Workers Compensation Claim Kit - Nevada

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

BHHC NV Claims Kit Introductory Letter – 07/31/2017 (page 3 of 19)

BHHC Instructions for NV Postings – 05/29/2018 (page 4 of 19)

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

Occupational Disease – 06/2018 (page 5 of 19)

NY Form D-2 – Brief Description of Rights and Benefits – 06/2018 (page 6 of 19)

NV Form D-22 – Notice to Employees – 07/1999 (page 7 of 19)

NV Form C-3 – Employer’s Report of Industrial Injury or Occupational Disease – 11/2005 (page 8 of 19)

NV Form C-1 – Notice of Injury or Occupational Disease – 10/2005 (page 9 of 19)

NV Form D-8 – Employer’s Wage Verification Form – 10/2010 (page 10 of 19)

NV Form D-23 – Employee’s Declaration of Election to Report Tips – 07/1999 (page 11 of 19)

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

19)

BHHC Authorization for the Release of Information – 02/16/2014 (page 13 of 19)

BHHC Medical History Request – 02/16/2014 (page 14 of 19)

BHHC General Employee Accident Report – 02/16/2014 (page 15 of 19)

BHHC General Supervisor Accident Report – 02/16/2014 (page 16 of 19)

BHHC General Witness Accident Report – 02/16/2014 (page 17 of 19)

BHHC Workers’ Compensation Fraud Posters (English & Spanish) – 08/10/2018 (pages 18-19 of 19)

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:

Online: 1. Go to our website: www.bhhc.com 2. Highlight “Workers Comp” in the menu 3. Highlight “Claims Center” 4. Click “Report a Claim”

Phone: (800) 661-6029 Fax: (800) 661-6984 E-mail: newclaim@bhhc.com

Nevada state law requires employers to report every industrial injury or occupational disease claim to their workers compensation carrier within 6 days of employer knowledge of an injury. State law also 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

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

WORKERS’ COMPENSATION POSTING REQUIREMENTS

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 be in at least 10-point font-size

To complete the form, please enter the name, address, contact person, and phone number for MCO/health care provider, along with the name of your designated insurer. For your convenience, our other contact information has been entered on the Poster. Please note, the form fields are designated to populate at text meeting the statutory font-size requirement.

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

Form D-2 – Brief Description of Rights and Benefits

• Post next to Form D-1 – Brief Description of Your Right sand 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.470)

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 Right sand 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 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 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. NAIW is an independent state agency and is not affiliated with any insurer. 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 Workers’ Compensation Section, 400 West King Street, Suite 400, Carson City, Nevada 89703, telephone (775)684-7270, or 3360 W. Sahara Ave., Suite 250, Las Vegas, NV 89102, 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

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. 6/18)

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

3360 West Sahara Avenue, Suite 250, Las Vegas, Nevada 89102, 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. 06/18)

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 BECOMPLETED AND MAILED TO THE INSURER WITHIN

EMPLOYER'S REPORT OF INDUSTRIAL INJURYOR OCCUPATIONAL DISEASE

First Name M.I. Last Name Social Security Birthdate Age Primary Language Spoken

Home Address (Number and Street)

City State Zip How long has this person been employed by youin Nevada?

In which state was employee hired? Employee's occupation (job title) when hired or disabled Department in which regularly employed:

Telephone Is the injured employee a corporate officer? . . . sole proprietor? . . . partner? Was employee in your employ when injured or disabled byoccupational disease (O/D)?

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)

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

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

WitnessNature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)

Did employee return to work next scheduledshift after accident? (if applicable)

If validity of claim is doubted, state reason .

Location of Initial Treatment

Treating physician/chiropractor name

IMPORTANTHow many days per week doesemployee work? From

Last day wages were earned

Scheduled Days Off Are you paying injured or disabled employee's wages during disability?

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

On the date of injury or disabilitythe employee's wage was:

For assistance with Workers' Compensation Issues you may contact the Office of the Governor Consumer HealthAssistance Toll Free : 1­888­333­1597 Web site: http://govcha.state.nv.us E­mail cha@govcha.state.nv.us

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

Employer's Signature and Title Date

Deemed Wage Account No. Class Code

Claims Examiner's Signature Date Status Clerk Date

Form C-3 (rev.05/10)

AM PM to PMAM

S M T W T F S Rotating

Was the employee hired to work40 hours per week?

If no, for how many hours aweek was the employee hired?

Did the employee receive unemployment compensation any time during the last12 months?

6 WORKING DAYS OF RECEIPT OF THE C­4 FORM

SexMale Female

Marital StatusSingle Married Divorced Widowed

Was the employee paid forthe day of injury?

Yes No

Corporate Officer Sole Proprietor Partner Yes No

Yes No

Yes No

Yes No

Will you have light duty workavailable if necessary?

NoYes

Emergency Room? Yes No NoYes

Yes No

For the purpose of calculation of the average monthly wage, indicate the employee's gross earning by pay period for 12 weeks prior to the date of injury ordisability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D­8). Gross earnings will include overtime, bonuses,and other renumeration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earningsfrom the date of hireto the date of injury or disability.

NoYes

Pay Period ends on:

SFTWTMS

Employeeis paid:

Weekly

BiWeekly

Monthly

Bi­Monthly

Otherper

Hour

Day Month

Week

Claim is:Accepted Denied Deferred Third­Party

Was more than one personinjured in this accident? (ifapplicable

If handwritten,please print.

Yes No

Hospitalized?

Employer's Name Nature of Business (mfg, etc.) FEIN OSHA Log Number

Office Mail Location . . if different from mailing address Telephone Number

City, State, Zip Code INSURER THIRD PARTY ADMINISTRATOR

Print Form

Reset Form

"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)

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)

EMPLOYEE'S DECLARATION OF ELECTION TO REPORT TIPS

For the Purpose of Workers' Compensation

Pursuant to NRS 616B.227

EMPLOYER:

EMPLOYEE:

EMPLOYEE IDENTIFICATION NUMBER:

DEPARTMENT:

SOCIAL SECURITY NUMBER:

PAY PERIOD: TO

AMOUNT OF TIPS RECEIVED DURING PERIOD: $

I understand that the reporting of false information may disqualify me from receiving workers’

compensation benefits, and may subject me to criminal and civil penalties. I declare under penalty of

perjury that the information provided concerning the amount of tips which I have received is true and

correct to the best of my knowledge. Those tips are declared as wages for the calculation of workers'

compensation.

Employee Signature Date

THIS FORM MUST BE SUBMITTED TO YOUR EMPLOYER BEFORE THE END OF THE PAYPERIOD THAT FOLLOWS THE PAY PERIOD INDICATED ABOVE.

D-23 (rev. 7/99)

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)

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Employee Name: Date of Injury: Employer Name: Date of Birth:

I hereby authorize the divisions of Berkshire Hathaway Homestate Companies, their representative or bearer, to review, inspect, copy, and/or photograph any and all of the following documents:

1. Any and all medical records, including but not limited to office and hospital records, laboratory results, diagnostic reports andfilms, psychiatric records, medical correspondences, doctor’s and nurse’s notes, and medical histories relevant to my workers’compensation claim. I also hereby give permission to Berkshire Hathaway Homestate Company representatives to contactthe attending physicians involved in the treatment of all related conditions.

2. All employment and human resource information including but not limited to: hiring and employment records, payroll andincome statements, documentation related to this or any other relevant injury and any other information pertinent to providing benefits and services necessary for the completion of this claim.

The released information is required for the following reasons:

1. To provide for adequate preparation, investigation, evaluation, review, and discovery of a claim for workers’ compensation benefits. Specifically, to determine the causation and the nature and extent of any possible pre-existing, concurrent oraggravating medical conditions with potential medical, legal, or factual implications in the this work-related injury or injuries.

2. To provide the treating physician, consultant or evaluator with medical information necessary to provide you with the bestpossible medical care and medical advice.

3. To facilitate recovery of all benefits paid toward your workers’ compensation claim from any third party responsible for thisinjury.

4. To ensure that you are accurately compensated for any amount of lost wages, time or resources while undergoing evaluation,treatment and recovery for this injury.

5. To obtain any information necessary to appropriately determine further actions as a result of the injury or condition and toprevent further issues for you and other employees.

This consent and authorization is effective immediately, and is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon, and if not earlier revoked, it shall terminate on conclusion of the claim without express revocation.

A copy or fax is as valid as the original.

(Names, addresses, and phone numbers of providers)

I have read this authorization and fully understand its entire contents. I have asked questions about anything that was not clear to me and I am satisfied with the answers I have received. I understand that I have a right to receive a copy of this authorization upon my request.

Signed: Date:

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

MEDICAL HISTORY REQUEST

Employee Name: Date of Injury: Employer Name: Completion Date:

Please complete this form by providing your medical history for the past 5 years. This will help ensure that we are able to provide all of your medical records to your current treating physician for you to receive the proper care for your work injury.

Thank you for your cooperation.

Past Injuries, Disabilities, or Other Medical Conditions

Hospitalizations HOSPITAL NAME, ADDRESS AND PHONE DATES ADMITTED

Treating Physicians or Groups DOCTOR OR GROUP NAME, ADDRESS AND PHONE DATES OF TREATMENT

EMPLOYEE’S ACCIDENT REPORT To be completed by the injured worker

Employee name Employer name

Date of accident Time of accident Time you began work on day of accident Location of accident (specify if off-site address)

How did the injury occur? What job duties were you performing? Please describe in your own words.

What part(s) of your body was injured (indicating right and/or left)?

Have you sought any medical treatment for these injuries? If so, specify where and when.

Have you ever injured this part of your body before (yes or no)? If so, please describe how and when the previous injury(s) occurred.

What witnesses were present when the accident occurred? Please provide names if applicable.

Who did you report the injury to? When was the injury reported? Please provide name(s) and job title(s).

What did you do after the accident occurred?

The above report is true and correct: SIGNATURE: DATE FORM COMPLETED:

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.

BHHC Workers Compensation Division • Representing Financial Strength & Integrity

$1000 Reward!For 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 (BHHC)*

In most states, it is a felony to make or cause to be made a knowingly false or fraudulent material statement in order to obtain workers compensation benefits. BHHC 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 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:

1 (800) 300-JAIL

*Maximum reward of $1,000 per conviction. In the event that more than one individual submits information regarding the same fraudulent claim, BHHC will equally divide the reward among those providing information used in obtaining the conviction. BHHC 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 intrepretation of this policy shall be resolved by BHHC at their sole discretion. Program subject to change or termination without prior notice.

BHHC Workers Compensation Division • Representing Financial Strength & Integrity

$1000 RECOMPENSA!INFORMACIÓN 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 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.

(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.