputable repair service.

3. POST-OCCURRENCE

a. Communicate any new or additional information to CCMI. Forward any correspondence from an attorney or suit papers to the adjuster immediately.

b. In the event you are contacted by a claimant about their claim, please refer them to handling adjuster. Once the claim has been reported to MIRMA, the city should not be involved in dealing with a claimant. If the claimant is unhappy about their claim, they should be advised to contact the adjuster or the adjuster’s supervisor.

D. AUTOMOBILE PHYSICAL DAMAGE & PROPERTY

1. PRE-OCCURRENCE

a. Inform supervisors and employees what to do in the event of a loss or accident.

b. Perform preventive maintenance on all city vehicles and buildings.

c. Smoke detectors and fire extinguishers should be in all city buildings.

2. OCCURRENCE

a. Report the claim online using Spectrum – or Complete the Notice of Occurrence/Claim Form and e/mail or fax it to MIRMA.

b. Call MIRMA immediately on any serious automobile accident or large property loss.

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c. Protect the building or damaged property from further loss. The city also has a duty to mitigate their damages and should take all reasonable steps to protect the property. Contact MIRMA or the CCMI adjuster if there are ever any questions on how to respond.

d. Preserve evidence and take photographs.

3. POST OCCURRENCE

a. Obtain two competitive, itemized estimates. Please advise all contractors and body shops that lump sum estimates will not be accepted. Failure to obtain an itemized estimate could delay the handling of your claim.

b. Follow the progress of the repairs.

c. Notify the CCMI adjuster if problems occur or additional damage is discovered.

SECTION V: GETTING STATUS INFORMATION

If you would like to know the current status of a claim you should contact the handling adjuster. Spectrum will give you an overview of your claims, but you will not see the detailed file notes or specific payment detail.

If you ever have any concerns or comments about the handling of a claim or the defense of a lawsuit please contact the Claims & Litigation Director.

SECTION VI: WHERE TO GET FORMS

All forms may be obtained from the MIRMA office in Columbia. The Worker's Compensation Report of Injury Form, WC-1, may also be obtained directly from the Division of Worker's Compensation website at http://www.dolir.mo.gov/.

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SECTION VII: CLAIMS STAFF

MIRMA

Glenn A. Price, Jr., AIC E-Mail: gprice@mirma.org Phone: 573-817-2554Claims & Litigation Director

Gina Viertel E-Mail: gviertel@mirma.org Phone: 573-817-2554Senior Workers’ Compensation Adjuster

Susan Cannady E-Mail: scannady@mirma.org Phone: 573-817-2554Claims Administrator

Corporate Claims Management (CCMI)

CCMI Main #: 636-519-0330

Miranda Huston-Range E-Mail: mhuston-range@patnat.com Direct: 636-728-6755Claims Supervisor

Johna Suchanek E-Mail: jsuchanek@patnat.com Direct: 636-728-6792 Property Claims Adjuster Phone:  314-971-3217

TransEleven Claims Managers, Inc.

Kathy Weber, Esq. E-Mail: kathyw@trans11claims.com Phone: 844-281-2811Executive Vice President Ext. 707

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REFERENCELOCATION CODES

LOCATIONMUNICIPALITY/UTILITY CODES

MIRMA MIRALBANY ALBARNOLD ARNAVA AVABEL-NOR BLNBELLEFONTAINE NEIG BLFBETHANY BTHCABOOL CABCANTON CANCARL JUNCTION CJNCHILLICOTHE CHLCHILLICOTHE UTIL CHLUCLARENCE CLRCLARKSVILLE CLVCOUNTRY CLUB CCVDE SOTO DESFESTUS FESFREDERICKTOWN FREFULTON FULGALLATIN GALHANLEY HILLS HHLHANNIBAL HANHANNNIBAL UTIL. HANUHERMANN HERHIGGINSVILLE HIGHOLTS SUMMIT HLTHUNTSVILLE HUNJACKSON JACKAHOKA KAHKENNETT KENKENNETT UTIL. KENULAMAR LAMLICKING LICLINN CREEK LINMACON MACMACON UTILITIES MACUMADISON MADMALDEN MALMANSFIELD MNF

LOCATIONMUNICIPALITY/UTILITY CODES

MARYVILLE MARMOBERLY MOBMOSCOW MILLS MCMMOUND CITY MDCMOUNTAIN GROVE MTGMOUNTAIN VIEW MTVNEW HAVEN NHVNEW LONDON NLDNEW MADRID NMDNORTHWOODS NTWPACIFIC PACPALMYRA PALPARIS PARPERRY PERPLATTE CITY PLTRICHLAND RICROCK PORT RKPROLLA ROLROLLA UTIL ROLUSAVANNAH SAVSEYMOUR SEYSHELBINA SHESLATER SLAST. CLAIR STCST. JAMES SJMSTANBERRY STATARKIO TARTHAYER THATIPTON TIPTRENTON TRNTRENTON UTIL TRNUUNION UNIUNIONVILLE UNVVANDALIA VANWEST PLAINS WTPWILLOW SPRINGS WISWINCHESTER WCHWOODSON TERRACE WOT

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DEPARTMENT CODES

001- Administration003- Airport004- Library005- Building Services/Custodial007- Vehicle Maintenance010- Public Works Engineering012- Wastewater014- Streets & Roadways016- Transportation017- Refuse019- Electric021- Water 023- Health Services/EMT025- Fire027- Police031- Aquatic Recreation032- Golf Courses033- Parks & Recreation035- Municipal Court036- Gas Utility039- Cemeteries

WORKERS’ COMPENSATION FIRST REPORT OF INJURY INSTRUCTIONS

FIELD NAME: DEFINITIONS OF FIELDS MANDATORY

G

E

N

E

R

A

L

EMPLOYER The name and address of Member employing or statutorily responsible for the employee

YES

CARRIER ADMINISTRATOR

CLAIM NUMBER

To be completed by MIRMA MIRMA will complete

REPORT PURPOSE CODE 00 – Original 02 – Change/Update YESJURISDICTION The governing body, territory, who will administer

the claim and whose statutes will apply to the claim adjustment process. Example: MO.

YES

JURISDICTION CLAIM NO. MO Division of Workers’ Compensation Injury Number DO NOT USEINSURED REPORT NO. A number used by the insured to identify a specific claim NOEMPLOYERS LOCATIONADDRESS

Do Not Use

LOCATION NUMBER Member’s three-letter code plus the Member’s three-number department code that represents the department that the employee’s payroll check is drawn on. (See Manual.)

YES

PHONE NUMBER The phone number of the employer. YESSIC CODE 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. (See Manual)

YES

EMPLOYER’S FEIN The FEIN (Federal Employer Identification Number) of the Member.

YES

CARRIER

CARRIER MIRMA YESPOLICY PERIOD Fiscal year in which the claim occurred YESCLAIMS ADMINISTRATOR MIRMA YESSELF-INSURANCE INDICATOR

Check this block. YES

CARRIER FEIN The FEIN (Federal Employer Identification Number) of MIRMA.

YES

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FIELD NAME DEFINITIONS OF FIELDS MANDATORY

EMPLOYEE

NAME, ADDRESS, D.O.B., SS#, SEX

The name, address and phone number of the injured worker.

YES

DATE OF HIRE, EMPLOYMENT STATUS

Date worker was hired by the CityFull-time, part-time, seasonal, volunteer

NO

PHONE, MARITAL STATUS Not required, but a contact phone number is essential and marital status may be necessary depending on the claim.

NO

NUMBER OF DEPENDENTS Number of dependents (spouse, children) Required in the case of a fatality injury, otherwise optional

YES if fatal injury

NCCI CLASS CODE NCCI code – see list of codes in the appendix YES

WAGE

RATE Weekly rate at which a benefit type is being paid. YESNO. DAYS WORKED/WEEK The number of the employee’s regularly scheduled work

days per week.NO

FULL PAY FOR DAY OF INJURY

Indicates whether full wages for the date of the accident/injury or illness were paid by the employer.

NO

DID SALARY CONTINUE Is employee receiving regular wages during an absence caused by a work injury.

NO

OCCURRENCE

TIME EMPLOYEE BEGAN WORK

The time when employee began work. NO

DATE OF INJURY/ILLNESS The date on which the accident occurred. YESTIME OF OCCURRENCE The time when the accident occurred. YESLAST WORK DATE The date the employee last worked. This date will not

reflect dates that the employee was absent from work in a paid status; vacation, comp. time, sick day, etc.

YES

DATE EMPLOYER NOTIFIED Date employer notified of the accident/injury. YESDATE DISABILITY BEGAN First day the injured worker lost time from work due

to the occupational injury or disease or as otherwise defined by statute.

YES

CONTACT NAME/PHONE NO. Name/telephone number for a representative of the employer.

YES

TYPE OF INJURY/ILLNESS Description of the type of injury/illness YESPART OF BODY AFFECTED The part of the body the claimant sustained injury to. YESDID INJURY/ILLNESSEXPOSURE OCCUR ON EMPLOYER’S PREMISES?

As requested. Answer yes or no. YES

TYPE OF INJURY/ILLNESS CODE

Code identifying type of injury (See manual) YES

PART OF BODY AFFECTED CODE

Code identifying part of body (See manual) YES

DEPARTMENT OF LOCATION WHERE ACCIDENT/ILLNESS EXPOSURE OCCURRED

Postal code that corresponds to the location where the injury occurred.

YES

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TREATMENT/OTHERS

FIELD NAME DEFINITION OF FIELDS MANDATORYPHYSICIAN/HEALTH CARE PROVIDER(NAME/ADDRESS)

The name and address of the physician or health care provider

YES

HOSPITAL (NAME/ADDRESS)

The name and address of the hospital. YES

WITNESS (NAME & PHONE) Name and phone number of party that witnessed accident/injury.

NO

DATE ADMINISTRATORNOTIFED

The date the claim administrator who is processing the claim received notice of the loss or occurrence.

YES

DATE PREPARED The date MIRMA finalized this report. MIRMA will fill this in

PREPARER’S NAME/TITLE Claims Administrator’s name & title who finalized report.

MIRMA will fill this in

PHONE NUMBER Phone number for MIRMA YESINITIAL TREATMENT A code used to identify the extent of medical

treatment received by the claimant immediately following the accident (Check most applicable)

YES

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Workers’ Compensation Wage Statement

Section 287.250 of the Workers’ Compensation Act requires a thirteen-week wage history when indemnity payments are to be made. Please provide the employees’ wage history for thirteen weeks prior to the date of injury. Please give fully and carefully all information requested.

Member: Employee:

Completed By: Date:

Please provide scheduled days missed due to injury:

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NCCI WORKERS’ COMPENSATION CLASSIFICATION CODESREFERENCE GUIDE

Code Description Jobs Included

5192 Coin Operated Machines, Repair and Installation ofInstall and Repair Parking Meters and Signs

5505 Street, Road Maintenance Street Maintenance and Construction, Street Cleaning

6045 Levee Construction Levee Construction

6217 Sanitary Land Fill Employees Working at Landor Excavation Fill/Compost Sites

6306 Sewer Construction or Sewer Construction and

Maintenance Maintenance

6836 Marina Marina Employees

7382 Bus Company Employees Bus Drivers

7403 Aircraft Operation and Em- All Airport Employeesployees or Airport Employees

7502 Gas Department Employees Gas Department Employees

7520 Waterworks Operation Waterworks

7539 Electric Power Company Electrical Production andDistribution

7580 Sewage Treatment Sewage Treatment and/orWastewater Plant Employees

7600 Telecommunications Internet/Cable TV EquipmentInstallation or Maintenance

7710 Fire Fighters Fire Fighters (IncludingVolunteer)

7720 Police Officers Police Officers (full time andreserve), Corrections Officers,Bailiffs, Crossing Guards, Turn Keys

8017 Food Service/Concessions All Employees Involved in Sale of Food/Beverages and Door Attendants

8264 Recycling All Employees Involved inRecycling Activities

8391 Auto Repair Shop All Auto Repair EmployeesIncluding Vehicle Maintenance And Mechanics

8601 Engineers Contracted Engineers From Architectural or Engineering Firms

8742 Social Services Employees, Social Services WorkersSalespersons/Collectors Or Salesmen That Travel

8810 Clerical All Clerical EmployeesIncluding Administration,Secretaries, Clerks,Accountants, Data Processingor Computer Operation,Dispatchers, Judges, CourtClerks, Mayors, Councils,Prosecutors, Trustees, ElectedOfficials, Cable-Broadcasting,Tourism, Board of Directors,Aldermen, Assessors,Treasurers, Collectors

8810 Library Employees (List Separately All Library EmployeesFrom Other Clerical)Including Clerical

8820 City Attorney All Attorneys HoldingOfficial Title of City Attorney

8824 Senior Center – Health Care Senior Center Employees providing Health Care

8825 Senior Center – Food Service Senior Center Employees providing Food Service

8826 Senior Center – All Other All other Senior Center Employees Employees

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8831 Animal Control Dog Catchers, Animal ShelterEmployees, Rabies Control

8832 Physician All Health DepartmentEmployees

8869 Day Care Facility All Employees Involved inChild Care/Babysitting

9014 Janitorial Services All Janitors and Building Maintenance Employees

9015 Swimming Pool/Buildings, NOC All Swimming PoolIncluding Life Guards

9060 Golf Course Employees Golf Course Employees

9063 Umpires and Instructors All Umpires and Instructors,Including YMCA Teachers and Instructors, Whether Paid on Fee Basis or Through City Payroll

9102 Parks Employees Park Maintenance andCemetery Mowing

9220 Cemetery Operation Grave Digging and Ground Maintenance

9403 Garbage or Refuse Collection Garbage Collection

9410 Municipal Employees, NOC Building Inspectors, Engineers Or Building Inspectors on City Payroll, Property Appraisers

Revised January, 2017 21

TYPE OF INJURY CODES

Code: Type of Injury

1. SPECIFIC INJURY

01 No Physical Injury02 Amputation03 Angina Pectoris (Condition Associated

with Heart Disease)04 Burn07 Concussion10 Contusion13 Crushing16 Dislocation19 Electric Shock22 Enucleation (To Remove, Ex. Tumor of

Eye25 Foreign Body28 Fracture30 Freezing31 Hearing Loss32 Heat Prostration34 Hernia36 Infection37 Inflammation40 Laceration41 Myocardial Infarction (Heart Attack)42 Poisoning-General (Not OD or Cumul.

Exposure)43 Puncture46 Rupture47 Severance49 Sprain52 Strain53 Syncope (Dizziness or Loss of

Consciousness)54 Asphyxiation55 Vascular Loss58 Vision Loss59 All Other – NOC

Code: Type of Injury

II. OCCUPATIONAL DISEASE OR CUMMULATIVE INJURY

60 Dust Disease NOC (All other Pneumoconiosis)

61 Asbestosis62 Black Lung63 Byssinosis64 Silicosis65 Respiratory Disorders (Gases,

Fumes, Chemicals, Etc.)66 Poisoning-Chemical (Other than

Metals)67 Poisoning-Metals68 Dermatitus69 Mental Disorder70 Radiation71 All other Occup. Disease, NOC72 Loss of Hearing73 Contagious Disease74 Cancer75 AIDS76 Video Display Terminal-Related

Disease77 Mental Stress78 Carpal Tunnel Syndrome79 Hepatitis C80 All Other Cumul. Injuries, NOC

III. MULTIPLE INJURIES

90 Multiple Physical Injuries Only91 Multiple Injuries Including Both

Physical & Psychological

Revised January, 2017 22

CAUSE OF INJURY CODES

Code: Cause of Injury Code: Cause of Injury

I. BURN OR SCALD-HEAT OR COLD EXPOSURE

01 Acid Chemicals02 Hot Object or Substances11 Cold Objects or Substances03 Temperature Extremes04 Fire or Flame05 Steam or Hot Fluids06 Dust, Gases, Fumes or Vapors07 Welding Operations08 Radiation09 Contact with, NOC14 Abnormal Air Pressure84 Electrical Current

II. CAUGHT IN OR BETWEEN

10 Machine or Machinery12 Object Handled20 Collapsing Materials (Slides or Earth)13 Caught In, Under or Between, NOC

III. CUT, PUNCTURE, SCRAPE INJURED BY

15 Broken Glass16 Hand Tool, Utensil; Not powered17 Object Being Lifted or Handled18 Powered Hand Tool19 Caught, Puncture, Scrape, NOC

IV. SLIP OR FALL INJURY

25 From Different Level (Elevation)26 From Ladder or Scaffolding27 From Liquid or Grease Spills28 Into Openings29 On Same Level30 Slipped, Did Not Fall31 Fall, Slip, Trip, NOC32 On Ice or Snow33 On Stairs

V. MOTOR VEHICLE

40 Crash of Motor Vehicle41 Crash of Rail Vehicle45 Collision with Another Vehicle46 Collision with a Fixed Object47 Crash of Airplane48 Vehicle Upset50 Motor Vehicle, NOC

VI. STRAIN OR INJURY BY

52 Continual Noise53 Twisting54 Jumping55 Holding or Carrying56 Lifting57 Pushing or Pulling58 Reaching59 Using Tool or Machine60 Strain or Injury By, NOC61 Wielding or Throwing97 Repetitive Motion

VII. STRIKING AGAINST OR STEPPING ON

65 Moving Parts of Machine66 Objects Being Lifted or Handled67 Sanding, Scraping, Cleaning Ops68 Stationery Object69 Stepping On Sharp Object70 Striking Against or Stepping on, NOC

VIII. STRUCK OR INJURED BY

74 Fellow Worker, Patient75 Falling or Flying Object76 Hand Tool or Machine in Use77 Motor Vehicle78 Moving Parts of Machine79 Object Being Lifted or Handled80 Object Handled by Others81 Struck or Injured, NOC85 Animal or Insect86 Explosion or Flare Back

IX. RUBBED OR ABRADED BY

94 Repetitive Motion95 Rubbed or Abraded, NOC

X. MISCELLANEOUS CAUSES

82 Absorption, Ingestion or Inhalation, NOC87 Foreign Matter (Body) in Eye(s)88 Natural Disasters89 Person in Act of a Crime90 Other Than Physical Cause of Injury91 Mold96 Terrorism98 Cumulative, NOC99 Other – Miscellaneous, NOC

Revised January, 2017 23

PART OF BODY CODES

Code: Part of Body

I. HEAD

10 Multiple Head Injury11 Skull12 Brain13 Ear (s)14 Eye (s)15 Nose16 Teeth17 Mouth18 Soft Tissue19 Facial Bones

II. NECK

20 Multiple Injury21 Vertebrae22 Disc23 Spinal Cord24 Larynx25 Soft Tissue26 Trachea

III. UPPER EXTREMITIES

30 Multiple Upper Extremities31 Upper Arm (Inc. Clavicle & Scapula)32 Elbow33 Lower Arm34 Wrist35 Hand36 Finger (s)37 Thumb38 Shoulder (s)39 Wrist (s) and Hand (s)

Code: Part of Body

IV. TRUNK

40 Multiple Trunk41 Upper Back Area (Thoracic Area)42 Low Back Area (Lumbar/Lumb. Sacr.)43 Disc44 Chest (Ribs, Sternum, Soft Tissue)45 Sacrum and Coccyx46 Pelvis47 Spinal Cord48 Internal Organs49 Heart60 Lungs61 Abdomen, Including Groin62 Buttocks63 Lumber &/or Sacral Vertebrae, NOC

V. LOWER EXTREMITIES

50 Multiple Lower Extremities51 Hip52 Upper Leg53 Knee54 Lower Leg55 Ankle56 Foot57 Toe (s)58 Great Toe

VI. MULTIPLE BODY PARTS

64 Artificial Appliance65 Insufficient Info. To Properly Classify66 No Physical Injury90 Multiple Body Parts91 Body Systems or Multiple Body Systems99 Whole Body

Revised January, 2017 24

SIC CODES

POSITION SIC Code

Airport 4581Ambulances (Motor Vehicles) 4119Animal Control 8699Automotive Repair 7538Building Maintenance 1542Cemeteries 9512City Manager 9111Clerical 7338Convention Centers 7389Custodian 7349Dispatchers 7338Elected Officials 9121Electrical Services 8711Engineering 8711Fire Protection 9224Fire Suppression 9224Golf Course 7992Inspection Services 7389Lawyers 9222Library 8231Meter Reader 3824Parking Garages 7521Parks & Preservation 9512Police Protection 9221Prosecutors 9222Public Order & Safety 9229Public Utilities 9631Public Works Facility 7699Recreation 7999Refuse Collection or Landfill 4953Snowplowing 4959Social Services 9441Street Maintenance/Repair 1611Transit Systems 4111Tree Trimming 0783Utilities-Electric Only 4911Utilities-Natural Gas Transmission 4922Utilities-Natural Gas Trans/Distrib 4923Utilities-Natural Gas Distribution 4924Utilities-Electric and Gas/Other Utilities 4931Utilities-Gas and Other Services 4932Utilities-Combination Utilities 4939Utilities-Water Supply 4941Utilities-Refuse Systems/WWTP 4953Utilities-Sanitation Collection 4212Utilities-Sewerage Systems/not WWTP 4952Vehicle Repair/Maintenance 7538Water Control & Quality Agencies–Gvrn. 9511Water/Sewer Pipeline Construction 1623

Revised January, 2017 25

Unclassified/All Other 9999

Revised January, 2017 26