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Sfqpsujoh!b!Xpsl.Sfmbufe!Jokvsz!jt!Ujnf!Tfotjujwf" <br />Dbmm!Uif!Ibsugpse“t!MpttDpoofdu!jnnfejbufmz!up!sfqpsu!b!dmbjn/ <br />2.911.438.4747 <br />Bwbjmbcmf!35!ipvst!b!ebz-!476!ebzt!b!zfbs/ <br />Uif!Cfofgjut!pg!Ujnfmz!Mptt!Sfqpsujoh; <br />Researc as sown tat faster loss reporting significantly affects loss costs. Te sooner we are notified, te sooner we <br />can inestigate te accident and coordinate wit yo, te inred employee, and te medical team to ensre te fastest <br />possile retrn to ealt and wor. <br />Uif!Fggfdu!pg!Ujnfmz!Sfqpsujoh!po!Dpouspmmjoh!uif!Dptu!pg!Zpvs!Mptt; <br />Bwfsbhf!Mptt!gps!Dmptfe!Dmbjnt <br />)Bddjefou!Zfbst!3113.3116* <br />Sfqpsu!Mbh!jo!EbztQfsdfou!Dibohf!jo!Mptt!Dptut <br />Dpnqbsfe!up!Gjstu!Xffl!Sfqpsu <br />Incident Day-6 <br />Wee 10 <br />Wee 213 <br />Wee 3 or 416 <br />1 Mont or Later24 <br />Tubuvupsz!sfrvjsfnfout!bmtp!ofdfttjubuf!uif!qspnqu!jojujbm!sfqpsujoh!pg!uif!bddjefou!dbvtjoh <br />jokvsz!ps!efbui/Gbjmvsf!up!dpnqmz!nbz!sftvmu!jo!b!gjofbcmf!pggfotf!cz!uif!Tubuf/ <br />Jogpsnbujpo!Zpv“mm!Offe <br />Company InformationIncident Information <br />oAccont meroType of inry rn, ct, etc. <br />oLocation Code if applicaleoEact ody part inred <br />oParent Company or program nameoWat cased te accident <br />oPolicy meroAny reason to estion te inry <br />oAny witnesses <br />Worker Information oAddress were inry occrred <br />oame, DOB, Address, PoneoWere was te inred employee treated Proide <br />oSocial Secrity mername, address, pone of medical proider. <br />oAge, GenderoWen was te accident reported to yo and y <br />oMarital Stats, mer of Dependantswom date, time <br />oire Date, Years in Crrent Position <br />oWage Information <br />Ofuxpsl!Qspwjefst <br />A listing of more tan 400,000 networ proiders alified to treat wor-related inries is aailale online at <br />www.talispoint.com/artet or y calling or etwor Referral nit at 1-800-32-3636 select 4 at te prompt. Since <br />networ referrals are often impacted y state specific rles, please call to learn ow to maimie or networ capailities <br />on ealf of yor employees. <br />Gpsn!XD!77!14!95 Printed in .S.A. <br /> <br />