BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
INTRODUCTION
The Board of Directors and the staff at Builders Insurance Group would like to welcome you as a
customer of Builders Insurance, a Mutual Captive Company. Builders Insurance is the largest
writer of workers’ compensation insurance in the state of Georgia. As your full service insurance
provider, it is our goal to provide you with the very best product and service at a fair price.
Builders Insurance, a Mutual Captive Company, has a number of services designed to help you
manage your workers’ compensation risks. Our Employers’ Guide to Workers’ Compensation
was designed to offer information about your workers’ compensation coverage. Our goal is to
provide answers to the questions we hear most frequently from you, our customer, and familiarize
you with the services we offer to enable you to use them most effectively.
The topics covered in this book include information regarding safety and loss control, the
development of the Experience Modification Factor and how it impacts your premium, claims
reporting and claims handling, premium accounting and audits, and premium discounts available
to you. Listed on the final page of this book are the names, phone numbers, and e-mail
addresses of our service team. Please contact a member of our service team for any additional
assistance you might need. Your call or e-mail will be answered promptly.
Builders Insurance also has a team of field loss control and safety consultants available to assist
you. Our consultant’s focus is to help you, the employer, integrate proven loss control techniques
into the overall business plan of your operations to improve the profitability of your company.
We look forward to serving you. We will work diligently with you to help control your workers’
compensation claims and insurance costs.
Again, welcome to Builders Insurance Group – Builders Insurance.
Association Membership Information
Builders Insurance Group is pleased to offer Georgia policyholders two options to satisfy
the association membership requirement of your insurance coverage with Builders
Insurance (A Mutual Captive Company).
Until 2008, the Home Builders Association of Georgia (HBAG) was the exclusive
association membership organization available to policyholders. In April 2008, Builders
Insurance Group launched a new endorsement agreement with the Contractors Benefit
Association (CBA), enabling policyholders to choose to be a member of either the CBA
or the HBAG.
Membership dues in the CBA are $60 per year and include access to cost saving benefits
on products and services ranging from office equipment to web development and payroll
processing.
When your HBAG membership expires, you have the option of renewing your HBAG
membership or enrolling as a new member in the CBA. If you choose to renew your
HBAG membership, you will experience no impact or interruption to your coverage with
Builders Insurance (A Mutual Captive Company).
4
BUILDERS INSURANCE GROUP
VINING INSURANCE COMPANY
ASSOCIATION INSURANCE COMPANY
PAY PLANS
Builders Insurance Group provides Association Insurance Company policyholders a variety of
flexible payment schedules. The payment plans are as follows:
PAYMENT SCHEDULES




Premium $1,000 to $2,500 = 25% Down and five (5) installments - Payment is due on
the first day of each of the five predetermined months.
Premium over $2,500 = 25% Down and nine (9) installments – Payment is due on the
first day of each of the nine predetermined months.
Other Options = May be available subject to underwriting approval.
Audit and Deductible Payments – the due date will be indicated on the invoice and/or
on the estimated billing
MAILING INSTRUCTIONS
Please mail your payments to us, Builders Insurance Group at the following address:
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
POST OFFICE BOX 116572
ATLANTA, GA 30368-6572
LATE NOTICE
A Late Notice will be issued within 7 days, after the due date, if payment has not been received in
our office.
CANCELLATION NOTICE
A Cancellation Notice will be issued within 12 days after the due date if payment has not been
received in our office. To reinstate a cancelled policy, a $60 reinstatement fee will be applied.
For checks returned due to Non-Sufficient Funds, a $30 fee will be applied.
5
Monthly Self Report (MSR)
Online Monthly Self Reports (MSR) is a valuable, time-saving solution to help you
simplify the way you do business with Builders Insurance Group. Take advantage of
this fast, accurate, and easy to use service tool to experience these benefits:

Convenience – Eliminate all paper forms to fill out and mail.

Cost savings – Access Is free, users save the stamp an time.

Accuracy – No need to make complicated calculations nd rils errors – Online
MSR automatically calculates the premium due.

Easy Payment option – No need to mail payments. All you need to do is complete
the worksheet and click “Pay Now” to automatically submit the payroll report and
you payment electronically. Accuracy – No need to make acomplicated
calculation and rils errors – Online MSR automatically calculates the premium
due.

Security – Information is transmitted using encrypted security so payroll and
payment records are safe. Each transaction is acknowledged with an email
confirmation for easy record keeping.
6
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
DEDUCTIBLE PREMIUM CREDITS
DEDUCTIBLES
You may choose to a have a deductible applied to each claim you report during the term of
the policy, subject to underwriting approval. Using a deductible for your workers’
compensation insurance works just like a deductible for your auto insurance. A
deductible is a pre-determined dollar limit that you agree to pay for each claim (or
individual injured worker) you report. To choose a deductible, review your loss history
and then determine what dollar amount you will be financially comfortable absorbing.
The amount of a deductible ranges from $500 to $2500. The deductibles and their
corresponding percentage discounts follow:
Amount Per Claim
$500
1000
1500
2000
2500
Percentage Discount
4.4
6.0
7.1
8.1
8.9
Remember, your insurance policy requires you to “tell us at once if injury occurs that may be
covered by this policy” (this includes disease or illness). Submit all bills to us and we will pay the
medical provider based on the fee scheduled (reduced) amount. You will be billed on a quarterly
basis until your deductible is met or the claim is closed. Should you have any questions, please
contact our Premium Accounting department at (678) 309 4114 or (800) 883 9305, Extension
4114.
7
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VININGS INSURANCE COMPANY
AVAILABLE ACCIDENT & ILLNESS PREVENTION SERVICES
Our loss control consultants are available to meet with you to assist with the development
and implementation of management systems to help prevent accidents. We can help you
implement health and safety programs, hazard identification methods, and various other
initiatives designed to provide a safe and healthful work environment for your
employees.
To provide additional information and assistance we offer the following services and
have the following materials on hand:
Safety Programs – The loss control and safety services department has a variety of
sample safety programs to assist you in the development and implementation of a written
safety program specific to your operations.
Accident & Illness Prevention On-Site Services – The loss control and safety services
department will provide on-site surveys, hazard identification, and policyholder program
review to assist the insured with improving their accident & illness prevention efforts.
These services will be available at policyholder request but may be initiated by the loss
control and safety services department as part of a programmed loss control routine.
Methods of Determining Service Commitments – The loss control and safety services
department will determine our accident & illness prevention service commitments using
the following criteria: policyholder request, loss history, loss ratio, underwriter request,
broker request, and experience modification factor.
Educational Resources – The loss control and safety services department has a number
of accident & illness prevention materials including jobsite safety handbooks, toolbox
safety talks manuals, and payroll stuffers.
Verification Methods – The effectiveness of these accident and illness prevention
services will be determined by verification of implemented recommendations and the
experience modification factor.
For more information, please call us at 800.883.9305 and ask to speak to a loss
prevention consultant.
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Safety Web Sites
Scaffold, Shoring and Forming Institute – www.rmis.com
Substance Abuse Mental Health Service Administration – www.samhsa.gov
The American Society of Mechanical Engineers – www.asme.org
The Occupational Safety and Health Administration (OSHA) – www.osha.gov
Underwriters Laboratories, Inc. – www.ul.com
U. S. Consumer Product Safety Commission – www.cpsc.gov
U. S. Department of Labor – www.dol.gov
U. S. Department of Transportation – www.dot.gov/
National Safety Council – www.nsc.org
NAHB Research Center – www.nahbrc.org/
National Association of Home Builders – www.nahb.com/
American Society of Safety Engineers – National - www.asse.org
American Standards Testing Materials – www.astm.org
Association of General Contractors – www.agcwa.com
American Industries Hygiene Association – www.aiha.org
American National Standards Institute – www.ansi.org
Bureau of Labor Statistics – stats.bls.gov
Centers for Disease Control – www.cdc.gov
9
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
MANAGING THE COST OF THE CLAIM
PANEL OF PHYSICIANS
The responsibility of directing the initial medical care for their injured or ill worker lies with the
employer. This is, in fact, one of the single most important steps the employer can take in
managing the overall success of the claim once it has occurred.
GEORGIA
Georgia state law requires that employers complete the Panel of Physicians (otherwise known as
the “Pink Panel”), post it, and educate workers regarding its use. The law further mandates six
medical providers are listed on the panel along with their address and phone number. Of these
six providers one must be an orthopedic surgeon, no more than two can be industrial clinics
(walk-in clinics), and one must be a minority physician (which is anything other than a Caucasian
male). If it is not feasible to include a minority doctor on your panel you must apply, in writing, to
the State Board of Workers’ Compensation to be granted an exception. The final two providers
you choose may be of any discipline. You may consider choosing an ophthalmologist and an
additional orthopedic surgeon.
In addition to posting the panel, the Georgia employer is also required to educate workers
regarding its use. We have included a form to be signed by your workers (a worker is any worker
for whom you provide workers’ compensation coverage) acknowledging the panel has been
explained to them and they understand that they must use a physician on the panel or be
responsible for any medical costs incurred themselves. A copy of the Panel of Physicians
Acknowledgement Form, in English and Spanish, follow.
STATES OTHER THAN GEORGIA
Employers in states other than Georgia should develop and maintain a list of physicians to whom
injured workers will be directed. Choose medical providers familiar with your business and
operations. Choose providers who can treat the potential injuries to which your workers are
exposed. For example, you may wish to choose an orthopedic surgeon and an ophthalmologist if
your workers are at risk for back injuries or eye injuries.
Our Medical Management Department can provide you with the names of medical providers in
any state. The providers on your list must be reasonably accessible to your workers. If you will
be working outside of your usual geographical area and need assistance with names and
addresses of providers there, please telephone (678) 309-4033 or (800) 883-9305, Extension
4033. Each provider should be contacted to confirm they will take workers’ compensation cases.
The provider should share your philosophy of quality care for the injured worker and a return to
work as quickly as possible.
10
Dear Policyholder:
Enclosed is an Official Posting Notice, commonly known as a “Panel of Physicians” or “Pink Panel.”
Georgia state law requires employers to complete the panel, post it in a common area and educate
employees regarding the use of the Panel.
Employers in states other than Georgia should develop and maintain a list of physicians to whom injured
workers will be directed.
To find qualified physicians to compile your Panel, please visit the First Health Network Web site at
www.bldrs.com:



Click on: For Policyholders; Claims Information; Panel of Physicians.
Click on the words: “clicking here.” Enter Client Id: BIG.
Click on: Channeling Tools. Choose your search.
A traditional posted Panel for Georgia shall consist of a minimum of six (6) non-associated physicians. It is
not limited to a minimum of six (6). The minimum Panel shall include an Orthopaedic physician, and no
more than two (2) physicians shall be from industrial/occupational clinics. The Panel shall include one (1)
minority physician.
Example:
 2 Urgent Care/Occupational Physicians
 1 Family Practice/General Physician
 2 Orthopedic Surgeons
 1 General Surgeon
 1 Ophthalmologist
Refer to Paragraph 4 on the “Pink Panel” and to Georgia State Board of Workers’ Compensation Rule 201
at http://sbwc.georgia.gov for a complete description of the requirements and minority definition.
It is recommended that you contact each physician to confirm he/she accepts Workers’ Compensation cases
and shares your philosophy of quality care and return to work as quickly as possible.
If you need further assistance, please contact Medical Management at
678-309-4172 or 1-800-883-9305 ext. 4172 or you may e-mail medmgt@bldrs.com.
Sincerely,
Medical Management /Builders Insurance Group
Revised 5-2-06/S.Dunn/MM Dept POST OFFICE
BOX 723099 / ATLANTA, GEORGIA 31139-0099
TELEPHONE 678 309-4000 / TOLL-FREE 800-883-9305
CLAIMS FAX 678 309-4075
11
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VININGS INSURANCE COMPANY
PANEL OF PHYSICIANS ACKNOWLEDGEMENT FORM
MEMORANDUM TO PERSONNEL FILE
This is to certify that I have reviewed the posted Panel of Physicians for work related injuries and
the Bill of Rights for the injured worker and I have been advised of their location and purpose by a
representative of ____________________________________ (employer/company name).
I understand that if I am involved in an on-the-job injury and emergency treatment is necessary,
that I may be taken to the nearest emergency room or other medical provider. I understand that
all follow up care must, thereafter, be rendered by a physician from the company’s Panel of
Physicians. If I want to obtain medical treatment from a physician or other medical provider not
listed on the company’s Panel of Physicians, I may do so; however, I will be responsible for all
medical expenses incurred from a physician (or any other medical provider) that is not on the
Panel.
I understand that if I am involved in an on-the-job injury and emergency treatment is NOT
necessary, I must accept the services of a physician from the company’s Panel (again, if I want to
obtain medical services from a physician or other medical provider not listed on the Panel I may
do so, with the understanding that I will be responsible for all medical expenses). The physician
that I select from the company’s Panel may arrange for appropriate consultations, referrals, and
other specialized medical services as the nature of the injury requires. If I am dissatisfied with the
physician that I select, I understand that I may make one (1) change without permission to a
second physician on the Panel. However, any further changes require the permission of the
company or the State Board of Workers’ Compensation.
I further understand that I must notify one of my supervisors as soon as an injury occurs,
regardless of the extent of the injury. I also understand that if I fail to immediately notify my
supervisors of an injury, I may be denied workers’ compensation benefits.
This _______________ day of __________________________, _______(year).
X_________________________________________
Employee/Worker
X__________________________________________
Employer/Company Representative/Witness
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BUILDERS INSURANCE GROUP
VININGS INSURANCE COMPANY
ASSOCIATION INSURANCE COMPANY
FORMULARIO DE RATIFICACIÓN SOBRE PANEL DE MÉDICOS
MEMORANDO PARA ARCHIVOS DE PERSONAL
El presente documento certifica que he analizado el Panel de Médicos para lesiones laborales y
la Declaración de Derechos para el trabajador lesionado que se han publicado, así como que he
sido informado por un representante de __________________________ (empleador/nombre de
la compañía) sobre dónde ubicar a dicho panel y cuál es su objetivo.
Entiendo que, en caso de sufrir una lesión en el lugar de trabajo y requerir tratamiento de
emergencia, puedo ser trasladado a la sala de emergencias más cercana o a otro proveedor de
servicios médicos. Entiendo que, posteriormente, toda atención de seguimiento debe ser
proporcionada por un médico del Panel de Médicos de la compañía. Si deseo obtener
tratamiento de parte de un médico u otro proveedor de servicios médicos no incluidos en el
Panel de Médicos de la compañía, podré hacerlo. No obstante, seré responsable por todos los
gastos médicos en que incurra por recibir servicios de un médico (u otro proveedor de servicios
médicos) no incluidos en el Panel.
Entiendo que, en caso de sufrir una lesión en el lugar de trabajo y NO requerir tratamiento de
emergencia, debo aceptar los servicios de un médico perteneciente al Panel de la compañía
(también en este caso, si deseo obtener servicios médicos de un médico u otro proveedor de
servicios médicos no incluidos en el Panel de Médicos de la compañía, podré hacerlo con el
entendimiento de que seré responsable por todos los gastos médicos). El médico que yo
seleccione en el Panel de la compañía podrá disponer las consultas, referencias y otros servicios
médicos especializados correspondientes según lo requiera la naturaleza de la lesión. En caso
de que yo no esté satisfecho con el médico seleccionado, entiendo que podré realizar un (1)
cambio sin permiso y optar por un segundo médico del Panel. Sin embargo, todo cambio
posterior requerirá el permiso de la compañía o la Junta de Compensación al Trabajador Estatal.
Entiendo, asimismo, que debo notificar a uno de mis supervisores tan pronto como se produzca
una lesión, independientemente del grado de la misma. Entiendo, además, que en caso de que
no notifique a mis supervisores sobre una lesión, podrán denegárseme los beneficios de
compensación al trabajador.
A los _______________ días del mes de __________________, _________(año).
X_________________________________________
Empleado/Trabajador
X__________________________________________
Empleador/Representante de la Compañía/Testigo
13
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VININGS INSURANCE COMPANY
BECOME A CERTIFIED DRUG-FREE WORKPLACE
Outlined below are the main components of a state certified drug-free workplace program you
must have in place in order to become eligible for a premium credit. The components include
implementing the following:

A written substance abuse program pursuant to the requirements of the law in your
state

Conduct drug testing:
1.
For all new hires
2.
For those employees you reasonably suspect may be substance abusers
3.
For injured employees who receive outside medical treatment following an
accident
4.
For workers who have successfully completed a substance abuse rehabilitation
program
5.
As a part of any required annual physical examination or periodic routine fitness for
duty exam

Conduct training for all employees, including supervisors, on an annual basis

Conduct additional training for supervisors, on an annual basis

Have either an Employee Assistance Program (EAP) or maintain a list of counseling
and treatment centers. The EAP providers must be easily accessible to employees and
the list of providers should be where it is readily available to all employees
For more information, contact the Department of Labor or the State Board of Workers’
Compensation in your state (phone numbers and address are available for your information at the
back of this handbook). In Georgia you may contact the Georgia Chamber of Commerce “Drugs
Don’t Work” program at (404) 223-2264. The Chamber will provide to you, at no cost, materials
that will assist with the development and implementation of your program.
Our Loss Control and Safety Services consultants are also available to assist you. Please call
(678) 309-4026 to speak with one of our consultants.
14
Additional assistance is available through many Chambers of Commerce. A number of local
chambers offer either one or all of the following services at no charge or at a discounted rate to
members:

Substance Abuse Policy on computer diskette

Drug Testing

Substance Abuse Training

Employee Assistance Programs or a list of treatment centers in your area
ANSWERS TO COMMONLY ASKED QUESTIONS
Q: Upon the implementation of a Certified Drug-free Workplace Program will I be required to test
all those I currently employ?
A: No. You must, however, provide a written notice to all current employees that a Drug-free
Workplace program will be implemented prior to its implementation. The requirements for
testing are: new hires, reasonable suspicion, post accident, post rehab, and routine fitness
for duty examinations.
Q: If I implement a Certified Drug-free Workplace Program am I required to drug test my
employees on a random basis?
A: No. Random drug testing is optional. If you choose to randomly test, be sure the selection
process you use ensures a true random selection of employees.
Q: If I implement a Certified Drug-Free Workplace Program am I required to terminate an
employee who tests positive for drugs?
A: No. Under state law, you may terminate an employee who tests positive or you may refer him
or her to substance abuse treatment. The employer generally is not financially responsible
for substance abuse treatment or rehabilitation. It is important that all employees who test
positive receive equitable treatment by the employer.
Q: Are there specific legal requirements for how the training should be done?
A: No. The state law has left the specifics up to the employer. You may conduct the training
using in-house personnel or outside consultants and speakers. The resources you use may
include videos, pamphlets, newsletters, or other materials. Be sure to document the training
you provide.
15
Q: If I implement a Certified Drug-free Workplace Program am I required to drug test uninsured
subcontractors?
A: No. Under the Drug-free Workplace law subcontractors do not become statutory employees,
therefore you are not required to drug-test subcontractors.
Q: How is the premium credit applied?
A: When you have completed the necessary requirements, such as providing and documenting
notice to your current employees that a certified drug free workplace program will be
implemented, and have drafted your written program, apply to the agency in your state
responsible for certifying programs. In many states you must be certified annually. Upon
receiving your certificate send a copy each year to:
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
UNDERWRITING DEPARTMENT
POST OFFICE BOX 723099
ATLANTA, GA 31139-0099
The discount will be effective from the date you became certified and will be applied at final audit.
Please note: In the State of Georgia you must send an initial application to the State Board with a
check for $25 and each year thereafter in order to maintain your certification and premium credit.
ALL EMPLOYERS ARE ADVISED TO SEEK LEGAL COUNSEL PRIOR TO IMPLEMENTING
SUBSTANCE ABUSE PROGRAMS
16
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VININGS INSURANCE COMPANY
POST ACCIDENT DRUG TESTING
The law in a number of states provides for the post accident drug and alcohol testing of injured
workers. In these states, testing for drug and alcohol abuse following a work related injury may
be conducted even though the employer has not implemented a certified drug-free workplace
program.
Testing the injured worker for drug and/or alcohol impairment should be conducted by the
medical facility providing care to the injured worker. The testing should take place as quickly as
possible following the accident after the worker’s medical condition has been stabilized.
An injured worker with a confirmed positive drug/alcohol test result could forfeit all workers’
compensation benefits. A confirmed positive test result creates the assumption that the
proximate cause of the accident is the result of drug/alcohol abuse. The burden to prove
otherwise lies with the employee. The injured work must be informed that the refusal to submit to
a drug/alcohol test results in the same rebuttable presumption that the proximate cause of the
accident was due to the abuse of drugs/alcohol. The refusal to submit to a drug/alcohol test
could result in the injured worker forfeiting all workers’ compensation benefits.
A consent form for post accident drug and alcohol testing (in both English and Spanish) is on the
following page. This form should be signed and dated by the employee, employer, and a witness
upon hire or anytime thereafter prior to the occurrence of an accident.
Anytime a worker is asked to leave the premises because of possible impairment due to drugs or
alcohol, management should be sure the employee has a safe, alternate means of transportation
and does not drive himself.
The first priority is always to attend to the injured worker first. The drug testing of an
injured worker should be conducted as soon as possible following an accident after the
worker’s medical condition has been stabilized.
17
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VININGS INSURANCE COMPANY
POST ACCIDENT DRUG TESTING CONSENT FORM
This is to acknowledge that a representative of ___________________________
(employer/company name) has explained to me that if I am injured in a work related accident, I
will be asked to submit to a drug test including any of the following types of tests or combinations
of tests: breath analysis, urinalysis, and/or blood tests to test for the presence of alcohol, illegal
drugs, and/or pharmaceutical drugs and/or controlled substances.
It has been explained to me and I understand that testing for drugs, controlled substances and/or
other medications which have been lawfully prescribed to me by a duly licensed physician will
only be used to determine whether or not I have been taking the prescribed medication in
accordance with my physician’s orders.
It has also been explained to me and I understand that if I refuse to submit to a drug test, my
employment may be terminated and I may not be entitled to any workers’ compensation benefits
including, but not limited to, medical benefits, income benefits, and rehabilitation benefits. I also
understand that a positive drug or alcohol test could result in immediate termination of my
employment and forfeiture of entitlement to workers’ compensation benefits.
This _______________day of _________________, ___________(year).
X_________________________________________________________
Employee/Worker
X_________________________________________________________
Employer/Company Representative/Witness
18
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VINING INSURANCE COMPANY
FORMULARIO DE CONSENTIMIENTO A PRUEBA DE DROGAS
POSTERIORMENTE AL ACCIDENTE
El presente tiene como fin ratificar que un representante de ________________________
(empleador/nombre de la compañía) me ha explicado que, en caso de sufrir una lesión en un
accidente laboral, se me solicitará someterme a una prueba de drogas, incluido cualquiera de los
siguientes tipos de pruebas o combinaciones de pruebas: análisis de aliento, de orina y/o de
sangre para descartar la presencia de alcohol, drogas ilegales, drogas farmacéuticas y/o
sustancias controladas.
Se me ha explicado y entiendo que la prueba de drogas, sustancias controladas y/o de otras
medicaciones que me hayan sido lícitamente recetadas por un médico con la correspondiente
licencia sólo será utilizada para determinar si he estado o no tomando la medicación recetada de
conformidad con las instrucciones de mi médico.
También se me ha explicado y entiendo que, en caso de negarme a someterme a una prueba de
drogas, mi empleo podrá ser finalizado y posiblemente no tenga derecho a recibir ningún
beneficio de compensación al trabajador, lo cual incluye —sin ninguna limitación— beneficios
médicos, de ingresos y de rehabilitación. Entiendo, asimismo, que el resultado positivo de la
prueba de drogas o alcohol podrá dar lugar a la finalización inmediata de mi empleo y la pérdida
del derecho a recibir beneficios de compensación al trabajador.
A los _______________ días del mes de ___________________, ________(año).
X_________________________________________
Empleado/Trabajador
X__________________________________________
Empleador/Representante de la Compañía/Testigo
19
BUILDERS INSURANCE GROUP
VININGS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
HIRING, ORIENTATION, AND SAFETY MEETINGS
Hiring
A good employee selection process is the key to a qualified workforce. The use of written job
applications helps the employer narrow the pool of applicants to those that are most qualified.
Checking references will help verify the applicant’s qualifications and employment history.
Orientation
Statistics show that almost half of all injured workers, regardless of the industry, are “new hires”.
New hires are considered those workers that have been working for you less than one year. That
means even if you hire someone that has experience, doing the job for which you hired them, the
chance of an on-the-job injury during that first year is extremely high.
There are a number of reasons for this high rate of injury during the first year of employment.
New employees may be unfamiliar with the tools, equipment, environment, or the processes you
use. One way to prevent new workers from being injured is to provide them a job and safety
orientation. An orientation introduces new workers to the policies and procedures of the company
as well as the corporate culture and goals of the organization. Following this orientation all new
workers should know how to perform their jobs properly.
A Sample Orientation Form is on the next page.
Safety Meetings
Conducting brief safety meetings on a regularly scheduled basis is an excellent way to help
employees maintain their safety awareness. These on-going training sessions are a good time to
introduce new equipment and processes to your employees. Safety meetings held on a regular
basis will help open the lines of communication within an organization. Conducting a short safety
meeting (perhaps as short as ten minutes) at a regular time each week can provide an
outstanding return on a relatively small investment.
Sample Safety Meeting Schedules 1 and 2 are on the following pages.
20
SAMPLE ORIENTATION CHECKLIST

Written Application

References Checked

Other _______________________



Verification of Legal Employment Status

MVR Checked

Certificates/Licenses Obtained

Driving Safety & Seat belt Use
Reviewed
Safety Officer Identified


Immediate Reporting of Accidents
Reviewed

Panel of Physicians Reviewed

Company Policy Statement Reviewed

Company Safety Policy Reviewed
Company Policy on Smoking &
Designated Areas Reviewed

Appropriate Attire Reviewed

Company Attendance Policy Reviewed


Company Drug/Alcohol Policy
Reviewed
Proper Lifting Techniques and Use Of
Lifting Aids Reviewed

Company Policy on Workplace
Housekeeping Reviewed


Other Training, Specific to This
Operation and/or Equipment Used, Provided

HAZCOM Training Provided
Other Training Provided _________


Other Policies Reviewed _________
Location of Emergency Phone Numbers
and Contacts Reviewed

Location & Proper Use of First Aid and
Appropriate Personal Protective Equipment
Reviewed

Location of Eye Wash and/or
Emergency Shower Identified



Location & Proper Use of Fire
Extinguishers Reviewed

Evacuation Route Reviewed
Other
___________________________________
____________________________
Other Emergency Procedures
Reviewed
___________________________________





21

PERSONAL PROTECTIVE EQUIPMENT &
APPROPRIATE TRAINING PROVIDED

Eye Protection

Gloves

Boots

Respirator

Hard Hat

Face Shield

Back Support

Apron

Hearing Protection

Shoes

Dust Mask

Other __________________________
Comments :___________________________________________________________________
____________________________
Employee Signature:___________________________
Date:_______________________________
Employer Signature:___________________________
Date:_______________________________
22
SAMPLE ORIENTATION CHECKLIST

Written Application

References Checked

Medical Questionnaires

Other _______________________


Verification of Legal Employment Status

MVR Checked

Certificates/Licenses Obtained
Other Personnel Forms and/or Documentation
_______________________________________________________________________

Safety Officer Identified

Immediate Reporting of Accidents Reviewed

Panel of Physicians Reviewed

Company Policy Statement Reviewed

Company Safety Policy Reviewed

Company Drug/Alcohol Policy Reviewed

Driving Safety & Seat belt Use Reviewed

Company Policy on Smoking & Designated Areas Reviewed

Appropriate Attire Reviewed

Company Attendance Policy Reviewed
Proper
Lifting Techniques and Use Of Lifting Aids Reviewed
Company
Policy on Workplace Housekeeping Reviewed
HAZCOM
Training Provided
23

Other Training, Specific to This Operation and/or Equipment Used, Provided

Other Policies Reviewed ______________________________________________

Other Training Provided _______________________________________________

Location of Emergency Phone Numbers and Contacts Reviewed

Location & Proper Use of First Aid and Appropriate Personal Protective Equipment Reviewed

Location of Eye Wash and/or Emergency Shower Identified

Location & Proper Use of Fire Extinguishers Reviewed

Evacuation Route Reviewed

Other Emergency Procedures Reviewed ___________________________________

Other _______________________________________________________________
PERSONAL PROTECTIVE EQUIPMENT & APPROPRIATE TRAINING PROVIDED






Eye Protection
Hard Hat
Hearing Protection
Gloves
Face Shield
Shoes
Comments
Employee Signature
Employer Signature






Boots
Back Support
Dust Mask
Respirator
Apron
Other __________________________
Date
Date
24
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
A SAMPLE SAFETY POLICY STATEMENT
Each company, regardless of its size, should have a policy statement that reflects management’s
philosophy and commitment toward safety. The company’s president or CEO should sign the
statement that has been drafted on company letterhead. The statement should be reviewed with
new employees during their orientation and a copy should be provided to them. If the company
has an office or a job-site trailer, the statement should be posted there.
Sample Safety Policy Statement
The management of (company name) is committed to providing and maintaining a safe and
healthful workplace for all employees. Safety is incorporated into every job we do. We adhere to
federal, state, and local safety regulations as well as recognized safe work practices for our
industry. Our business is conducted with the highest regard for the safety and well-being of all
our employees.
Safety is of the utmost importance; it is considered an integral part of every task every employee
performs. Each worker at (company name) shall be just as responsible for how safely he or she
performs his/her work as any other element of that task.
We at (company name) believe that no job is so important, nor a service so urgent, that it cannot
be performed in a safe manner. It is our policy at (company name) that employees report all
accidents, injuries, and unsafe conditions to the appropriate company representative. Any unsafe
condition must be corrected before work is begun.
The responsibility for workplace safety is shared among management, supervisors, and
employees. The full cooperation and compliance with safety policies and procedures is required
of everyone here at (company name). We are counting on you to do your part by recognizing
your responsibility to incorporate safety into every task, every day.
Thank you for your cooperation.
___________________________________
________________________________
President/CEO
Date
25
Company:
Work Area:
Inspected by:
Date of Inspection:
WORK AREA SAFETY CHECKLIST SAMPLE
General Work Environment
Worksites clean and orderly?
Work surfaces kept dry or appropriate means taken to assure the surfaces are
slip-resistant?
All spilled materials or liquids cleaned up immediately?
Combustible scrap, debris and waste stored safely and removed from the
worksite promptly?
Accumulations of combustible dust routinely removed from elevated surfaces
including the overhead structure of the buildings?
Combustible dust cleaned up with a vacuum system to prevent the dust going
into suspension?
Metallic or conductive dust prevented from entering or accumulating on or
around electrical enclosures or equipment?
Covered metal waste cans used for oily and paint soaked waste?
Oil and gas fired devices equipped with flame failure controls that will
prevent flow of fuel if pilots or main burners are not working?
At least minimum number of toilets and washing facilities provided?
Toilets and washing facilities clean and sanitary?
Work areas adequately illuminated?
Pits and floor openings covered or otherwise guarded?
Yes No
___ __
Exiting or Egress
All exits marked with an exit sign and illuminated by a reliable light source?
Are the directions to exits, when not immediately apparent, marked with
visible signs?
Doors, passageways or stairways, that are neither exits nor access to exits and
which could be mistaken for exits, appropriately
marked "NOT AN EXIT",
etc.
Exit signs provided with the word "EXIT" in lettering at least 5 inches high
and the stroke of the lettering at least 1/2 inch wide?
Yes No
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___
___
___
___
___
__
__
__
__
__
___ __
___ __
___ __
26
Exit doors side-hinged?
All exits kept free of obstructions?
At least two means of egress provided from elevated platforms, pits or rooms
where the absence of a second exit would increase the risk of injury?
Sufficient exits to permit prompt escape in case of an emergency?
Special precautions taken to protect employees during construction and repair
operations?
Is the number of exits from each floor of a building and the number of exits
from the building itself appropriate for the building occupancy load?
Exits stairways that are required to be separated from other parts of a
building enclosed by at least two-hour, fire-resistive construction in buildings
more than four stories high, and not less than one-hour fire resistive construction
elsewhere?
When ramps are used as part of required exiting from a building, is the ramp
slope limited to 1 foot vertical to 12 feet horizontal?
When an exit must be made through an unframed glass door, glass exit door,
etc. are the doors fully tempered and do they meet the safety requirements for
human impact?
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
Yes
Exit Doors
Doors that are required to serve as exits designed and constructed so that the
way of exit travel is obvious and direct?
___
Windows that could be mistaken for exit doors made inaccessible by means
of barriers or railing?
___
Exit doors able to open from the direction of exit travel without the use of a
key or any special knowledge or effort when the building is occupied?
___
Are revolving, sliding, or overhead doors prohibited from serving as a require
exit door?
___
Where hardware installed on a required exit door allow the door to open by
applying a force of 15 pounds or less in the direction of the exit traffic?
___
Doors on cold storage rooms provided with an inside release mechanism that
will release the latch and open the door even if it's padlocked or otherwise
locked on the outside?
___
When exits doors open directly onto any street, alley, or other area where
vehicles may be operated, are barriers and warning provided to prevent
employees from stepping into the path of traffic?
___
Are there viewing panels in doors that swing in both directions and are
located between rooms where there is frequent traffic?
___
Portable Ladders
Ladders maintained in good condition, joints between steps and side rails
tight, all hardware and fittings securely attached and movable parts operating
freely without binding or undue play?
Non slip safety feet provided on each metal or rung ladder?
No
__
__
__
__
__
__
__
__
Yes No
___ __
___ __
27
Ladder rungs and steps free of grease and oil?
Is it prohibited to place a ladder in front of door openings towards the ladder
except when the door is blocked open, locked or other wise guarded?
Is it prohibited to place ladders on boxes, barrels or other unstable bases to
obtain additional height?
Are employees instructed to face the ladder when ascending or descending?
Employees prohibited from using ladders that are broken, missing steps,
rungs, or cleats, have broken side rails, or from using other faulty equipment?
Employees instructed not to use the top step of ordinary stepladders as a
step?
When portable rung ladders are used to gain access to elevated platforms,
roof, etc., does the ladder always extend at least 3 feet above the elevated
surface?
When portable rung or cleat ladders are used, is it required the base places so
that slipping will not occur or it is lashed or other wise held in place?
Portable metal ladders legibly marked with signs reading "CAUTION: Do
not use around electrical equipment" or equivalent wording?
Employees prohibited from using ladders as guys, braces, skids, gin poles, or
for other than their intended purposes?
Employees instructed to adjust extension ladders only while standing at the
base, not while standing on the ladder or any position above the ladder?
___ __
Walkways
Aisles and passageways kept clear?
Aisles and walkways marked as appropriate?
Wet surfaces covered with non-slip materials?
Holes in the floor, sidewalk or other walking surfaces repaired properly,
covered or other wise made safe?
Are there safe clearance for walking in aisles where motorized or mechanical
handling equipment is operating?
Materials or equipment stored in such a way that sharp projectiles will not
interfere with the walkway?
Spilled materials cleaned up immediately?
Changes of direction or elevations readily identifiable?
Aisles or walkways that pass near moving or operating machinery, welding
operations or similar operations arranged so employees will not be subjected to
potential hazards?
Adequate headroom provided for the entire length of any aisle or walkway?
Standard guardrails provided wherever aisle or walkway surfaces are
elevated more than 30 inches above any adjacent floor or the ground?
Bridges provided over conveyers and similar hazards equipped with proper
railing?
Yes
___
___
___
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
No
__
__
__
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
28
Floor and Wall Openings
Floor openings guarded by a cover, guardrail or equivalent on all sides
(except entrance to stairways or ladders)?
Toe boards installed around the edges of permanent floor openings?
Skylight screens of such construction and mounting that they will with stand
a load of at least 200 lbs.
Glass in windows, doors, glass walls, etc. which are subject to human impact
of sufficient thickness and type for the condition of use?
Grates or similar type covers over floor openings, such as floor drains, of
such design that foot traffic or rolling equipment will not be affected by the
grate spacing?
Unused portions of service pits and pits not actually in use either covered or
protected by guardrails or equivalent?
Manhole covers, trench covers and similar covers, plus their supports,
designed to carry a truck rear axle load of at least 20,000 pounds when located
in roadways and subject to vehicle traffic.
Floor or wall openings in fire resistive construction provided with doors or
covers compatible with the fire rating of the structure and provided with a self
closing feature when appropriate?
Yes No
Stairs and Stairways
Standard stair rails or handrails on all stairways having four or more risers?
Stairways at least 22 inches wide?
Stairs have at least 6'6" clearance?
Stairs angle no more than 50 and no less than 30 degrees?
Stairs of hollow pan type treads and landing filled with solid material?
Steps on stairs and stairways designed or provided with a surface that renders
them slip resistant?
Stairway handrails located between 30 and 34 inches above the leading edge
of stair treads?
Stairway handrails have at least 1 and 1/2 inches of clearance between the
handrails and the wall or surface they are mounted on?
Stairway handrails capable of withstanding a load of 200 pounds, applied in
any direction?
Where stairs or stairways exit directly into any area where vehicles may be
operated, are adequate barriers and warnings provided to prevent employees
from steeping into the path of traffic?
Stairway landings have a dimension measured in the direction of travel, at
least equal to the width of the stairway?
Vertical distance between stairway landings limited to 12 feet or less?
Stairway provided to the roof or each building 4 or more stories in height,
provided the roof slope has a 4 inch drop in 12 inches or less?
Yes
___
___
___
___
___
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
No
__
__
__
__
__
___ __
___ __
___ __
___ __
___ __
___ __
___ __
___ __
29
Elevated Surfaces
Signs posted, when appropriate, showing the elevated surface load capacity?
Surfaces elevated more than 30 inches above the floor or ground provided
with standard guardrails?
Elevated surfaces (beneath which people or machinery could be exposed to
falling objects) provided with standard four inch toe boards?
Permanent means of access and egress provided to elevated storage and work
surfaces?
Required headroom provided where necessary?
Material on elevated surfaces piled, stacked or racked in a manner to prevent
it from tipping, falling, collapsing, rolling or spreading?
Dock boards or bridge plates used when transferring materials between docks
and trucks or rail cars?
Yes No
___ __
___ __
___ __
___ __
___ __
___ __
___ __
30
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
AGREEMENT TO FOLLOW YOUR COMPANY’S WRITTEN POLICIES AND PROCEDURES
A SAMPLE FORM
TO ALL EMPLOYEES, SUBCONTRACTORS, SUPPLIERS, AND CUSTOMERS
OF _____________________________________________________ COMPANY
Safety is more than just a company goal; it is a requirement in all operations of this organization.
Management of this organization is committed to providing and maintaining a safe and healthy
environment for all employees, subcontractors, suppliers, and customers.
The written safety policies and procedures of this company have been developed and
implemented for the protection of those persons authorized to be on our job-sites.
It is a condition of employment with this company that all employees strictly adhere to the
requirements of our written policies (including safety procedures, instructions, and rules) as well
as all applicable federal, state, and local codes, regulations, and requirements. Failure to do so
will result in the appropriate disciplinary action up to and including termination.
It is a condition of all subcontracts, service contracts, and purchase orders issued by this
company that our written safety policies and the safety procedures, instructions, and rules issued
in conjunction with them are complied with, as well. Failure to do so is a breach of contract terms
and will be dealt with appropriately.
While on our job sites all visitors, including but not limited to: suppliers, owner representatives,
agents of the architect or engineer, customers, regulatory authorities, and insurance company
representatives are required to follow all applicable safety policies and procedures.
It is our policy that any unsafe condition, practice, or injury be immediately reported to a
supervisor of this company. All accidents and incidents must be investigated and steps taken to
prevent recurrence. Any task considered unsafe because of the tools, equipment, environment,
or lack of skill or training is not to be performed until a supervisor of this company has corrected
the unsafe conditions or acts surrounding the task. Any recommendation to improve our safety
program is encouraged.
The primary responsibility for the coordination, implementation, and maintenance of our company
safety program has been assigned to __________________________________
Who can be reached at ________________________________or __________________.
Safety is the responsibility of everyone. By working together and staying alert we can prevent onthe-job injuries.
______________________________________
President/CEO
____________________
Date
31
BUILDERS INSURANCE GROUP
(A MUTUAL CAPTIVE COMPANY)
FILING A CLAIM
The first priority is to attend to the injured worker. If the injury or illness is an emergency, seek
qualified medical attention at the nearest facility. Once the emergency has passed, care will generally revert
to a medical provider chosen by the employer. If the injury is minor and requires only first aid, the responder
should be appropriately trained and use the proper personal protective equipment.
As soon as you, the employer, are notified of an injury or illness, immediately report the claim to our
Notice of Injury Center. Your claim may be e-mailed, phoned, faxed, or mailed to us. A Case Specialist will
answer your call between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday. Our case specialist
will verify your workers’ compensation coverage and gather information regarding the injury.
E-MAIL:
www.buildersinsurancegroup.com
Click on E-claims
PHONE:
(678) 309-4040 or (800) 883-9305, Extension 4040 FAX:
MAIL:
Claims Department
Post Office Box 723099
Atlanta, GA 31139-0099
(678) 309-4075
If our specialist is unavailable to take your call, please leave a voice mail message and your call will
be returned promptly.
If, upon the initial report of the claim it is thought to be serious enough to be a “lost time” claim, you
will receive a copy of the report which was phoned or e-mailed to us within seven business days for your
review and verification. A copy will also be sent to the appropriate state agency.
WHAT TO DO IF YOU BELIEVE THE CLAIM IS QUESTIONABLE
If you believe an injury reported to you is questionable, share that information with the case specialist
(or note it on your initial report). If you obtain additional information at a later date that may affect the status
of the claim, please notify the adjuster handling the claim immediately. Remember, your insurance policy
requires you to “tell us at once if injury occurs that may be covered by this policy” (this includes disease
and/or illness). Remember, too, that the employer may not deny an injured worker medical care.
Forward all additional information regarding the claim, including medical bills, medical reports,
employee medical status reports, legal forms, and court orders, etc. directly to us. Please include the
case/claim number and the name of the adjuster.
The initial contact with an injured worker will impact just how successfully the claim is concluded.
Your representative designated to contact the injured worker should have a good understanding of the
worker’s compensation system in your state and be capable of establishing a good and lasting rapport
between the injured employee and the employer.
32
33
MANAGING THE COST OF THE CLAIM
HOW TO IDENTIFY A POTENTIALLY FRAUDULENT CLAIM
Each year insurance fraud costs policyholders millions of dollars in lost premiums through false
claims filed under workers’ compensation. When someone falsifies or exaggerates a job-related
injury or illness to collect workers’ compensation benefits that’s considered fraud and it’s a crime.
These are some clues to help identify a potentially fraudulent claim:

Accidents that happen at unattended workplaces

Accidents that happen without witnesses when there are several workers at the workplace

Claims that go unreported for several days or weeks

Weekend accidents when no work was scheduled

Lack of cooperation in accepting transitional duty in your Return to Work program after being
released by the attending physician

Radically different accounts of the accident or manner in which the injury occurred,
especially inconsistent reports from the same person

Claimant repeatedly misses or reschedules appointments with the doctor

Nature and extent of alleged injuries are inconsistent with how the accident occurred and/or
the diagnosis of the doctor
If you believe that a claim may be fraudulent, please contact the adjuster handling your claim. Information
about your suspicions will be kept confidential and the claim will be investigated.
FRAUD HOTLINE
Builders Insurance Group has established a telephone hotline for co-workers of injured workers
who suspect fraud at their workplace. Call the hotline at (678) 309-4150 or (800) 883-9305,
extension 4150. To report, follow the simple voice prompts.
Informational flyers regarding the Fraud Hotline are available by calling our sales and marketing
department at (678) 309-4023 or (800) 883-9305, Extension 4023.
34
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
MANAGING THE COST OF THE CLAIM
MANAGING THE MEDICAL
Our Medical Case Management department is staffed by experienced registered nurses who are
trained in the management of occupational injuries which arise as a result of on- the-job
accidents. The primary responsibility of our case management staff is to assist the injured worker
in understanding the nature and extent of their injuries, establish reasonable treatment plans with
the treating physicians and assist our claim adjusters in directing the medical process so the
claim can be brought to a successful conclusion.
Our case management nurses function as an advocate for the employee and their family, to
ensure the injured worker is receiving quality and appropriate health care services from the
medical providers involved in their treatment. They communicate with the adjuster to keep them
abreast of the injured worker’s medical condition and with the employer to identify modified duty
so the injured worker can return to gainful employment and minimize the length of lost time.
Our staff can also assist you by providing names of medical providers in your area. For
assistance, please telephone (678) 309-4033 or (800) 883-9305, Extension 4033. The providers
on your panel must be reasonably accessible to your workers. If you plan to work outside your
usual geographical area and need assistance with your panel there, our staff can help you with
that, as well. Please telephone (678) 309-4033 or (800) 883-9305, Extension 4033 for
assistance.
Prior to placing a medical provider on your panel, you should contact each facility to confirm they
will take workers’ compensation cases. The provider should share the philosophy of the insurer
and the employer, that of quality care for the injured worker and a return to work as quickly as
possible.
35
BUILDERS INSURANCE GROUP
ASSOCIATION INSURANCE COMPANY
VININGS INSURANCE COMPANY
THE IMPORTANCE OF RETURN TO WORK PROGRAMS
Injured employees should be returned to work, within the physical limitations imposed by the
treating physician, as quickly as possible. Return to Work Programs ultimately help control the
cost of the claim and thereby future workers’ compensation insurance costs, as well. The
benefits, to the employer of these programs are enormous.
To benefit employer and employee, be proactive and identify meaningful tasks a returning worker
can perform before the accident occurs. The wage you pay the worker, to perform the transitional
job, may be less than he was earning at his job prior to the injury. Part of the difference in the
rate of pay will be made up by workers’ compensation Temporary Partial Disability (TPD)
Benefits.
Following his release for transitional duty, if an injured worker refuses “suitable employment” his
compensation may be suspended. If the employer is unable or unwilling to offer such a position
the injured worker continues to be eligible for lost time benefits.
Incorporating a returning injured employee into the workplace creates a “peer influence” by coworkers. This influence encourages the worker to begin full employment just as soon as he is
able. By resuming a work schedule (perhaps an abbreviated work schedule at first) the employee
resumes a routine of rising and dressing each morning which is an important factor in returning to
good health. The worker also resumes his status as a valuable team member with a common
goal, an invaluable factor in returning to good health.
Once a worker has remained out-of-work for a prolonged period of time it is very difficult for that
worker to return to full employment, ever. We have compiled a list of negative events that may
occur in such a case. An injured or ill employee who does not return to work in a timely manner
may:








Lose sight of the fundamental goal of returning to good health
Relate every ache, pain, ailment, and discomfort to the work-related accident
Become comfortable with poor health and the attention it brings along with the relief from
responsibility it provides
Experience a sense of apathy and a distinct loss of confidence
Become depressed and acquire a heightened awareness of pain and perhaps an
increased use of pain medication
Think of oneself as a chronic victim as the perceived value of the claim grows
increasingly large
Develop new habits and a lifestyle that will be difficult to maintain without a large
financial settlement
Suffer an acceleration of the normal aging process
36
Return-to-Work Policy Sample
PURPOSE
[Company] has implemented a Return-to-Work Program for employees injured at work. The
purpose of this program is to return an injured employee to work as soon as possible following an
injury. This program is intended to minimize the production lost by the company and wages lost
by the employee as a result of an on-the-job injury. This program is necessary to limit the amount
of lost workdays an injured or ill employee may incur by providing meaningful work of a restricted
or limited nature.
PROGRAM ADMINISTRATION
The RTW Coordinator administers the RTW Program.
PROGRAM BENEFITS
The Return-to-Work Program is designed to benefit the insured employees by addressing both
personal and professional issues. Some important benefits are:
 Helping employees return to the work that they have been trained to perform and that
they enjoy doing.
 Helping employees to continue their former work relationships.
 Helping employees to maintain good mental health through proper medical treatment,
moral support, and job placement upon recovery.
 Helping employees develop new skills through skills training and/or gradually
redevelop old skills by providing temporary work hardening placements.
 Helping employees to return to salaried positions with earnings and benefits as close
as possible to their pre-injury earnings and benefits.
TYPES OF RETURN EMPLOYMENT
To provide the broadest possible assistance and opportunity for returns to work, the Return-toWork Program includes the following possibilities:
 Return to the pre-injury position upon full recovery
 Return to the pre-injury position with reasonable accommodation, or
 Return to another permanent position.
NOTE: The RTW effort could begin with placement in a temporary transitional duty position for
work hardening and/or new skills development in order to prepare the employee for one of the
above return possibilities.
EMPLOYEE RESPONSIBILITIES UNDER THE RETURN TO WORK PROGRAM
Injured employees have the responsibility to follow the medical provider’s advice and direction for
treatment/recovery and to attend all scheduled medical and physical therapy appointments.
Injured employees must also keep their employer informed of their treatment and progress toward
recovery on a regular basis so that the employer can make appropriate plans and complete any
necessary accommodations for their return.
37
Return-To-Work Policy Statements
Sample 1
Developing and following proper safety procedures for all operations is a critical
part of any loss prevention program. A carefully managed program will help
promote an efficient and productive workforce. In the event that an accident
does occur, [Company] has instituted a program to help an employee return to
gainful employment in our facility as soon as possible. We will identify jobs that
are suitable for a modified work position and we will select a Return-To-Work
Coordinator to manage the development and implementation of the program.
Our goal in establishing this program is to speed rehabilitation of injured
employees and restore them to full earning capacity.
Signature__________________________________
Date _____________________________________
Sample 2
[Company] will make every reasonable effort to provide suitable return-to-work
opportunities for every employee who is unable to perform his/her regular
duties following a work-related injury. This may include modifying the
employee’s regular job or, if available, providing temporary alternate work
depending on the employee’s physical abilities.
Only work that is considered productive and meaningful to the business shall be
considered. Injured workers who are participating in the early return-to-work
program are expected to provide feedback in order to improve the program’s
future development.
Signature__________________________________
Date _____________________________________
38
Return-To-Work Coordinator’s Checklist

Seek immediate medical help for the injured worker.

If the injury is not life threatening, ask the employee how the
injury/incident happened.

Remind employee of the Company’s Return-to-Work Program. Have the
employee sign the Acknowledgement Form and provide him/her with a
list of the Panel Doctors.

Give the employee the physical capabilities checklist and a job analysis to
take with him/her to the doctor.

Notify insurance carrier and claims representative of injury.

Contact the injured worker within 12 hours.

Contact the injured worker within three days.

Contact the injured worker at least every two weeks.

Employee satisfied with medical care being provided by panel doctor.

Modified job available. If yes, what job? ___________________________

Notify employee in writing that modified work is available.

Notify insurance carrier and claims representative of modified position.

Notify physician of modified work available.

Coordinate RTW job analysis with manager.
39
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
MANAGING THE COST OF THE CLAIM
ACCIDENT INVESTIGATION
Successful accident prevention and loss control depend, in part, on effective accident
investigation and analysis. An investigation can help identify the causes of an accident so similar
accidents can be prevented. Accident investigations can also document facts needed for a
settlement negotiation or court hearing. Conducting accident investigations can discourage the
filing of a fraudulent claim.
The key to a successful accident investigation program is a commitment to the immediate followup, after an accident, with the implementation of corrective actions and procedures in order to
prevent another accident. Conducting accident investigations can help an organization promote
better relations with its employees by demonstrating concern for their safety and well-being.
QUESTION:
What is an accident investigation?
ANSWER:
It is:
1.
The gathering, analysis, and evaluation of information collected by the investigator (the
first line supervisor)
2.
The comprehensive and objective report of what happened; and most importantly
3.
The action plan management will put into place in order to prevent the recurrence of
accidents
QUESTION:
Why investigate?
ANSWER:
Our first inclination is to return things to normal as quickly as possible. An
accident, however, indicates there has been a serious breakdown in the system. If an
investigation is not conducted a valuable opportunity to identify and correct a potentially
hazardous situation is lost. It is crucial to look beyond the immediate causes of the accident,
sometimes referred to as unsafe acts and unsafe conditions, and identify the underlying causes in
order to treat more than just the symptoms.
QUESTION:
Which accidents should be investigated?
ANSWER:
1. Any accident that results in a fatality or serious personal injury
2.
Any accident that results in serious property damage
3.
Any accident that resulted in minor personal injury or property damage
but could have potentially caused more serious injury or property damage
40
4.
Any “near-miss” or “close call” that could have resulted in serious
personal injury or property damage
5.
A series of minor accidents or incidents occurring around the same tool,
vehicle, or piece of equipment
QUESTION:
ANSWER:
Who should conduct the investigation?
The first-line supervisor should investigate the accident because he or she
is familiar with the tools, equipment, process, environment, and the people involved in
performing the job. Furthermore, it is the responsibility of the supervisor to develop and
implement the measures he believes will prevent a recurrence of the accident and he will
follow-up to make sure the measures implemented are working.
QUESTION: When should the accident investigation be conducted?
ANSWER:
The investigation should be conducted just as quickly as the injured are
attended to and the area is secured to prevent further physical harm or property damage. A
quick response is important because as time passes evidence is lost and details forgotten.
Most importantly, another accident may occur before corrective measures are put into place.
Prompt investigation gets the most complete and useful information.
QUESTION:
What is the primary focus of the investigation?
ANSWER:
The accident investigation must be a fact-finding mission not a
faultfinding mission. The purpose of the investigation is to determine where the breakdown
occurred and put corrective measures in place to prevent a recurrence.
QUESTION:
ANSWER:
Should an accident be reenacted?
No. Because injuries sometimes occur when accidents are reenacted, it is
suggested accidents not be reenacted for investigation purposes.
QUESTION: Where should the accident investigation take place?
ANSWER:
The investigation may take place where the accident occurred as long as it
has been determined the area is safe.
Any recommendations or procedures you develop and implement must be
practical, as this will determine, in part, how seriously your safety program is perceived.
Accident Investigation is a monitoring function that occurs after the fact when the hazard control
system has broken down. Learning from this experience is painful but not learning from it can be
disastrous.
Accident Investigation is a vital part of loss control; in fact, it can be one
of the most valuable loss control tools you will ever use.
QUESTION:
ANSWER:
How to go about investigating an accident?
For your use an Accident Investigation form follows on the next page.
41
SUPERVISOR’S ACCIDENT/INCIDENT INVESTIGATION FORM
COMPANY/EMPLOYER NAME _________________________ DATE _________________
NAME OF SUPERVISOR/INVESTIGATOR ______________________ TITLE ___________
INJURED EMPLOYEE NAME ___________________________
SS # __________________
INJURED EMPLOYEE ADDRESS ________________________ PHONE # ______________
INJURED EMPLOYEE AGE _______________________DATE OF BIRTH _______________
INJURED EMPLOYEE JOB TITLE ________________ LENGTH OF EMPLOYMENT _____
DATE OF INJURY ____________________ DAY______ TIME_________ AM_____PM____
DATE REPORTED _________________TO WHOM __________________________________
WHERE DID INJURY OCCUR ___________________________________________________
EMPLOYER PREMISES__Y__N
1ST AID ADMINISTERED __Y __N
OUTSIDE MEDICAL TREATMENT __Y __N
DOES EMPLOYER HAVE PANEL OF PHYSICIANS __Y __N WAS INJURED EMPLOYEE DRUG TESTED __ Y __N
LOST TIME INJURY ___Y ___N
HOW MANY DAYS LOST _______ DATE LAST WORKED_____________
NAME OF TREATING PHYSICIAN/MEDICAL PROVIDER ____________________________________________
ADDRESS OF TREATING PHYSICIAN/MEDICAL PROVIDER ________________________ PHONE # ______
EMPLOYEE RELEASED BY PHYSICIAN__Y__N
EMPLOYEE RETURNED__Y __N DATE RETURNED______
DOES EMPLOYER PROVIDE TRANSITIONAL DUTY__Y__N EMPLOYEE PERFORM TRANSITIONAL DUTY__Y__N
DESCRIBE THE INJURY ___________________________________________________________________________
_______________________________________________________________________________________________
DESCRIBE HOW THIS INJURY OCCURRED AND THE TASK THE INJURED WORKER WAS PERFORMING WHEN
HURT
_________________________________________________________________________________________________
WHAT TOOLS AND EQUIPMENT WAS THE INJURED WORKER USING WHILE PERFORMING THIS TASK _____
_________________________________________________________________________________________________
42
WHAT TRAINING DID THE INJURED WORKER RECEIVE IN ORDER TO PERFORM THIS TASK _______________
_________________________________________________________________________________________________
SAFETY EQUIPMENT/PERSONAL PROTECTIVE EQUIPMENT REQUIRED WHEN PERFORMING THIS TASK
_________________________________________________________________________________________________
SAFETY EQUIPMENT/PERSONAL PROTECTIVE EQUIPMENT USED BY THE INJURED WORKER WHILE
PERFORMING THIS TASK
____________________________________________________________________________
_________________________________________________________________________________________________
DESCRIBE THE ENVIRONMENT OR WEATHER AT THE TIME OF THE ACCIDENT/INCIDENT ________________
_________________________________________________________________________________________________
COULD THIS INJURY HAVE OCCURRED ANY OTHER WAY ___Y ___N
IF YES, HOW ____________________
_________________________________________________________________________________________________
SUPERVISOR NAME _______________________________ LENGTH OF TIME IN THIS POSITION ____Mos ____Yrs
WITNESS NAME __________________________________________________WITNESS PHONE #
_________________
WITNESS ADDRESS
_________________________________________________________________________________
WITNESS NAME ________________________________________________ WITNESS PHONE
#_________________
WITNESS ADDRESS
__________________________________________________________________________________
INJURIES TO OTHERS
________________________________________________________________________________
_________________________________________________________________________________________________
EQUIPMENT DAMAGE
_______________________________________________________________________________
_________________________________________________________________________________________________
PROPERTY DAMAGE
_______________________________________________________________________________
_________________________________________________________________________________________________
EVIDENCE RETAINED I.E., DAMAGED TOOL, SCAFFOLD PLANK, ETC. ___________________________________
_________________________________________________________________________________________________
43
PHOTOS
___________________________________________________________________________________________
_________________________________________________________________________________________________
WHAT ACTIONS AND/OR PROCEDURES WILL YOU IMPLEMENT IN ORDER TO PREVENT SIMILAR
OCCURRENCES
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
DATE TO BE IMPLEMENTED _____________________________ BY WHOM ________________________________
DATE OF FOLLOW-UP TO DETERMINE SUCCESS OF ACTIONS/PROCEDURES
_____________________________
BY WHOM
__________________________________________________________________________________________
44
How does loss experience affect your insurance costs?
Rates are calculated using a tool called an Experience Modifier. The modifier is based upon your loss
history compared to those within your industry. Builders Insurance Group uses industry data provided by
an independent organization, the National Council on Compensation Insurance (NCCI). Builders Insurance
Group is required to include this modifier when it calculates the final premium amount.
Here is an example of the impact the modifier can have on a company’s costs.
Company A
(Poor loss history)
Base Premium:
Company B
(Good loss history)
$20,000
$20,000
Experience Modification:
x 1.4
x .8
Adjusted Premium:
28,000
Difference:
16,000
$12,000 per year/$1,000 per month
This is the cost of insurance to the market based on each company’s experience.
Your premium is based on the average losses expected based upon prior experience.
How can you lower your costs? Builders recommends:

Do not use Uninsured Subcontractors. Obtain Certificates of Insurance
for all subcontractors. An uninsured subcontractor injured on your
worksite will increase your modifier. An insured subcontractor’s losses
affect their insurance, not yours.

Reduce claims through safe work practices and carrying a deductible on
your policy.
Fewer Claims = Lower Modifier = Lower Premium

Have a Back-to-Work Program. This will lower the cost of each claim,
reducing the impact on your modifier. By getting your people back to
work faster, you lose less productivity.
Builders Insurance Group wants to help our valued customers understand their insurance
coverage and make it as cost-effective as possible. Questions? Please feel free to contact
your Builders Loss Control representative at (678) 309-4000. Thank you for your
business.
www.buildersinsurancegroup.com
1. 800.883.9305
45
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
EXPERIENCE MODIFICATION FACTOR
THE TIMELINE
The National Council on Compensation Insurance (NCCI) determines your experience
modification factor by using your claims experience of certain years. If you think of the calculation
as being based on a five-year rolling block of time, it’s easy to remember which years are used.
The current year, or the year for which the mod is being calculated, is not used nor is the claims
experience from the next most previous year. The claims experience from the three preceding
years is what is used.
The experience modification is calculated six months prior to the renewal date of your policy each
year. For example if your policy renews on January 1, 2004 your experience modification factor
is assigned six months prior to that, or on July 1, 2003.
42 Months
30 Months
18 Months
1st
Year
01/01/00
2nd
Year
01/01/01
3rd Year
4th Year
5th Year
01/01/02
01/01/03
01/01/04
Looses value
here on
07/01/03
46
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
ANNUAL AUDIT - A GUIDE
Your original annual premium, for your organization, was calculated using your estimated payroll amount
for the upcoming year. To ensure the premium you have paid is neither too little nor too much, a review
of your payroll records will be conducted within 90 days of the end of your policy term.
QUESTION:
What policy period is to be audited?
ANSWER: From the first day the policy is effective to the last day the policy is effective. A
cancelled policy is audited up to and including the date of cancellation.
QUESTION: What records are needed in order for the audit to be conducted?
ANSWER: Payroll records, quarterly reports, and overtime records (totaled by class code)
covering the effective date of the policy are all needed, as are Certificates of Insurance provided
you by subcontractors.
QUESTION: Who from the policyholder’s organization should be present?
ANSWER:
A representative from your company who is authorized to verify the classification
of employees.
SUBCONTRACTORS ~ A Certificate of Insurance for workers’ compensation coverage is required from all
subcontractors covering the time period each one worked for you. If no certificate is in your possession at the
time of the audit you, the contractor, are required to pay the workers’ compensation premium for the
subcontractor for the time he worked for you.
The law requiring workers’ compensation coverage varies from state to state. For example in Georgia the law
requires all employers with three or more workers to have workers’ compensation insurance; in Florida employers
with four or more employees are required to have coverage. Builders Insurance Group requires all
subcontractors to have workers’ compensation coverage, even if they have no employees and are considered
independent contractors, otherwise you will be responsible for paying the premium due.
Builders Insurance Group does not accept exclusion forms from independent contractors.
CERTIFICATES OF INSURANCE ~ Any certificate you are provided should be the original certificate, not a fax or
a photocopy. The certificate should indicate your company as the certificate holder. It is suggested you
periodically check with the subcontractor’s insurance carrier to be sure the policy remains in effect.
Please note, in some instances it may be necessary for you to obtain two Certificates of Insurance from a
subcontractor whose policy effective date overlaps your effective date. For example: If your policy date is July 1,
2005 to July 1, 2006 and the subcontractor’s policy renewed on January 1, 2006 then you will need certificates for
the January 1, 2005 to January 1, 2006 and the January 1, 2006 to January 1, 2007 policy terms.
Should you have any questions regarding your audit please call our Audit department at (678)
309-4124 or (800) 883-9305, Extension 4124.
47
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
VOLUNTARY CANCELLATION
Voluntary cancellation of your workers’ compensation policy must follow specific procedures
pursuant to Georgia state law. To cancel or non-renew your policy, the procedures are as
follows:

Provide Builders Insurance Group a written request (10 days in advance of the
cancellation date) dated and signed by an officer of the company who is a named officer in the
information we have on file for your company. Include the reason for the termination and the date
for which the termination is requested. Or, you must return the original Builders Insurance policy
that was issued to you. A request from your agent cannot be accepted.
~ OR ~

Provide Builders Insurance Group an ACORD Policy Release form signed and dated
by an officer of the company (10 days in advance of the cancellation date). Include the reason for
the termination and the date for which the termination is requested. Or, you must return the
original Builders Insurance policy that was issued to you. A request from your agent cannot be
accepted.

All future cancellation dates will be honored

Other cancellation dates will be effective as of the date we receive the
request for cancellation in our office

Only with a Letter of Assumption or a Declarations Page from the new
carrier provided to us by the agent or insured may a cancellation be backdated
Please note: Simply discontinuing payment may cause you to be financially responsible for
premiums that have continued to accrue over time and/or complicate the refunding of any monies
that may be due you.
SHORT RATE PENALTIES
Short rate penalties will be applied to Builders Insurance policies cancelled during the policy
period because the insured has duplicate coverage or because the coverage is no longer
wanted. These penalties do not apply if the company is no longer in business. Any short rate
penalties applied are calculated using Rule 10 of the National Council on Compensation
Insurance (NCCI) and will appear on the cancellation audit.
48
Independent Contractor vs Statutory Employee
By Robert D. Ingram
And Michael Murawski
Do you want your insurance premiums to increase? Most builders would answer no. Yet builders
unwittingly might cause their premiums to increase every time they tell uninsured, independent
contractors, “Don’t worry. I’ll deduct the premiums from your pay. If anything happens, we’ll
cover it.” The law does not require builders to accept responsibility for all accidents.
The Georgia Workers’ Compensation Act long has had a “statutory employer” provision that
obligates a principal contractor (and its insurer) to pay for certain work-related injuries to
employees of its uninsured subcontractors. The application of that law can be complicated and it
is important that you are aware of several facts:
1.
You as the statutory employer pay an additional premium to cover the risk and additional
cost of workplace injuries to your uninsured, independent contractors’ employees;
2.
If you charge that back to the independent, he is not paying the premium – you are. You
are recouping your expenses;
3.
You may be responsible for injuries to the subcontractors’ employees, but not to the
subcontractor or owner;
4.
You are responsible for their injuries only if those injuries happen on or about the
premises on which the specific work involving the contract is undertaken and only while they are
doing the contracted work;
5.
You may not be responsible for his employees’ injuries if you own the property (as in the
case of a “spec” project) whether or not you withhold money from your payments to the
independent contractor that cover your added premium costs; and
6. When you make promises that extend your coverage and potential liability, you may be
obligating yourself and your insurance carrier legally to make payments beyond the duty imposed
by law.
The legislative motive behind the statutory employer law is to “encourage statutory employers to
require subcontractors to carry workers’ compensation insurance.” In an effort to educate its
policyholders on how to reduce their premiums, Builders Insurance Group is distributing an
“Independent Contractor Agreement” form to help you understand and remember basic facts
about your legal relationships with your subcontractors.
Policyholders will receive these agreements by mail. If you need additional copies or have
questions, call Michael Murawski of Builders Insurance Group at (678) 309-4000.
(Robert D. Ingram is a senior partner of Moore, Ingram, Johnson & Steel L.L.P., which represents
Builders Insurance Group. Michael Murawski is a quality assurance specialist with Builders
Insurance Group).
49
Independent Contractor Understanding
This bulletin represents the understanding between Builder’s Insurance Company policyholders
(hereinafter referred to as company) and its independent contractors (hereinafter referred to as
contractor).
As part of the agreement to undertake work as an independent contractor for company,
contractor agrees that company may withhold some amount of the payments ordinarily due to
contractor for contractor’s services for this job in order to recoup the additional expense to
company because contractor does not have current Workers' Compensation coverage in a
manner acceptable to the State of Georgia, Insurance Department, whether or not contractor may
be subject to the Georgia Workers’ Compensation Act.
Company understands, and contractor agrees, that company may be responsible under the
Georgia Workers' Compensation Act for certain injuries to contractor's employees and hereby
certifies that it currently has such acceptable insurance in force on this date to cover its liabilities
as a potential statutory employer pursuant to the Georgia Workers’ Compensation Act.
Contractor understands that company’s responsibility to contractor’s employees is more limited
and in certain cases non-existent when compared to company’s responsibility to its own
employees whether or not money is withheld. For example, company shall be responsible for
work-related injuries occurring only to contractor’s employees and only while they are working on,
in, or about the premises on which company has undertaken to execute work for another party.
To obtain maximum protection for its own employees, contractor must purchase its own
insurance coverage.
This document represents the full and total representations regarding Workers’ Compensation
arrangements between company and contractor.
_____________________________________________________________________________
(Contractor)
(Date)
50
SAMPLE HOLD – HARMLESS AND SUBCONTRACTOR AGREEMENT
This Agreement, as negotiated herein, is entered into by and between ___________________________,
“Subcontractor” and _________________________________, “Contractor.”
The Subcontractor and the Contractor, for the consideration stated herein, mutually agree as follows:
Article 1. Statement of Work:
The Subcontractor shall furnish all labor, materials, equipment, and services to perform and complete all
work required for the construction of:
_________________________________________________________________________________
_________________________________________________________________________________
Article 2. The Contract Price:
The Contractor shall pay the Subcontractor for the performance of the contract, subject to agreed
alterations, the sum of
__________________________________________ ($______________).
Article 3. Insurance:
The Contractor requires certificates of insurance from Subcontractor
Statutory limits for Workers’ Compensation with Employer Liability
General Liability limit of at least $300/600 
The Contractor requires that Subcontractor name Contractor as an additional insured on Subcontractor’s
General Liability insurance policy.
Article 4. Indemnification and Arbitration:
The work performed by the Subcontractor shall be at the risk of the Subcontractor exclusively.
Subcontractor shall indemnify, defend, and hold harmless the Contractor from and against any and all
claims, actions, losses, judgments, or liabilities arising from or in any way connected with the work
performed, materials furnished, or services provided under this Agreement. Further, Subcontractor agrees
that any and all disputes between Contractor and Subcontractor shall be settled through arbitration, in
accordance with the Federal Arbitration Act -Title 9, US Code.
Article 5. Warranty:
Subcontractor warrants its work for a period of _______ year(s) against all defects in materials or
workmanship.
Article 6. Miscellaneous:
This is the entire Agreement between the parties and is governed by the laws of the State of Georgia. Any
amendment(s) must be given in writing. Subcontractor is an independent contractor and not an employee of
Contractor.
SUBCONTRACTOR
Company: ____________________________
By: __________________________________
Title: ________________________________
Date: ________________________________
CONTRACTOR
Company: ____________________________
By: __________________________________
Title: ________________________________
Date: ________________________________
This sample agreement is for informational purposes only and should not be considered legal advice. Builders Insurance accepts no
legal responsibility for the correctness or completeness of this material. We recommend that you consult with your legal counsel and
agent regarding your individual circumstances.
51
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
WORKERS’ COMPENSATION STATE SPECIFIC INFORMATION
ALABAMA – www.dir.state.al.us.wc
State of Alabama
Department of Industrial Relations
Workers’ Compensation Division
Industrial Relations Building
649 Monroe Street
Montgomery, AL 36131
Phone: (800) 528-5166
(334) 242-2868
Fax:
(334) 261-3143
Fraud: (800) 923-2533
The state of Alabama requires employers with more than four (4) full-time or part-time employees,
including officers of a corporation, to have workers’ compensation coverage. Employers of
domestic employees, farm laborers, or casual employees and municipalities having a population
of less than 2,000 (according to the most recent federal census) are not required to provide
coverage but can elect to be covered by the provision of the Alabama Workers’ Compensation
Law. There are exemptions to this provision. For more information visit the State of Alabama
website at www.dir.state.al.us.wc.
The Alabama Legislature has provided for a 5% premium credit to employers with a drug-free
workplace program. The program must be in compliance with the provision of Code of Alabama,
1975, Sections 25-5-330 through 25-5-340. Your Drug-free Workplace Program must be certified
by the state. For more information contact the Medical Section at (800) 528-5166 or (334) 2422868 or the website at www.dir.state.al.us.wc.
52
FLORIDA – www.2.myflorida.com/les/wc
State of Florida
Department of Labor and
Employment Security
Division of Workers’ Compensation
301 Forrest Building
2728 Centerview Drive
Tallahassee, FL 32399-0680
Phone: (850) 922-2514
Fax:
(850) 922-6779
Fraud: (850) 742-2214
Workers’ compensation coverage is required in the state of Florida if you are in an industry other
than construction and have four or more employees, full-time or part-time (an exempted corporate
officer does not count as an employee). Any state or local government must carry workers’
compensation insurance.
If you are in the construction industry, and have one (1) or more employees (including yourself),
you are required to carry workers’ compensation coverage (an exempted sole proprietor, partner,
or corporate officer does not count as an employee).
If you are a farmer, and have more than five (5) regular employees and/or twelve (12) or more
other workers for seasonal agricultural labor lasting thirty (30) days or more, you are required to
carry workers’ compensation. For more information call the Employer Help Line at (850) 9216966 or visit the state’s website at www2.myflorida.com/les/wc.
The state law in Florida provides for a 5% premium credit for those employers having a drug-free
workplace program that meets the criteria set forth in s. 440.102, Florida Statutes. Your Drugfree Workplace Program must be certified by the state. Florida law also provides for a 2% credit
for employers with a safety program meeting certain criteria. For more information refer to Florida
Statutes Section 440.101 and 440.102, or call the Employer Help Line at (850) 921-6966 or visit
the state’s website at www2.myflorida.com.les.wc.
53
GEORGIA – www.ganet.org/sbwc/
State of Georgia
Georgia State Board of Workers’ Compensation
270 Peachtree Street, Northwest
Atlanta, GA 30303-1299
Phone:
(404) 656-3875
(800) 533-0682
Fax:
(404) 656-7768
Fraud:
(404) 657-1391
Safety Library: (404) 651-9057
Subsequent Injury Trust Fund: (404) 206-6360
Georgia state law requires all employers, including public corporations and non-profit
organizations, that have at least three (3) full-time or part-time employees to carry workers’
compensation insurance. For more information call the Georgia State Board of Workers’
Compensation at (404) 657-1391 or visit the state’s website at www.ganet.org.sbwc.
Georgia employers who have implemented a state certified Drug-free Workplace Program eligible
to receive a 7.5% premium credit. For additional information call the State Board at (404) 6571391 or visit the state’s website at www.ganet.org/sbwc/.
NORTH CAROLINA – www.comp.state.nc.us/
State of North Carolina
North Carolina Industrial Commission
4319 Mail Service Center
Raleigh, NC 27699-4319
Phone: (919) 807-2500
Fax:
(919) 715-0282
Fraud: (888) 891-4895
North Carolina state law requires any employer with three (3) or more employees to carry
workers’ compensation insurance. Officers of the corporation are considered employees. Any
employer having one or more employees engaged in activities which involve the use of or
presence of radiation is required to have workers’ compensation coverage. For additional
information call the Industrial Commission at (919) 807-2500 or visit the state’s website at
www.comp.state.nc.us/.
54
SOUTH CAROLINA – www.wcc.state.sc.us
State of South Carolina
Workers’ Compensation Commission
Post Office Box 1715
1612 Marion Street
Columbia, SC 29201-1715
Phone: (803) 737-5700 – Jackie Brady, Operator/Info
Fax:
(803) 737-5768
South Carolina law requires employers regularly having four or more part-time or full-time
employees to carry workers’ compensation coverage. There are exceptions to this; for additional
information call the Coverage and Compliance Division at (803) 737-5706.
TENNESSEE – www.state.tn.us/labor-wfd/wcomp.html
State of Tennessee
Department of Labor and Workforce Development
Workers’ Compensation Division
710 James Robertson Parkway
Andrew Johnson Tower
Gateway Plaza, Second Floor
Nashville, TN 37243-0661
Phone: (615) 532-4812
(800) 332-2667
Fax:
(615) 532-1468
Tennessee state law requires employers with five (5) or more part-time or full-time employees to
carry workers’ compensation insurance. Family members are included in the count if they meet
the definition of employee. Subcontractors and anyone engaged in the construction industry
must carry workers’ compensation on their employees even if they have less than five
employees. A five percent (5%) premium credit is available to employers in Tennessee who
implement a certified Drug-free Workplace Program. For more information or assistance contact
the Tennessee Department of Labor and Workforce Development at (615) 741-2395 or visit their
website at www.state.tn.us/labor-wfd/wcomp.html.
55
VIRGINIA – www.vwc.state.va.us
State of Virginia
Virginia Workers’ Compensation Commission
1000 DMV Drive
Richmond, VA 23220
Phone: (804) 367-8600
Fax:
(804) 367-9740
The state of Virginia requires employers with three or more employees to carry workers’
compensation insurance. For more information contact the Workers’ Compensation Commission
at (804) 367-8600 or visit their website at www.vwc.state.va.us.
Premium credits up to 5% are available to employers implementing a Drug-free Workplace
Program that meets the criteria established by their insurer.
PENNSYLVANIA - dli.state.pa.us/landi/cwp/view.asp?a=138&q=220671
State of Pennsylvania
Department of Labor and Industry
Bureau of Workers’ Compensation, Room 103
1171 South Cameron Street
Harrisburg, PA 17104-2501
Employer Services Help Line: 717-772-3702
Claims and Benefits Help Line: 717-772-4447 or 1-800-482-2383
Safety Committee Certifications: 717-772-1917
The state of Pennsylvania requires any employer who hires at least one employee,
part-time or full-time to carry workers’ compensation insurance. For more information, contact the
Bureau of Workers’ Compensation Employer Services Helpline at 717-772-1878. Generally,
executive officers and domestic workers can be exempted from coverage.
If you establish a safety committee for the purpose of hazard detection and accident prevention,
you may be eligib le for a 5% discount which can b e continued for five years. Contact the
Pennsylvania Department of labor and Industry at 717-772-1917
WHERE REFERNECE IS MADE TO LAWS AND EREGULATION, KNOW
GOTH WILL CHANGE OVER TIME. PLEASE CONSULT THE APPROPRIATE
STATE AGENCY OR YOUR OWN LEGAL COUNSEL, WHEN APPROPRIATE.
56
BUILDERS INSURANCE GROUP
BUILDERS INSURANCE
(A MUTUAL CAPTIVE COMPANY)
STATE AGENCIES FOR OCCUPATIONAL SAFETY AND HEALTH
These are state agencies designated to administer activities of states and other jurisdictions
under the Occupational Safety and Health Act.
ALABAMA
U.S. Department of Labor
OSHA
2047 Canyon Road
Birmingham, AL 35216
Phone: (205) 731-1534
Phone: (800) 321-6742
Fax:
(205) 731-0504
NORTH CAROLINA
N. Carolina Department of Labor
Occupational Safety & Health Div.
4 West Edenton St.
Raleigh, NC 27601-1092
Phone: (919) 807-2900
Phone: (800) 522-0762
Fax: (919) 807-2855
FLORIDA
Charlene Vespi, Consultant
University of South Florida
Tampa, FL
Phone: (813) 974-9962
SOUTH CAROLINA
S. Carolina Department of Labor
Licensing and Regulation
Columbia, SC 29204
Phone: (803) 737-9220
Fax:
(803) 734-9772
GEORGIA
Georgia Department of Labor
Safety Engineering Division
1700 Century Circle
Atlanta, GA 30345
Phone: (404) 679-0687
Phone: (800) 869-1041
Fax:
(404) 679-5818
TENNESSEE
OSHA Division
Tennessee Department of Labor
710 James Robertson Pkwy., 3rd
Nashville, TN 37243-0659
Phone: (615) 741-2793
Phone: (800) 249-8510
Fax:
(615) 741-3325
MISSISSIPPI
Department of Environmental Quality Industry
Post Office Box 20305 St.
Jackson, MS 39289-1305
Phone: (601) 961-5171
Fax:
(601) 961-5743
VIRGINIA
Virginia Dept, of Labor &
Powers-Taylor Bldg.13, S. 13th
Richmond, VA 23219
Phone: (804) 786-2377
Fax:
(804) 371-6524
PENNSYLVANIA
Department of Labor & Industry
Bureau of Workers’ Compnesation
Health & Safety Division
1121 S. Cameron Street, Room 324
Harrisburg, PA 17104-2501
(717)772-1636
57
OSHA REGIONAL OFFICES
REGION III – PHILADELPHIA
Region III includes:
Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia
U.S. Department of Labor – OSHA
The Curtis Center, Suite 740 West
170 S. Independence Mall West
Philadelphia, PA 19106-3309
Phone: (215) 861-4900
Fax:
(215) 861-4904
The Curtis Center
170 South Independence Mall West
Philadelphia, PA 19106-3309
Phone: (215) 861-5120
Fax:
(215) 861-4904
AREA OFFICES
850 North Fifth Street
Allentown, PA 18102
Phone: (610) 776-0592
Fax:
(610) 776-1913
Baltimore Area 1099
Winterson Road, Suite 140
Linthicum, MD 21090-2218
Phone: (410) 865-2055 or 2056
Fax:
(410) 865-2068
58
Charleston Area
405 Capitol Street, Suite 407
Charleston, WV 25301
Phone: (304) 347-5937
Fax:
(304) 347-5275
Erie Area
3939 West Ridge Road, Suite B12
Erie, PA 16506-1857
Phone: (814) 833-5758
Fax:
(814) 833-8919
Harrisburg Area
49 North Progress Avenue
Harrisburg, PA 17109
Phone: (717) 782-3902
Fax:
(717) 782-3746
Norfolk Area
Federal Office Building, Room 614
200 Granby Street
Norfolk, VA 23510-1819
Phone: (757) 441-3820
Fax:
(757) 441-3594
Washington District Sup.
820 First Street, N.E., Ste. 440
Washington, D.C. 20002-4205
Phone: (202) 523-1452
Fax:
(202) 523-3573
Wilkes-Barre Area Director:
The Stemaier Building
7 N. Wilkes-Barre Blvd., Ste. 410
Wilkes-Barre, PA 18702-5241
Phone: (717) 826-6538
Fax:
(717) 821-4170
Wilmington Area
844 N. King St., Room 2209
Wilmington, DE 19801-3319
Phone: (302) 573-6518
Fax:
(302) 573-6532
Philadelphia Area
U.S. Customs House, Room 242
Second & Chestnut Streets
Philadelphia, PA 19106-2902
Phone: (215) 597-4955
Fax:
(215) 597-1956
Pittsburgh Area
1000 Liberty Avenue
Federal Building, Room 1428
Pittsburgh, PAA 15222-4101
Phone: (412) 395-4903
Fax:
(412) 644-6380
59
REGION IV – ATLANTA
Region IV includes:
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and
Tennessee
U.S. Department of Labor – OSHA
Atlanta Federal Center
61 Forsyth Street Southwest, Room 6T50
Atlanta, GA 30303
Phone: (404) 562-2300
Fax:
(404) 562-2295
AREA OFFICES
Atlanta-East Area
LaVista Perimeter Office Park
Building Seven, Suite 110
Tucker, GA 30084-4154
Phone: (770) 493-6644
Fax:
(770) 493-7725
Atlanta-West Area
2400 Herodian Way, Suite 250
Smyrna, GA 30080-2968
Phone: (770) 984-8700
Fax:
(770) 984-9031
Nashville Area Dir.: Ron McGill
2002 Richard Jones Road, Ste. C-205
Nashville, TN 37215-2869
Phone: (615) 781-5423
Fax:
(615) 781-5486
Birmingham Area Dir
Vestavia Village
2047 Canyon Road
Birmingham, AL 35216-1981
Phone: (205) 731-1534
Fax:
(205) 731-0504
60
CONT.
Columbia Area
1835 Assembly Street, Room 1468
Columbia, SC 29201-2453
Phone: (803) 765-5904
Fax:
(803) 765-5991
Fort Lauderdale
8040 Peters Road, Bldg. H-100
Fort Lauderdale, FL 33324-4029
Phone: (954) 424-0242
Fax;
(954) 424-3073
Frankfort area
John C. Watts Federal Office Building
330 West Broadway, Room 108
Frankfort, KY 40601-1922
Phone: (502) 227-7024
Fax:
(502) 227-2348
Raleigh Area
300 Fayetteville St. Mall, Room 438
Raleigh, NC 27601-9998
Phone: (919) 856-4770
Fax:
(919) 856-4183
Savannah Area
450 Mall Blvd., Suite J
Savannah, GA 31406-1418
Phone: (912) 652-4393
Fax:
(912) 652-4329
Tampa Area
5807 Breckenridge Pkwy., Suite A
Tampa, FL 33610-4249
Phone: (813) 626-1177
Fax:
(813) 626-7015
Jackson Area
3780 I-55 North, Suite 210
Jackson, MS 39211-6323
Phone: (601) 965-4606
Fax:
(601) 965-4610
Jacksonville Area
Ribault Building, Suite 227
1851 Executive Center Drive
Jacksonville, FL 32207
Phone: (904) 232-2895
Fax:
(904) 232-1294
61