Excess Workers' Compensation Program - Claims Reporting Procedures


Occurrence reports, formally filed claims, and lawsuits served upon SELF Excess Workers' Compensation Program members must be reported within 30 days to the SELF office, 1531 "I" Street, Suite 300, Sacramento, California 95814, (916) 321-5300, FAX (916) 321-5311, if they involve any of the following:

A.
 injuries to spinal cord (including surgery to the spinal cord or spinal column for any reason), paraplegia, or quadriplegia;
B.
 a fatality;
C.
 amputation or paralysis of a major extremity
D.
 second or third degree burns to 25% or more of the body
E.
 serious head or brain injuries (including skull fractures or loss of any sensory ability);
F.
 any occurrence which causes serious injury or death to two or more employees
G.
 any occurrence which results in a claim for loss time disability exceeding one (1) year
H.
 any injury which requires multiple surgeries to major body parts (limbs, spine, head, major organs, cardiovascular system);
I.
 any case with potential life-pension exposure

In addition to the above, the member shall give prompt written notice to SELF for any Workers' Compensation claim in which the incurred value (amounts paid plus outstanding reserves) totals 50% of the self-insured retention level.

Should a member question whether or not to report a specific claim, he/she should call SELF's Chief Executive Officer.

Notice of accident given to SELF shall contain complete details on the injury, disease or death. Documents required with the report are:

A. SELF's Initial Report Form
B. The Employer's Report of Injury (form 5020) or equivalent information, copies of any Qualified Medical Examination or Agreed Medical Examiner reports, most recent comprehensive medical report, copy of the payment ledger showing all payments made to date for all costs, summary of payments by category of payment, e.g. medical expense, compensation, current reserves by category
C. Summary of any investigations completed, application and claim form, any findings of any state WC official or judicial body, any disability rating, current status and issues remaining and the specific plan of action to resolve issues and the expected time for completion, and any other pertinent information.
Subsequent reports are due every six months and are to include any new documents listed above.

At SELF's election and expense, SELF has the right to participate with you in the settlement, defense or appeal of any claim, suit, judgment, or proceeding which might involve an exposure to SELF. According to the SELF Joint Powers Agreement, Bylaws and Memorandum of Coverage, you have agreed not to make any voluntary settlement involving loss to SELF without the written consent of the SELF Executive Director.