MKT.02.12.157.L

Welcome to Key Risk. We look forward to working together to deliver better outcomes in workers compensation.

Our mission is to enrich each client’s risk management strategies by creating and executing comprehensive solutions proven to protect people, support business and exceed expectations. Key Risk claim professionals and risk management specialists offer your organization the benefit of efficient claim handling and jurisdictional expertise.

Key Risk provides risk management, claims and managed care services to workers compensation policies written on behalf of member insurance companies of W. R. Berkley Corporation, rated A+ (Superior) Financial Size Category XV by A.M. Best Company.

Important claim reporting information is available from our website at www.KeyRisk.com. For more information about your workers compensation program from Key Risk, please contact your independent insurance agent or call us directly at 800.942.0225.

Thank you for the opportunity to support your organization’s workers compensation program.

ExpertiseSpecializationRelationships

Risk Management

TMEssentials

Online Claim Access & Reporting

Outcome-Based Managed Care & Bill Review

Dedicated Local Team Focused on Workers Compensation

Financial StrengthRated A+ (Superior)

A.M. Best Company, Inc.

Risk ManagementExpertise

Specialization inClaim Management

W O R K I N G T O G E T H E R . D E L I V E R I N G B E T T E R O U T C O M E S .

Better Outcomes In Workers Compensation

Working Together

As a policyholder you are provided access to a variety of services and resources to help manage your overall workers compensation program:

Every Client Deserves Personal AttentionThe prevention of workplace injury and illness ultimately reduces the overall workers compensation costs for an employer. Focused on collaboration and producing measurable outcomes, we work with employers to reduce workers compensation exposures, establish integrated action plans and develop effective transitional duty programs.

Essentials™, Key Risk’s innovative approach to risk management, provides dedicated risk management services to your business - small, medium or large. Policyholders are provided automatic access to a variety of safety and risk management resources, including:

Essentials Online VideosWritten Safety Programs &

Presentation MaterialsSafetyConnections

Webinars

Online access and 24-hour claim reporting Employers can report claims through our 24-hour client call center, by fax, by email or online via MasterKey Connects®, a state-of-the-art risk management information platform.

MasterKey Connects, provides your organization online access to real time claim information. You can set

automatic alerts, and generate reports specific to the needs of your organization. Information on setting up a MasterKey Connects account is available from our website.

Dedicated Claim ServicesOur claim professionals work together with injured workers, medical providers and employers to develop effective strategy for each injured worker.Our claims professionals offer efficient claim handling with a focus on jurisdictional and industry-specific expertise.

Layered Network of Medical & Pharmacy Providers

CompCareLX is our layered network of medical providers developed to ensure employees receive the best care possible when an injury occurs. A custom panel of providers is provided to each employer.

Our pharmacy benefits management program assists injured workers in receiving prescriptions quickly, with no out-of-pocket expense. Key Risk’s pharmacy benefits management Instant Access Card should be utilized for all injury related prescriptions.

In the event of injury please complete and provide each injured employee with a copy of the Instant Access Card. An electronic version of the Instant Access Card and a list of network pharmacies by zip code are available from www.KeyRisk.com.

Case Management Nurse case managers are available to collaborate with the medical provider, employer and claim professional to ensure a successful return to work for the injured employee.

Outcome-Based Medical Bill ReviewSophisticated rules-based system combined with the expertise of our trained medical bill review team offers employers reduced medical costs in the event there is a workplace accident.

Transitional DutyWorking together with injured employees, medical providers and employers to identify transitional duty opportunities, we are committed to helping injured workers return to work as soon as medically possible.

Risk Management

TMEssentials

www.KeyRisk.com

Overview of Services

Claims Management

TMEssentials

Essentials™, Key Risk’s innovative approach to risk management, provides dedicated risk management services to your business - small, medium or large.

With a focus on jurisdictional and industry expertise, our risk management services team truly understands the challenges and opportunities employers face. Our approach allows us to optimize opportunities, provide quicker responses, and enhance client service.

The prevention of workplace injury and illness ultimately reduces the overall workers compensation costs for an employer. Focused on collaboration and producing measurable outcomes, we work with employers to reduce their workers compensation exposures, establish integrated action plans and develop effective transitional duty programs. Results include a safer workplace, fewer injuries and the overall improvement in an organization’s experience modification factor - a primary component used in calculating workers compensation premium.

For employers, increased frequency of claims indicates increased potential for a large loss. Our risk management team works with employers to develop an integrated approach to safety focused on improving production and reducing the frequency of claims.

Offering both standard resources as well as custom-tailored solutions, our outcome-focused safety programs include benchmarks such as the incidence rate of claims within a specific industry in addition to practical steps to surpass those benchmarks.

Through MasterKey Connects®, a state-of-the-art risk management information platform, our clients have online access to real time claim information. Employers

can generate reports specific to their needs.

Providing Workers Compensation Essentials to Your Business - Small, Medium or Large

www.KeyRisk.com

Risk Management

TMEssentials

Risk Management & Safety Resources

Policyholders are provided automatic access to a variety of risk management resources:

Dedicated Risk Management Services

Essentials Online Videos

Written Safety Programs and Presentation Materials

SafetyConnections

Training Materials

KeyCares Quarterly Wellness Newsletter

ExpertiseSpecializationRelationships

RMS.02.12.242.I

Key Risk is a member company of W. R. Berkley Corporation, whose insurance company subsidiaries are rated A+ (Superior), Financial Size Category XV by A.M. Best Company and A+ (Strong), by S&P. Products and services are provided by one or more insurance company subsidiaries of W. R. Berkley Corporation. Not all products and services are available in every jurisdiction and the precise coverage afforded by any insurer is subject to the actual terms and conditions of the policies as issued.

For more information on solutions available from Key Risk, please contact your independent insurance agent at 800.942.0225.RMS.02.12.242.I

An essential part of any viable safety program is the availability of up-to-date, accurate resources to help keep your safety program moving in a positive direction. Here are some of the most commonly requested resources available to you as a Key Risk client, free of charge. If you need a specific topic not listed below, contact riskmanagement@keyrisk.com. A sampling of resources is included below:

Employee Training ProgramsAccident Investigation Ergonomics Safety Committee DevelopmentAging Workforce Forklift Safety Slips, Trips, & Falls PreventionBack Safety Hazard Communications Substance AbuseBloodborne Pathogens Lockout / Tagout Transitional DutyCombative Residents Machine Guarding Transportation SafetyDriving Safety Management Training on Workers CompensationDrug Free Workplace Safe Patient/Resident Handling

SafetyConnectionsSafetyConnections are intended to serve as tools for safety awareness training for your team. All current titles are available from MasterKey Connects®, including those featured below:

Age…Does it Matter? Heat Stress Awareness in Senior AdultsBloodborne Pathogens: More than just HIV-AIDS Hurricane Clean-Up: After the DisasterCombative Behavior in Healthcare Incident Reporting: I think I’m Hurt – Now What?Defensive Driving – Guidelines for Employees Knife Safety RemindersDriving Safety – Is it Important to You? Ladder SafetyErgonomics: Does your workstation fit you? Mechanics of LiftingE-Verify Needlestick Prevention: Are You Stuck on Safety?Fire Prevention: Smart Fire Safety Rules Preventing Slips, Trips, and FallsForklift Safety Resident/Patient Lifting: Be PreparedGait Belts: If I Just Had Handles! Restaurant Self-Inspection ChecklistGlobal Harmonization:The Revised Hazard Communication Standard

Start of School: A Lesson in Safety

Hazard Communication Standard: The Employees Right to Know Violence Prevention StrategiesHazards Found in Nature Wellness: Tips for a Healthier YouHeat Stress Who’s In Control…Lockout/Tagout

Essentials Online Videos - Over 600 TitlesEssentials Online Videos provides over 600 online video offering featuring safety and risk management topics. Many online videos include follow-up quizzes and supporting materials. Additionally, more than 350 of the topics are also available in Spanish. An extensive collection of safety training DVDs is also available from our DVD library.

Clients may request any of these resources directly from their risk management professional or by sending an e-mail to riskmanagement@keyrisk.com.Risk Management

TMEssentials

When an injury does occur, Key Risk claim professionals are solution-driven and dedicated to assisting each injured worker throughout the entire claim process.

All claims should be reported to Key Risk Immediately.

Claims reported within the first 24 hours have proved to produce better outcomes for the injured worker and cost up to 15% less than those reported days after an injury.

REPORTING OPTIONSThere are four options for reporting claims.

1. Online: From www.KeyRisk.com, click on MasterKey Connects®, log in and select “Report a Claim.” For access, please call 800.942.0225, Ext. 3361952 for set-up information.

2. Telephone: Contact our 24-Hour Client Service Call Center at 866.847.8872

3. Email: support@keyrisk.com.

4. Fax: 888.576.7329

Forward any additional claims correspondence, such as medical bills or witness statements, to:

Key RiskP.O. Box 49129

Greensboro, NC 27419

Visit our website at www.KeyRisk.com for claimtools and resources.

MKT.01.11.184.H

The following entities comprise the Optum Workers Compensation and Auto No-Fault division: PMSI, LLC, dba Optum Workers Compensation Services of Florida; Progressive Medical, LLC, dba Optum Workers Compensation Services of Ohio; Cypress Care, Inc., dba Optum Workers Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; PMSI Settlement Solutions, LLC, dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers Compensation Medical Services and dba Optum Workers Compensation Services, collectively and individually referred as “Optum.” IMP14-1714-90

First Fill Form: Complete and take to your pharmacy

First Fill Information

Key Risk

RxBin #: 610011 RxPCN: IRX Group Number: B31412

group

Member ID:

Member Name:

Employer Name:

Date of Injury:

Member ID is month and year of

injury plus last 4 digits of

claimant’s SSN number (e.g.,

MMYYYYSSSS)

Injured worker’s first & last name

Pharmacy Help Desk:

1-800-547-3330

Employer:

Immediately upon receiving notice of injury, fill in the information below and give it to your injured employee. Injured Worker:

1. If you need a prescription filled for a work-related injury or illness, go to an Optum® participating network pharmacy.

2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost.

ATTENTION INJURED WORKER

Use of this prescription form is restricted to prescriptions for your allowed condition only. To receive your medication coverage, present this form to a network pharmacy. This is for a one time prescription fill. If you require additional prescriptions, a permanent card will be mailed to you. For questions, call Optum at 1-800-547-3330.

Pharmacist:

1. Please process this prescription through OptumRx. 2. For questions regarding transmission, rejections or if you encounter any problems processing this

prescription, please call Optum at 1-800-547-3330.

Revised 12.05.13 (38.03.10.101.C)

Authorization

The undersigned has filed a claim for workers compensation benefits (hereafter referred to as the “Claim”). The amount and type of information sought pursuant to this authorization will depend upon the nature of the Claim, but will be used solely to facilitate determination regarding validity of the Claim and the payment of benefits or the administration of the insurance program under which the Claim has been made. Authorizing the disclosure of information is voluntary, and acceptance of the Claim will not be conditioned upon signing this authorization. This authorization is subject to revocation at any time, except to the extent that any party has already acted in reliance upon it. Any revocation must be submitted in writing to Key Risk, P. O. Box 49129, Greensboro, NC 27419.

The undersigned authorizes the release of information and communication between his or her health care provider(s) (including, without limitation, medical laboratories, pharmacies, pharmacy benefit managers, and medical suppliers) and representatives of Key Risk Management Services/Berkley Insurance Company (“Key Risk”).

This release of information applies to all applicable medical records, medical information, bodily fluid and tissue samples, and benefit payment information with respect to any illness, injury, medical history, consultation, prescription, treatment, or benefit, and copies of all applicable records thereof, which may be appropriate or necessary throughout the course of this Claim. This authorization shall specifically include, but shall not be limited to, medical records, medical information and benefit payment information pertaining to or relating to the treatment of Acquired Immune Deficiency Syndrome, HIV, mental illness, and drug or alcohol related problems.

The undersigned also authorized the Social Security Administration and the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors, to release to Key Risk information concerning his or her workers compensation injury, entitlement dates and benefit amounts.

The undersigned further authorizes Key Risk to release any such information to its reinsurers, attorneys, second injury fund consultants, or to medical laboratories, medical peer review panels, CMS, state insurance or fraud agencies, managed care vendors, industry anti-fraud or law enforcement organizations, research and statistical reporting organizations, or the undersigned's employer and its excess insurer, to the extent that Key Risk considers doing so to be reasonably appropriate or necessary for the purposes of its administration of the Claim or the insurance program under which the Claim has been made.

Information disclosed to Key Risk is from records whose confidentiality is protected by various state or federal laws. Any further disclosure of this information may no longer be subject to certain protections provided under federal privacy regulations. Unless revoked earlier by the undersigned, in writing, this authorization shall be valid for three years after Key Risk has closed the Claim. A copy of this authorization is to be considered as valid as the original.

Employee Signature Date

Employee Name Employer (Please Print) (Please Print)

Claim Number Date of Birth

Workers Compensation

866.841.1044Confidential Hotline Number

FRAUDHOTLINE

Workers Compensation Fraud Hurts Everyone!It’s against the law – Cheaters can be fined or go to jail!It impairs your employer’s ability to compete in the marketplace by affectinginsurance rates, salaries, and jobs!

If you suspect fraud, call the hotline!Workers compensation pays your medical bills and other expenses and replacespart of your salary if you are injured while working.Key Risk will pay what’s due to injured workers, but is dedicated to reducing fraudto help control costs for your employer and protect your job.

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