MCDONALD'S WORKERS' COMPENSATION - STORE SAFETY AND CLAIMS GUIDE

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MCDONALD'S WORKERS' COMPENSATION - STORE SAFETY AND CLAIMS GUIDE
McDonald’s
                      WORKERS’
                    COMPENSATION

                       STORE SAFETY AND
                         CLAIMS GUIDE

                                              Phone: 877-200-1718
                                               Fax: 877-644-3670
                                      McDonalds@BesnardInsurance.com
                                  www.ProfitingFromSafety.com
                        “The Best Run McDonald’s Choose Besnard Insurance”

                                                      Amerisure Client Book
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MCDONALD'S WORKERS' COMPENSATION - STORE SAFETY AND CLAIMS GUIDE
Section 9

           Claims Management

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MCDONALD'S WORKERS' COMPENSATION - STORE SAFETY AND CLAIMS GUIDE
Attention Store Managers
                               SAFETY IS NO ACCIDENT
                    YOU CAN CONTROL YOUR WORKERS’ COMPENSATION COSTS!

Experience has demonstrated that some employees will take advantage of an unmanaged claims
situation. A cost control approach is simple when you follow these steps with every report of
injury.

MANAGEMENT PROCEDURES FOR CLAIMS HANDLING:

     1. If the injury is serious or life threatening and requires immediate
        treatment, call 911 and have employee transported to the nearest
        medical facility.
     2. For all serious or disabling injuries, you must immediately phone in
        the injury report.
     3. For all other injuries, instruct the employee that it is mandatory to
        seek medical treatment from an approved medical facility/physician
        and to comply with post injury drug testing requirements.

SEND EMPLOYEE TO HOSPITAL ONLY IF SERIOUS OR A LAST RESORT!

     1. All claims must be reported to The Insurance Company within 24 hours of
        occurrence by either the company office manager, manager on duty, or the supervisor.
        Make sure someone is prepared to answer questions about the claimant and events
        surrounding the accident.
     2. Prompt reporting of injuries has been shown to dramatically reduce claims costs
        and legal involvement!
     3. If an employee refuses medical treatment, they should sign the waiver of medical
        treatment, but a post injury drug test should still be performed if this is a part of your
        HR policy.
     4. Hand the employee their responsibilities packet and inform them to ask the doctor to
        contact you after the employee is treated to help establish Return to Work opportunities. It
        is imperative to get the employee back to work as soon as possible to lower workers’
        compensation costs among many other benefits.
     5. Any reported injuries that are felt to be “questionable” should still be reported as normal
        incidents, but let the adjuster know your concerns by phone.
     6. Report to the adjuster immediately any of the following regarding Preexisting Conditions.
            o Pre-existing conditions which existed for the employee before the injury
            o Existing conditions which may have contributed or worsened the injury
            o Copy of any medical accommodation form which might have documented existing
               conditions

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MCDONALD'S WORKERS' COMPENSATION - STORE SAFETY AND CLAIMS GUIDE
Workers Compensation
                                  CLAIM MANAGEMENT CHECK-LIST
                           (Please attach this document to the outside of internal claim folder)

Workers Name: ____________________ Date of Accident: ______ Store #: _____

STORE MANAGER

          Offered the injured worker medical treatment
              o provided them with a list of clinics and corresponding forms to take to the physician

          Send the injured worker for a post-accident drug screen (if applicable in your HR policy)

          If the injured worker declines care, have them sign the waiver of medical treatment form

          Complete and perform an Accident Investigation (complete the form)

          Report Claim – immediately (always within 24 hours)

               o     Everything sent to the Insurance Company (or your Main Office)

CLAIMS MANAGER

          Help Store Secure the video (gather surveillance tapes as soon as possible)

          Return to Work

               o     Follow-up with the worker to schedule their return shift
               o     Request that the injured worker return to you with a work status and Dr’s note – remember
                     the 7 DAY PERIOD. It is important to get the injured worker back to work within 7 days.

          Return to Work (Leadership Communication)
             o Contact your leadership if it is not going to be possible to return them in 7 days from
                 accident date or if they do not follow up with you
             o Call your claims adjuster with an update

          Follow-up with Store Manager
              o Ensured worker returned by the specified time/date

                                               Download this Form at
                   http://www.besnardinsurance.com/resources/MCD/MCD_WC_ClaimsChecklist.pdf

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EMPLOYEE WAIVER
                           OF MEDICAL TREATMENT
DATE:

EMPLOYEE NAME:

As of the date noted above, I am notifying my employer of an injury that occurred on

                              , 201__

         My supervisor did not receive notification of this incident.
         My supervisor did receive notification of this incident on                                        , 201__

This injury, (briefly describe condition)

occurred during the normal scope and duties of employment.

At this time, I have been requested by my employer to be medically evaluated by a preferred medical
provider within the managed care network. I decline to be medically evaluated for the above
noted condition.

I understand that by signing this document, any future claims regarding this injury will require a medical
evaluation by a preferred medical provider within the managed care network or I may be responsible for
any medical bills or lost wages. I also understand that should I seek treatment for this injury, I must first
notify my supervisor and go to a provider in the managed care network.

                           SHOULD THE CONDITION BECOME LIFE THREATENING
                           SEEK APPROPRIATE EMERGENCY CARE IMMEDIATELY

EMPLOYEE STATEMENTS

By signing this form I acknowledge:
     I have not sought medical treatment for this injury
     I understand that it is the policy of my employer to have a post-accident drug screen and this refusal
       of medical treatment does not remove the requirement that I receive a post-accident drug screen.
     I have read the above information and agree it is factual and true statement. I authorize any
       physician, hospital or healthcare provider to release and furnish any and all medical records or
       other information pertaining to the above listed condition.

_
             Employee Signature                                              Supervisor/Witness Signature

_
                    Date                                                                    Date

                                     Download this Sample Form at
      http://www.besnardinsurance.com/profitingfromsafety/downloads/MCD_EMPLOYEE_WAIVER.pdf

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McDonald’s Worker Injury
                           NOTICE OF INJURY
1. Caller’s Name:
2. Caller’s Job Title:
3. Caller’s Contact Phone:
4. Caller’s Fax Number:
5. Operator Name:
6. Operator’s Office
   Mailing Address:
7. Name of Injured:
8. Male or Female:
9. Injured’s Home Phone:
10. Injured’s Social Security:
11. Injured’s Date of Birth:
12. Injured’s Home Address:

13. Job Duty When Injured:
14. Full or Part Time:
15. Date of Injury:                                                      16. Time of Injury:
17. Address & Store Number
    Where Injury Occurred:
18. Was Injury on Property:                                              19. If not, where?
20. Body Part Affected:
21. Description of Accident:

22. Description of Injured: (height, weight,
     color hair, length of hair, facial hair,
     glasses, etc.)
23. Any Video of the Accident?                                           24. Do you agree with accident?
25. Did injured receive medical treatment?                               26. If yes, where?
27. Was treatment authorized?                                            28. Has Injured Returned to Work?
29. Injured’s Hourly Rate of Pay:                                        30. Average Hours Per Week:
31. Injured’s Supervisor:                                                31. Has Supervisor Been Notified?
33. Date the Injured Last Worked:                                        34. Injured returned to work yet?

Please use as a tool to help you when calling the claim into your insurance company. It is very important to
                 get as much detail as you can about the claim including witness statements.

          Contact your claims adjuster for more specific reporting questions, State specific forms, etc.

                                         Download this Form at
       http://www.besnardinsurance.com/profitingfromsafety/downloads/MCD_InjuryNotice_Sample.pdf
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Benefits of a Thorough Investigation
A thorough investigation often results in many benefits:

                It may prevent incident recurrence.
                It reveals the possible causes of operational interruptions and indicates
                 possible corrective action.
                It eliminates economic losses resulting from possible damaged tools,
                 machines, and materials.
                It creates an awareness of areas to consider.
                It may reveal how methods and procedures can be improved.

Investigations Reduce Claim Frequency

Studies have shown that investigation also results in a substantial decrease in claim
frequency. Through investigation, the cause of an incident may be determined,
potentially reducing the risk of a similar incident recurring.

What to Investigate
Explore as many details as necessary to uncover the root cause of the incident.
Details could include:

    Practices utilized. Was there a departure from the proper procedure?
    Physical conditions. Was there a physical issue with equipment or tools?
    Incident source. Were there any tools, materials, or equipment involved?
    Type of incident. How was the person affected or what damage occurred?
    Part of body affected. Which part(s) of the body is the subject of complaint?
    Personal factor. What was the reason for the person's unsafe action or practice?

Whom to Interview and How

Interview all crew members or customers involved immediately following the incident. Follow these
basic guidelines when interviewing those involved and those who witnessed the incident.

 Put the person at ease. Emphasize prevention as your goal.
 Interview at the scene of the incident, if possible.
 Ask for the person's version of the incident. Let the person speak without interruption.
 Ask only necessary questions. Avoid "why" questions to avoid defensiveness.
 Repeat the person's story as you understand it. This assures the person that you understand
  clearly what happened and allows the person to correct any mistakes, if necessary.
 Close the interview on a positive note of prevention. This reaffirms the purpose of the interview
  and sets the tone for the rest of your investigation
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MANAGER’S ACCIDENT
                                           INVESTIGATION FORM

                                            DATE                                                TIME

                                                                                                                                        AM    PM
                                            EMPLOYEE INVOLVED                                   AGE

   NOTE TO SUPERVISOR:
                                            POSITION                                            DATE EMPLOYED
   Remember, an accident
   investigation is not
   designed to find fault or
                                            MANAGER ON DUTY                                     HAS THIS INCIDENT BEEN REFERRED TO
   blame. It is an analysis to                                                                  THE SAFETY COMMITTEE?
   determine because that                                                                           YES       NO
   can be controlled or
                                            HOW LONG HAS THE EMPLOYEE BEEN                      WAS THE TASK:
   eliminated.                              DOING THIS TASK?                                       ROUTINE   INFREQUENT
   When completing the                                                                             NEW EXPERIENCE
   investigation, try to answer             HAS THE EMPLOYEE HAD THE PROPER                     WERE THERE WITNESSES? IF SO,
                                            TRAINING?                                           ATTACH STATEMENT
   these questions.

 How did the accident                      DID THE ACCIDENT RESULT IN INJURY?                  HAVE SECURITY RECORDINGS BEEN
  occur?                                                                                        RETAINED?

 Where did it happen?                      NATURE AND EXTENT OF INJURY?

 What station did this
  occur?                                    DATE INJURY REPORTED?                              WAS FIRST AID GIVEN?

 Who was injured?
                                            HOW DID THE ACCIDENT OCCUR?
 When did it happen?

   RECOMMEND                                PRIMARY CAUSE OF ACCIDENT?
   CHANGES:

   No investigation is                      RECOMMENDATIONS TO PREVENT RECURRENCE
   complete unless corrective
   action is suggested.
                                            NAME OF PERSON RESPONSIBLE FOR CORRECTIVE ACTION
   FOLLOW-UP:
   Determine what action is
   being taken on your                      WHAT ACTION HAS BEEN TAKEN?
   recommended changes.

                                            SIGNED                                                              DATE

                                  Download this Form in both English/Spanish at:
             http://www.besnardinsurance.com/resources/MCD/MCD_ManagersAccidentInvestForm.pdf
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Accident Additional Statements
                         Please use this form to gather additional written statements
                   from the claimant about the accident as well as any additional witnesses

CLAIMANT STATEMENT
(Please explain in detail how the accident occurred? What are your complaints/injuries?)

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________

Name: __________________________

Signature____________________                       Date__________

I confirmed this information is accurate and true.

WITNESS STATEMENT
(What did you see, what do you remember? Were there any additional witnesses? What did the injured
worker tell you?)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________

Name: __________________________

Signature____________________                       Date__________

I confirmed this information is accurate and true.

                                        Download this Form at
http://www.besnardinsurance.com/profitingfromsafety/downloads/MCD_ADDITIONAL_STATEMENTS.doc

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Insurance Claims
When accurate and detailed information is sent to an insurance carrier immediately, claims are
more accurately evaluated and costs are reduced. Claim costs increase significantly when
claims are reported more than 3 days after the accident occurred.

Benefits of Prompt Reporting

         Reduces fear and anxieties of those affected by the incident
         Assures proper medical attention and future medical direction
         Creates earlier return-to-work results
         Eliminates hidden costs of workers' compensation
         Initiates case management

Report All Incidents within 24 Hours

Report any incident at your restaurant within 24 hours. Reporting incidents within 24 hours
ensures that the injured employee will get the care they need as quickly as possible, and also, that
further investigations may be performed. Also, corrective action can be accessed and shared with
other locations immediately.

Fraud
Worker’s Compensation fraud can be a costly to your stores. Working closely with insurance
adjuster is one way to reduce the potential for fraud. Being familiar with the indicators of fraud is
another way. Whenever fraud indicators are identified and reported to the insurance company,
there is a good chance that the claim can be denied (if it is confirmed to be fraudulent).

Indicators of fraud include:
          Injury that has no witness other than the employee
          Injury occurring late Friday or early Monday
          The circumstances of the injury change as time goes by
          The injury changes, or becomes worse
          Employee is disgruntled
          Injury not reported until a week or more after it supposedly occurred
          Injury occurring before a holiday, or in anticipation of termination
          Injury occurring in a location where the employee would not normally work
          Injury that is inconsistent with normal job duties
          Employee observed in activities inconsistent with the reported injury
          Employee history of workers' comp claims
          Conflicting diagnoses from subsequent treating providers
          Evidence of employee working elsewhere while drawing benefits

Note – Report all injuries, even if multiple indicators of fraud are identified. Indicators of fraud are not
guarantees that the injury did not happen. It is important to ensure that employees are taken care of, and
to let the insurance company investigate the claim. Alerting them to your concerns will trigger the
investigation!

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Return to Work Procedures
Returning an injured crew member to the restaurant is important to all of the parties.
Employees heal faster when they return to work, and make more money while
working than while on Worker’s Compensation. Employers also benefit from
keeping a trained employee on staff, and not having to shift schedules around for
the missing employee, or worse yet, having to train a new employee. Return to
work keeps insurance costs down, and is easier to implement than one might think.

The key in the process then is how to create an effective program that allows
employees to return to gainful employment, as fast as possible? The first key is
having transitional duty job tasks available prior to the injury. Obviously it is
impossible to know who will be injured, when, and what the restrictions will be, but it
is possible to identify tasks that any injured employee can perform. Looking for
tasks in four major categories can cover just about any type of injury an employee
will have. Restrictions typically cover the amount an employee may lift, whether or
not they can use both hands, or whether or not they can stand.

Here are the categories to address:

           Lifting 25 Pounds Or Less – This restriction is common on any strain injury.
            At a McDonalds, there items that weigh more than 25 pounds. Boxes of
            frozen foods and containers of iced tea are some of these items. Most
            positions can be easily modified with lifting eliminated.

           Use of One Arm – Employee’s who strain an arm, burn a hand, or fall and
            injure an arm/hand will have this restriction.

           Sitting – If an employee suffers an injury to his or her leg or back, the
            restriction may be for the employee to sit.

           Sitting and Standing – Some doctors will want the employee to take
            frequent breaks, or alternate sitting and standing. The Drive Through
            attendant may be a good position for this restriction, or cashier.

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Return to Work Procedures (continued)

     Once the program is in place, it is important that all employees in the store be
     trained. Supervisors should be made aware that employees will be returned to
     work, and may need assistance once they return. Employees should be trained
     from their first day that if at any point they have an injury, they will be returned to
     work. Employees should be made aware of how Worker’s Compensation works,
     and that they will make more money when they return to work, than if they are
     away.

     Use the modified duty program defined below to assist a crew member in
     returning to work.

     Modified Duty Program

     The modified duty program includes four job classifications. These classifications
     define the physical abilities required for the task and allow you and the attending
     physician to determine the type of work a crew member may be able to handle
     when he or she returns to work. The table below outlines the classifications of
     duties including various restrictions.

     Note: Jobs may need to be varied for specific restrictions offered by the attending physician.

            McDonalds Transitional Duty Jobs by Classification

                                                        Sedentary-type Work

                                                                Light Work

                                                              Medium Work

                                                               Heavy Work

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McDonalds Transitional Duty Jobs by Classification
Classification                            Definition
Sedentary-type work                       Sedentary-type work includes lifting 10 pounds (4.5
                                          kilograms) maximum. This work involves sitting, occasional
                                          walking, standing, and wrapping and packaging finished food
                                          products, such as hamburgers and fries. The following
                                          positions would be considered sedentary-type work:
                                          - Drive-thru or front counter order-taker cashier
                                          - Assemble Kids Meals Boxes

Light work                                Light work involves lifting 20 pounds (9.1 kilograms)
                                          maximum, with frequent lifting or carrying up to 10 pounds
                                          (4.5 kilograms). These jobs also include a small degree of
                                          pushing and pulling of arm and leg controls, and walking or
                                          standing, some to a significant degree. The following
                                          positions are light- work positions:
                                          - Runner
                                          - Milkshakes and soft serve preparation
                                          - Fry station
                                          - Production caller
                                          - Biscuit preparation
                                          - Salad assembly
                                          - Setup transition or service
                                          - Hotcakes preparation
                                          - Pie preparation
                                          - Host or hostess
Medium work                               Medium work involves lifting 50 pounds (22.7 kilograms)
                                          maximum, with frequent lifting or carrying of objects
                                          weighing up to 25 pounds (11.3 kilograms). These jobs
                                          include the following:
                                          - All grill area positions
                                          - Grill setup or transition
                                          - Dining room and restroom pre-close and close
                                          - Service pre-close and close
                                          - Back room pre-close and close
Heavy Work                                Heavy work involves lifting 100 pounds (45.4 kilograms)
                                          maximum with frequent lifting, or carrying objects weighing
                                          up to 50 pounds (22.7 kilograms) these positions include the
                                          following:
                                          - Maintenance
                                          - Unloading Trucks

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RETURN-TO-WORK POLICY
                                                                (Sample)

Please read the following carefully. This policy applies to all employees with work
related injuries.

      Our Company is committed to maintaining the safety, health and productivity
       of our employees.

      Modified and transitional duty is a temporary work offer pending determination
       of an employee’s ability to return to regular duty work.

      It is this company’s policy that injured employees accept and fully cooperate
       with modified and transitional duty work found suitable by the attending
       physician.

      Failure to accept modified or transitional duty work that the attending
       physician has found to be within the employee’s capabilities may result in the
       reduction or suspension of time loss benefits.

      Failure to comply with the company’s return-to-work policy and procedures
       without authorized exception may subject the employee to disciplinary action.

      All employees are responsible for reading and understanding this company’s
       policy and procedures for return-to-work and discussing any questions or
       concerns with management.

Employee Name: ______________________________

Employee Signature: ______________________ Date: ________

                              Download the English/Spanish of this document at
                    http://www.besnardinsurance.com/profitingfromsafety/rtw-a-win-for-all/

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Return to Work Letter - SAMPLE
Instructions for Employer:
This is to be sent by the employer to employee with a copy of the doctor’s release via regular and certified
mail. Please be sure to copy your insurance company.

A reasonable time has to be given for the employee to show up timely for light duty work.

__________
(Date)

________________
________________
________________
(Address)

Dear          :

We are pleased to learn that you have been released to return to employment at ____________.
According to _________________, you are able to return to ____ duty position. Such a position is
available at _____________________, the details of which are as follows:

                    Position Title: ________________________________________________
                    Job Description: ______________________________________________
                    ____________________________________________________________
                    ____________________________________________________________
                    ____________________________________________________________
                    ____________________________________________________________

                    Date to Report to Work: ________________________________________
                    Location to Report to: _________________________________________
                    Person to Report to: ___________________________________________
                    Time to Report: ______________________________________________
                    Schedule as Follows: __________________________________________
                                         __________________________________________

                    Wage rate: ____________

We are please to be able to offer you this position within the work guidelines established by
_____________________. If you have any questions prior to your start date, please call me at
_______________.
                                                              Very truly yours,

                             Download the English/Spanish of this SAMPLE document at
            http://www.besnardinsurance.com/profitingfromsafety/downloads/ReturntoWorkLetter.doc

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Section 10

                       Other Resources

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Helpful Safety Web Sites

McDonald’s Safety Resources (and Newsletter)
          www.ProfitingFromSafety.com
          www.mcdsafety.com

Insurance Company Specific Sites
          Amerisure: www.mcdAmerisure.com

Other Sites
          Workers Compensation 101 – Learn the Basics
          http://www.besnardinsurance.com/workers-compensation-2/faqs/

          Hiring Support
          http://www.besnardinsurance.com/profitingfromsafety/hiring-support/

          Automobile Safety
          http://www.besnardinsurance.com/profitingfromsafety/category/automobile/

          Property and General Liability
          http://www.besnardinsurance.com/profitingfromsafety/category/propertyliab/

          Employment Practices Liability
          http://www.besnardinsurance.com/profitingfromsafety/category/employment-practices/

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The Latest in Slip and Fall Prevention

Preventing slips and falls is most directly related to a clean floor, but there are new,
cutting edge techniques that can not only help keep your floors clean, but also
reduce the time and effort it takes to keep them clean. Also, floors can be treated to
help to increase the coefficient of friction. Here are a few of the many cutting edge
methods to help keep the floor clean, and reduce slip and falls:

Automated Floor Scrubbers – Automated floor scrubbers put down water and
cleaning solution, scrub the floor, and vacuum it back up again. This helps to clean
the floors, and also reduce drying times as well. Cleaning is much faster, and
requires less effort by your employees. In addition to a cleaner floor, the potential
for strains is also reduced. Approved floor scrubbers can be found at
www.profitingfromsafety.com. See ‘Safety Product – ECOLAB Scrub N Go’.

Weighted Deck Brushes – A weighted deck brush is similar to a regular deck brush,
with the exception that it has a weighted head. This allows for the brush to provide
the pressure to the floor, opposed to the employee. The issue with standard deck
brushes is that as the employee fatigues, the scrubbing of the floor is reduced,
causing sections of the floor to be not as clean as others. If the employee is tired by
the time they arrive at the fryer, then most likely, the floor of the restaurant will not
clean, as grease can be tracked from the fryer to other parts of the restaurant.

In addition to the weighted deck brush, additional deck brushes are available with U-
Shaped heads, that are helpful in cleaning around fixed tables, and V-Shaped
heads, that are helpful in cleaning baseboards. Note, all three of these brushes can
help to reduce time and effort in cleaning effectively. Approved, alternative deck
brush reviews can be found at www.profitingfromsafety.com, to include videos and
analysis of the problem. See ‘Smarter Floor Cleaning,’ and ‘The Meaning of Dirty
Mop Water.’

Floor Treatments – Older tile may not have the same coefficient of friction, even
when clean, as newer tile. Years of foot traffic and scrubbing may have created a
smoother surface that can lead to increased slips and falls. Even new tile can be
made to have a higher coefficient of friction, even when wet, after being treated
properly. All floor treatments, however, are not the same. First, not all are
approved. Also, some can etch the floor and remove group sealants. Approved
floor treatment articles and reviews can be found at www.profitingfromsafety.com.
See ‘Reducing Slips and Falls in Restaurants.’ This article reviews the NO-Slip floor
treatment.
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WORKER INJURY
              SERIOUS OR LIFE-THREATENING
            EMERGENCY REPORTING PROCEDURES
Report all work-related injuries and illnesses that have, or will, result in
            medical attention other than on-site first aid to:

                                                AMERISURE MUTUAL INS CO

                          24 Hour Reporting Hotline
                               (888) 784-6609
                     (MCMC – Amerisure’s Claims Adjusting Company)

     IF ACCIDENT/ILLNESS/                                     THEN REPORT TO AMERISURE:
     INCIDENT RESULTS IN:
                   1) Fatality                                         Call Report in Immediately
      2) Serious or Severe Injury                                      Call Report in Immediately
             3) Hospitalization                                        Call Report in Immediately
        4) Loss of Consciousness                                       Call Report in Immediately
                 5) Disability                                         Call Report in Immediately
       Any other illness or injury                          Mail or fax report within 5 calendar days.

                                WHEN IN DOUBT CALL IN REPORT TO
                                          AMERISURE MUTUAL INS CO
                                                 AS SOON AS POSSIBLE

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Introductory letter to Physician
                                                       Coventry/ First Health
Date: __________________________
Employer Name: ________________________________________________________________________________
Employer Telephone Number ______________________________________________________________________

Dear Health Care provider,

____________________________________________________ is scheduled for an initial visit as an employee of
____________________________________________________, which is a participant in the AMERISURE INSURANCE COMPANY /
COVENTRY FIRST HEALTH NETWORKThis letter does not confirm that the injury or condition is covered by Workers’ Compensation
Insurance. That determination will be made as soon as an investigation is completed by our claims adjsuter.

DRUG TESTING IS REQUIRED:
               □ Urinalysis
               □ Breathalyzer (blood test if necessary)

We are working closely with COVENTRY/ FIRST HEALTH and the envolved medical providers to ensure that out employees receive access to
timely and medically necessary treatment for their industrial injuries. In the best interest of our employees, we will have modified work available,
which would allow the employee to return to work at the earliest possible date.

                                          PLEASE CONTACT AMERISURE INSURANCE COMPANY
                                                         At (800) 282-2743
                                               WHEN ONE OF THE FOLLOWING OCCURS

     1.   New Injury with disability greater than 7 days
     2.   Hospitilization
     3.   Anticipated Surgery
     4.   Physical Therapy of Chiropractic Treatment Recommended
     5.   Referral to provider
     6.   Assistance Required to Return Injured Employee to Work
     7.   Repeat Major Diagnostic Studies

     All claims for treatment must be submitted to the address below on a HCFA 1500, UB 92, or the appropriate form required by the state.
     Please submit all medical reports with the Bills within the time frame required by the apllicable state law. .

                                                      AMERISURE INSURANCE COMPANY
                                                     P.O. BOX 33478- Detroit, Michigan 48232
                                                   Phone: (800) 282-2743- o- Fax: (727) 561-7153

     Should you have questions regarding your participation in the COVENTRY/FIRST HEALTH NETWORK, please refer to the provider’s
     manual.

     Sincerely,

                       Print Name                                                               Signature

Download at: www.mcdAmerisure.com
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Carta Introductoria al Médico
                                                        (Coventry/ First Health)
Fecha: __________________________
Nombre del Empleador: ________________________________________________________________________________
Numero de Teléfono del Empleador: ______________________________________________________________________

Estimado Proveedor de Cuidados de Salud:

____________________________________________________ está programado para una visita inicial como empleado de
____________________________________________________, el cual es participante de AMERISURE INSURANCE
COMPANY / COVENTRY FIRST HEALTH NETWORK. Esta carta no confirma que la lesión o la condición esté cubierta por el Seguro de Compensación para
Trabajadores (Workers’ Compensation Insurance). Esa determinación se hará tan pronto nuestro ajustador de reclamos complete la investigación.

ES REQUERIDO EL EXAMEN DE DROGAS:
              □ Análisis de Orina
              □ Breathalyzer (análisis de sangre si es necesario)

Estamos trabajando conjuntamente con COVENTRY/ FIRST HEALTH y con los proveedores de salud involucrados para asegurar que nuestros empleados
reciban acceso al tratamiento médico oportuno y necesario para sus lesiones laborales. En el mejor interés de nuestro empleado, nosotros modificaremos los
trabajos disponibles, lo cual le permitirá al empleado regresar al trabajo lo más pronto posible. Por favor tenga esto presente al tratar a este empleado.

                              POR FAVOR PONGASE EN CONTACTO CON AMERISURE INSURANCE COMPANY
                                                      AL: (800) 282-2743
                                          CUANDO ALGUNO DE LOS SIGUIENTES OCURRA:

     8.    Nueva lesión con incapacidad mayor a 7 días y No dada de alta para regresar al trabajo
     9.    Hospitalización
     10.   Cirugía anticipada
     11.   Terapia física o Tratamiento Quiropráctico Recomendado
     12.   Referido al proveedor
     13.   Asistencia requerida para regresar al empleado lesionado a trabajar
     14.   Repetir estudios de Diagnóstico Mayor

     Todas las reclamaciones para tratamiento tienen que ser sometidas o presentadas a la dirección que aparece debajo, en un
     HCFA 1500, UB 92 o los formularios apropiados requeridos por el Estado. Por favor someta o presente todos los reportes
     médicos dentro del margen de tiempo requerido por la ley del Estado aplicable.

                                                          AMERISURE INSURANCE COMPANY
                                                         P.O. BOX 33478- Detroit, Michigan 48232
                                                          (800) 282-2743- o- Fax: (727) 561-7153

     Si usted tiene alguna pregunta acerca de su participación en COVENTRY/ FIRST HEALTH NETWORK, por favor refiérase al
     manual de proveedores.

     Sinceramente,

                             Nombre                                                                     Firm

Download at: www.mcdAmerisure.com

                                                                                                                                               72
Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)
Your McDonald’s Insurance Team

                                                    3000 Bayport Drive Suite 400
                                                         Tampa, FL 33607
                                                      PHONE: (877) 200-1718
                                                       FAX: (877) 644-3670

                                                          Joe Besnard
                                                   Account Executive, Ext. 204
                                               Joe.Besnard@BesnardInsurance.com

                                                       Adam Besnard
                                                 Account Executive, Ext. 205
                                             Adam.Besnard@BesnardInsurance.com

                                                    Vivian Arencibia (Florida)
                                               Account Service Manager, Ext. 203
                                            Vivian.Arencibia@BesnardInsurance.com

                                          Vanessa Alfonso (Non-Florida/Other States)
                                              Account Service Manager, Ext. 208
                                           Vanessa.Alfonso@BesnardInsurance.com

                                                         Kristina Baker
                                                    Account Services, Ext. 201
                                             Kristina.Baker@BesnardInsurance.com

                                                           Milly Travieso
                                                     Account Services, Ext. 207
                                                    Milly@BesnardInsurance.com

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Safety Book – 2012 Copyright © Besnard & Associates All Rights Reserved – (Please be sure to read the Disclaimer on the last page)
Disclaimers
Besnard & Associates and its insurance company partners assist employers in evaluating workplace safety
exposures. Surveys, materials, and related services may not reveal every hazard, exposure and/or violation
of safety practices. Inspections by your insurance company do not result in any warranty that the
workplace, operations, machinery, appliances or equipment are safe or in compliance with applicable
regulations. Any recommendations and related services are not and should not be construed as legal advice
or be used as a substitute for legal advice. Employee protection and safety is ultimately the responsibility of
the employer.

Statements in this book or on web sites as to forms, policies, coverages, or other information provide
general information only. This information is not an offer to sell insurance. Insurance coverage cannot be
bound or changed via submission of any online form/application provided on this site or otherwise, email,
voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance
coverage go into effect unless and until confirmed directly by a licensed broker. Any proposal of insurance
we may present to you will be based upon the information you provide to us via this online form/application
and/or in other communications with us. Please contact our office at (877) 200-1718 to discuss specific
coverage details and your insurance needs. All coverages are subject to the terms, conditions and exclusions
of the actual policy issued. Not all policies or coverages are available in every state. Information provided
on this Site does not constitute professional advice; if you have loss control, HR, legal, tax (or financial
planning questions), you should contact an appropriate professional. Any hypertext links to other sites are
provided as a convenience only; we have no control over those sites and do not endorse or guarantee any
information provided by those Sites.

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                              Corporation and its affiliates, used with permission.

           All material in this book is © 2012 Copyright Besnard & Associates All Rights Reserved.

                   Unauthorized reproduction or use of any materials is strictly prohibited by law.

                                http://www.besnardinsurance.com/profitingfromsafety/disclaimer/

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