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LOS ANGELES UNIFIED SCHOOL DISTRICT

Owner Controlled Insurance Program The School Repair and Construction Program

Insurance

Manual

Los Angeles Unified School District Insurance Manual September 26, 2007 – OCIP II

Table of Contents

Overview ...................................................................................................................................... 1

Definitions................................................................................................................................ 2

OCIP Project Directory.............................................................................................................. 3

OCIP Administrators ............................................................................................................... 3 OCIP Owner............................................................................................................................. 4

OCIP Coverages.......................................................................................................................... 5

Excluded Parties ...................................................................................................................... 5 Evidence of Coverage .............................................................................................................. 5 Summary Description of OCIP Coverages .............................................................................. 5

Contractor and Subcontractor Required Coverage ................................................................ 8

Workers’ Compensation and Employer’s Liability.................................................................. 9 Commercial General Liability/Umbrella Liability ................................................................ 10 Automobile Liability............................................................................................................... 10 Property Insurance ................................................................................................................ 10 Watercraft and Aircraft Liability ........................................................................................... 10 Professional Liability............................................................................................................. 10 Pollution Liability .................................................................................................................. 11

Contractor and Subcontractor Responsibilities..................................................................... 12

Contractor Bids...................................................................................................................... 13 Adjustments for OCIP Insurance Costs ................................................................................. 13 Enrollment.............................................................................................................................. 14 Maintaining Enrollment in the OCIP..................................................................................... 15 Safety Standards..................................................................................................................... 15 Payroll Reports ...................................................................................................................... 16 Insurance Company Payroll Audit......................................................................................... 16 Change Order Procedures ..................................................................................................... 17 Demolition / Abatement Work................................................................................................ 17 Close Out and Audit Procedures ........................................................................................... 17

Claim Reporting Procedures ................................................................................................... 19

Workers’ Compensation Claims ............................................................................................ 19 Liability Claims...................................................................................................................... 20 Automobile Claims................................................................................................................. 20 Pollution Claims .................................................................................................................... 21 Builders Risk Claims.............................................................................................................. 21

Forms ......................................................................................................................................... 22

Los Angeles Unified School District Insurance Manual September 26, 2007 – OCIP II

O C I P P R O J E C T D I R E C T O R Y

Overview Welcome to the LAUSD School Repair and Construction Program Owner Controlled Insurance Program.

The LAUSD has arranged for its construction projects to be insured under its Owner Controlled Insurance Program (OCIP). An OCIP is a single insurance program that insures the District, the Board, all Enrolled Contractors (and their Enrolled Subcontractors), and other designated parties for Work performed at the Project Site(s). Certain Contractors and Subcontractors are excluded from this OCIP. These parties are identified in Section 3 of this Manual.

Coverage under the OCIP includes Workers’ Compensation, Employer’s Liability, General Liability, Excess Liability, Builders Risk, and Contractor's Pollution Liability Insurance for operations of Enrolled Parties at the Project Site (“OCIP Coverages”).

The District will pay the insurance premiums for the OCIP coverages described in this Manual. You should notify your insurance broker/insurer(s) of the coverages provided under this OCIP for on-site activities to avoid the duplication of coverage. Each bidder is required to exclude from its bid price the cost of the OCIP Coverages provided by the District.

The Contractor's and Subcontractor's cost of insurance would include the reduction in insurance premiums, related taxes and assessments, markup on the insurance premiums and losses retained through the use of a self-funded program, self-insured retention or deductible program. The total cost of insurance must include expected losses within any retained risk. The Contractor must deduct the cost of insurance for all their Subcontractors from the bid in addition to their own cost of insurance.

DISCLAIMER:

The information in this Manual is intended to outline the OCIP. If any conflict exists between this Manual and the OCIP insurance policies the insurance policies will govern.

Section

1

Los Angeles Unified School District Insurance Manual September 26, 2007 - OCIP II 1


Definitions

Parties performing labor or services at the Project site are eligible to enroll in the OCIP unless an Excluded Party.

ELIGIBLE PARTIES:

Those eligible Contractors and Subcontractors that have submitted all necessary enrollment information and have been accepted into the OCIP as evidenced by a Confirmation Letter and Certificate of Insurance.

ENROLLED PARTIES, CONTRACTORS/ SUBCONTRACTORS:

“Excluded Parties”: EXCLUDED PARTIES:

(a) Hazardous materials remediation, removal and/or transport companies and their consultants;

(b) Architects, surveyors, engineers, and soil testing engineers, and their consultants;

(c) Vendors, suppliers, fabricators, material dealers, truckers, haulers, drivers and others who merely transport, pickup, deliver, or carry materials, personnel, parts or equipment or any other items or persons to or from the Project site;

(d) Contractors and each of their respective Subcontractors who do not perform any actual labor on the Project site, during the term of the Contract;

(e) Any parties or entities not specifically designated by in its sole discretion, even if otherwise eligible.

LAUSD’s Owner Controlled Insurance Program - A coordinated insurance program providing certain coverages, as defined herein, for the District, Eligible and Enrolled Contractors, and eligible and Enrolled Subcontractors performing Work at the Project Site.

OCIP:

Aon Risk Services, Inc. PROGRAM ADMINISTRATOR:



Section

2 OCIP Project Directory The following list includes key insurance personnel involved in the OCIP.

OCIP Administrators

OVERALL PROGRAM ADMINISTRATION: Aon Risk Services, Inc. (213) 630-3200 (telephone) 707 Wilshire Boulevard, Suite 6000 (213) 689-4358 (fax) Los Angeles, CA 90017

John Porter – Program Manager (213) 630-3308 (telephone) (847) 953-0779 (fax) [email protected] Fred Mesa – Program Administrator (866) 226-1420 (telephone) (Primary Contact for Enrollment,

Payroll, Claim Kits, Forms, etc.) (800) 363-6695 (fax) [email protected]

BUILDERS RISK PROGRAM ADMINISTRATION

Driver Alliant Insurance Services 1301 Dove Street, Suite 200 Newport Beach, CA 92660 Claims Office: 600 Montgomery Street, 9th Floor San Francisco, CA 94111

Julia Gossard-Gordon – Account Manager (949) 660-8141 (telephone)

(949) 756-2713 (fax) [email protected]

Robert Frey – Claims Manager (415) 403-1445 (telephone) (415) 402-0773 (fax) [email protected]


mailto:[email protected]




OCIP Owner

Los Angeles Unified School District Division of Risk Management & Insurance Services 333 South Beaudry Avenue, 28th Floor (213) 241-1843 (telephone) Los Angeles, CA 90017

Steven La Shier – Director of Risk Management

(213) 241-2645 (telephone) (213) 241-8956 (fax) [email protected] (213) 241-1843 (telephone) Robert Reider – OCIP Manager (213) 241-8956 (fax) [email protected] (213) 241-0441 (telephone) Jimmy Otero – Acting Construction Safety

Manager (Existing Construction Division) [email protected] (213) 893-7453 (telephone) Chris Bartku – Construction Safety Manager

(New Construction Division) (213) 972-3893 (fax) [email protected]






O C I P I N S U R A N C E C O V E R A G E

Section

3 OCIP Coverages This chapter provides a brief description of OCIP Coverages. You must refer to the actual policies for details concerning coverage, exclusions and limitations.

Excluded Parties Excluded Parties must meet the insurance requirements established in Section 4 and provide evidence of coverage to the District.

Evidence of Coverage Each Enrolled Party will be issued a Workers’ Compensation policy. The OCIP Administrator will provide a Certificate of Insurance evidencing Workers’ Compensation, general liability, excess liability, builders’ risk, and contractor’s pollution liability insurance to each Enrolled Contractor and Enrolled Subcontractor, each of whom will be a named insured on the OCIP policies. Complete copies of the insurance policies are available for your review in the OCIP Administrator's office

Summary Description of OCIP Coverages The following descriptions on these pages provide a summary of OCIP insurance coverages ONLY. Contractors and Subcontractors should refer to the policies for actual terms, conditions, exclusions and limitations.



Workers’ Compensation and Employers Liability:

State California Each Enrolled Party will be issued a separate Workers’ Compen-sation policy Part One – Workers’ Compensation: Statutory Limit

Part Two – Employer’s Liability: Annual Limits per Enrolled Party

Bodily Injury by Accident, each accident $2,000,000 Bodily Injury by Disease, each employee $2,000,000 Bodily Injury by Disease, policy limit $2,000,000

Commercial General Liability Coverage Form: Occurrence Limits of Liability Shared by All Enrolled Parties A single policy will be issued covering all Enrolled Parties. General Aggregate $4,000,000

Products/Completed Operations Aggregate $4,000,000 Bodily Injury & Property Damage – Each Occurrence $2,000,000 Personal/Advertising Injury – Each Occurrence $2,000,000 Fire Damage Legal Liability $1,000,000 Medical Expense $5,000 • This insurance will NOT provide coverage for products liability to any insured

party, vendor, supplier, off-site fabricator, material dealer or other party for any product manufactured, assembled or otherwise worked upon away from the Project Site.

• Ten (10) Years Products & Completed Operations Extension beyond final acceptance of the entire project with a single, non-reinstated aggregate limit.

The policy contains exclusions. Some of these exclusions are: Real & Personal Property in the care, custody or control of the insured; Asbestos; Lead; Discrimination & Wrongful Termination; ERISA; Architects & Engineers Errors & Omissions; Owned & Non-Owned Aircraft, Watercraft, Pollution and Automobile Liability; Nuclear Broad Form Liability, Terrorism.

Excess Liability Shared by All Enrolled Parties

Each Occurrence Limit $100,000,000 Annual General Aggregate Limit $100,000,000



• Policy follows form of underlying Commercial General Liability and Employer’s Liability policy wording (provisions, coverage, exclusions, etc.).

Builders Risk Projects under $50 Million Each Occurrence Limit $50,000,000 Deductible - Each Loss $10,000

All projects in excess of $50 million in construction value must be submitted for individual underwriting prior to binding coverage.

Contractor’s Pollution Liability Shared by All Enrolled Parties Each Occurrence Limit $50,000,000 Annual General Aggregate Limit $50,000,000 Contractor or Subcontractor Deductible - Each Loss $250,000 Aggregate Deductible $1,000,000

NOTE: Insurance coverage and limits provided under the OCIP are limited in scope and are specific to Work performed after the inception date of your enrollment into this OCIP. Your insurance representative should review this information. Any additional coverage you may wish to purchase will be at your option and expense.

NOTE: Contractors and Subcontractors are advised to arrange their own insurance for Contractor or Subcontractor owned or leased equipment and materials. The OCIP will not cover Contractor or Subcontractor property.


R E Q U I R E D C O V E R A G E S

Section

4 Contractor and Subcontractor Required Coverage Contractors and all Subcontractors are required to maintain coverage to protect against losses that occur away from the Project Site or that are otherwise not covered under the OCIP.

Contractors and Subcontractors are required to maintain insurance coverage for the duration of the Contract that protects the District from liabilities. These liabilities may arise from the Contractor’s and Subcontractor’s operations performed away from the Project site, from coverages not provided by the OCIP, or from operations performed by Excluded Parties. The OCIP places Contractors and Subcontractors into one of two main categories: Enrolled Parties or Excluded Parties.

Enrolled Parties are to provide evidence of Workers’ Compensation, General Liability, and Excess/Umbrella Liability insurance for off-site activities and Automobile Liability insurance for both on-site and off-site activities as per the insurance specifications in the Contract. See Section 2 for the definition of Enrolled Parties. Prime Contractors provide their Certificate of Insurance to Aon upon enrollment in the OCIP. Subcontractors provide their Certificates of Insurance to their Prime Contractor.

Excluded Parties must provide evidence of Workers’ Compensation, General Liability, Excess/Umbrella Liability and Automobile Liability insurance for all activities including both on-site and off-site activities as per the insurance specifications in the Contract. See Section 2 for the definition of Excluded Parties. Prime Contractors and Subcontractors should provide their Certificates of Insurance to Nida Niravanh at LAUSD (see below).

See Section 7 for sample

Certificate of Insurance

All Prime Contractors must submit verification of insurance in the form of a Certificate of Insurance on a standard ACORD form 25-S. They must provide verification of insurance to the OCIP Administrator within ten (10) working days of Notice of Intent to Award of contract, prior to mobilization and within ten (10)



days of any renewal, change or replacement of coverage. A sample of an acceptable Certificate of Insurance is provided in Section 7.

Contractor/Subcontractor will submit, adding LAUSD as an additional insured, General Liability/Workers' Compensation certificates of insurance for off-site/excluded work and Automobile Liability certificates of insurance for on-site/off-site/excluded work to:

Los Angeles Unified School District Division of Risk Management & Insurance Services 333 South Beaudry Avenue-28th Floor Los Angeles, CA. 90017-5141 Attention: Nida Niravanh

Please note the requirements for thirty (30) days notice of cancellation, modification or material change. The additional insured endorsement shall state that the coverage provided to the additional insureds is primary and non-contributing with respect to any other insurance available to the additional insureds.

Certificate of Insurance

Within 5 days of Notice of Intent to Award, prior to mobilization and within ten (10) days of renewal, change or replacement of coverage, Prime Contractors will submit a Certificate of Insurance to Aon evidencing the coverage and limits as specified in this section.

All Contractors and Subcontractors are responsible for monitoring their Enrolled Subcontractors and Excluded Parties’ Certificates of Insurance. The District reserves the right to disapprove the use of Subcontractors unable to meet the insurance requirements. Certificates of Insurance evidencing compliance are to be available to the District or the OCIP Administrator upon request.

A 30-day notice of cancellation provision and additional insured status is required on all Certificates.

The limits of liability shown for the insurance required of the Contractors and Subcontractors are minimum limits only and are not intended to restrict the liability imposed on the Contractors and Subcontractors for Work performed under their Contract.

Eligible Contractors shall provide evidence of Workers’ Compensation insurance for off-site activities.

Workers’ Compensation and Employer’s Liability Part One - Workers’ Compensation: Statutory Limit Part Two - Employer’s Liability: Annual Limits: Excluded Parties

shall provide evidence of Workers’ Compensation applicable to on and off-site projects.

Bodily Injury by Accident, each accident $1,000,000 Bodily Injury by Disease, each employee $1,000,000 Bodily Injury by Disease, policy limit $1,000,000



Commercial General Liability/Umbrella Liability Eligible Contractors shall provide evidence of general liability insurance for off-site activities.

Annual Limits: General Aggregate $2,000,000

Products/Completed Operations Aggregate $2,000,000 Excluded Parties shall provide evidence of general liability insurance applicable to on and off-site projects and must add the District and other parties as additional insureds to their policy.

Personal/Advertising Injury Aggregate $1,000,000 Each Occurrence Limit $1,000,000 Coverage must be an Occurrence form and it must apply to bodily injury and property damage for operations (including explosion, collapse and underground coverage), independent contractors, products and completed operations. Limits can be provided by a combination of a primary Commercial General Liability policy and an Excess or Umbrella Liability policy.

Automobile Liability A Commercial Business Auto Policy which covers all owned, hired and non-owned automobiles, trucks and trailers with coverage limits not less than $1,000,000 Combined Single Limit each accident for bodily injury and property damage. Coverage will apply both on and away from the Project Site(s). All Subcontractors shall be required to maintain limits of not less than $1,000,000 Combined Single Limit.

All Contractors and Subcontractors shall provide evidence of automobile liability. The OCIP does not cover automobile liability.

Property Insurance Contractors and Subcontractors are advised to arrange their own insurance for owned and leased equipment, whether such equipment is located at a Project Site or “in transit”. Contractors and Subcontractors are solely responsible for any loss or damage to their personal property including contractor tools and equipment, scaffolding and temporary structures, whether owned, used, leased or rented by the contractor. Contractors and Subcontractors are also responsible for any loss or damage to property or materials created or provided under the Contract.

Watercraft and Aircraft Liability The operator of any watercraft or aircraft of any kind must maintain liability naming the District and the respective Contractor and/or Subcontractor as an additional insured with primary and non-contributory wording. In addition, the limit of liability must be satisfactory to the District. Such insurance requirements will be determined as the need arises.

Professional Liability All professional service firms must provide professional liability insurance The District does

not provide Professional Liability Insurance.



appropriate for their profession and satisfactory to the District.

Pollution Liability Specifically excluded from OCIP coverage is Work related to the removal, remediation or abatement of hazardous materials, i.e., asbestos, lead, PCBs, heavy metals, etc. Contractors/subcontractors performing this type of work must provide and maintain a Pollution Liability Policy covering the exposures mentioned above. The District will determine limits based on the nature of the contract and the risk involved.

Note: Waivers Required The Contractor's Workers’ Compensation, General Liability, Automobile Liability and Umbrella or Excess Liability insurers shall provide Waivers of Subrogation in favor of the District and other designated parties. General Liability and Excess Liability Insurance policies will name the District, the Board, its officials, employees and agents and the OCIP Administrator as additional insureds and it will state that the coverage is primary and non-contributory.


C O N T R A C T O R - R E S P O N S I B I L I T I E S

Section

5 Contractor and Subcontractor Responsibilities Throughout the course of the Project(s), Contractors and Subcontractors will be responsible for reporting and maintaining certain records as outlined in this section.

The Contractors and Subcontractors are required to cooperate with the District and its OCIP Administrator in all aspects of OCIP implementation and administration. Responsibilities of the Contractor include all contract responsibilities, and the following:

Safety Pre-Qualification prior to submitting a bid. Contractors may only contract with Subcontractors that they have safety pre-qualified

Excluding the cost of OCIP insurance from their bids, if eligible for the OCIP

Providing each Subcontractor with a copy of this Insurance Manual & Safety Standards

Enrollment in the OCIP, if eligible, within ten (10) working days of notice of intent to award of contract

Including OCIP provisions in all contracts with Subcontractors

Providing timely evidence of other insurance or contractor required insurance to the OCIP Administrator within ten (10) working days of notice of intent to award of contract

Notifying the OCIP Administrator of all subcontracts awarded

Maintaining and reporting monthly payroll records

Cooperating with the OCIP Administrator’s requests for information

Complying with insurance, claim and safety procedures

Monitoring its Subcontractor's Certificates of Insurance



Notifying the OCIP Administrator immediately of any insurance cancellation, modification, material change or non renewal of Contractor required insurance

Responsibilities of Subcontractors of all tiers:

Enrollment in the OCIP, if eligible

Safety pre-qualification

Maintaining and reporting monthly payroll records

Cooperating with the OCIP Administrator's requests for information

Complying with insurance, claim and safety procedures

Monitoring its Subcontractor's Certificates of Insurance

Contractor Bids The District provides insurance for all Enrolled Contractors and Enrolled Subcontractors under the OCIP for Work performed at the Project Site(s). The section below, “Adjustments for OCIP Insurance Costs” describes the procedure for bidding, and how you must identify the cost of insurance and then exclude your insurance costs from the bid. Section 7 of this Manual contains worksheets that can help you estimate your insurance costs for this Project. The OCIP Administrator can also assist you in identifying the insurance costs.

See Section 7 for sample forms that can help identify your insurance costs. See Section 2 for information on contacting the OCIP Administrator.

Adjustments for OCIP Insurance Costs Each Contractor and Subcontractor is required to exclude the Costs of OCIP Coverage’s from its bid price for the proposed scope of work (including subcontracted work whether or not the Subcontractor is identified at the time of the bid). “Costs of OCIP Coverages” is defined as the amount of Contractor’s and its Subcontractors’ reduction in insurance costs due to eligibility for OCIP Coverages as determined by the Owner using Aon Form-1 and Aon Form-2 located in the Insurance Manual and information available to the District and/or the OCIP Administrator regarding the costs of similar coverages taking into account limits of liability, coverages, and rating of the insurer.

The Contractor's and Subcontractor's cost of insurance would include the reduction in insurance premiums, related taxes and assessments, markup on the insurance premiums and losses retained through the use of a self-funded program, self-insured retention or deductible program. The total cost of insurance must include expected losses within any retained risk. The Contractor must deduct the cost of insurance for all their Subcontractors from the bid in addition to their own cost of insurance.



To aid the Contractor and its Subcontractors in identifying its Workers’ Compensation, employer’s liability insurance, general liability insurance, excess liability insurance, builders risk insurance and contractor’s pollution liability insurance costs the Insurance Credit Worksheet form (Aon-1), is included in Section 7 as a sample to assist the Contractor and Subcontractor in determining the cost of insurance to be deducted from the bid. A separate form can be used for the Contractor’s self-performed work, each identified Subcontractor and for unidentified Subcontractors at the time of the bid. The worksheets are to assist the Contractor in removing the insurance costs from their competitive bid. Do not include these worksheets with the bid submission.

Each Enrolled Contractor and Enrolled Subcontractor may be required to submit insurance documentation that supports the Cost of OCIP Coverage’s deducted from the bid. Documentation may include the following pages from the Workers’ Compensation, Employer’s Liability, General Liability, Excess Liability, Builders Risk and Contractor’s Pollution Liability (as applicable) policies: • Declarations or information page • Rate page(s) • Deductible endorsements • Verification of experience modification(Workers’ Compensation only) • 5 Years of loss history for entities that retain losses

Change orders must be priced by the Enrolled Parties to exclude the cost of insurance. Under the District’s OCIP, the final payroll is determined by an audit by the OCIP insurer. The audited contract information will be used to calculate the Contractor’s and Subcontractor’s true insurance costs (in the absence of the OCIP). If the results of this comparison demonstrate that the final, actual payrolls would have produced a different deduction for insurance costs, an additional

amount will be withheld from the Contractor’s payments under the Contract.

Contractors are solely responsible for ensuring that their Subcontractors of all tiers also deduct the cost of insurance from their bid.

Enrollment Each Enrolled Contractor shall provide details about its Subcontractors to the OCIP Administrator, in order to enroll them in the OCIP. The Contractor and Subcontractor must complete and submit the

See Section 7 for sample OCIP forms.

Enrollment Application form (Aon-3); a sample is included in Section 7. This form must be completed and submitted to the OCIP Administrator within 10 working days of notice of intent to award contract award and prior to mobilization on the Site(s) to obtain coverage under the OCIP.



A separate Enrollment Application form (Aon-3) is required for each Eligible Subcontractor of any tier that performs Work at the Project Site. A separate Workers’ Compensation policy will be issued to each Enrolled Contractor and Enrolled Subcontractor.

Each Enrolled Contractor or Enrolled Subcontractor will receive a Confirmation Letter. A Confirmation Letter is a letter issued by the OCIP Administrator that confirms acceptance of the applicant into the District OCIP.

Note: Enrollment Is Not Automatic Enrollment into the OCIP is required, but not automatic. All Eligible Contractors and all Eligible Subcontractors MUST complete the enrollment forms and participate in the enrollment process for OCIP coverage to apply. Access to the Project Site will not be permitted until Enrollment into the OCIP is complete.

Maintaining Enrollment in the OCIP If you do not comply with all the terms of this Manual in a timely manner, including the Construction Safety Standards, you may not remain enrolled in the OCIP. Contractors eligible for enrollment in the OCIP who are not enrolled in the OCIP will not be granted access to the Project Site(s).

Note that OCIP coverage will cease 60 days after the date of Substantial Completion is reached on the project.

Safety Standards establish minimum standards for contractor safety programs. Safety Standards are provided to all participants during the bidding process.

Safety Standards Each Contractor and Subcontractor is required to have a written safety program and to provide a designated safety representative who is on Site when any Work is in progress. If there are fifty (50) workers or more on a job-site, the Contractor shall have a DEDICATED, FULL-TIME, Safety Representative that has no other tasks other than administering the Contractor’s and LAUSD’s Safety Programs. Safety Representative Requirements are as specified in the contract and LAUSD Safety Program. Minimum standards for Contractor safety programs are outlined in the LAUSD’s Safety Standards.



Payroll Reports Each Enrolled Contractor and Enrolled Subcontractor of every tier must submit monthly payroll reports. The reports will identify worker-hours and payroll by Workers’ Compensation classification code for all Work performed at the Project Site. This information will be used to provide the District's insurers with information required for determining the District's premium.

All Enrolled Contractors and Enrolled Subcontractors must submit payroll reports prior to the 10th of the following month. A Payroll Report form (Aon Form-4), provided in Section 7, is the only acceptable form. The monthly worker-hour and payroll reports should include supervisory and clerical personnel that are on-site and cover all Work performed at or emanating directly from each Project Site.

The payroll report (Aon Form-4) for the prime contractor and all subcontractors must be submitted with the contractors request for payment. The District will not process payment requests unless the Aon Form-4 payroll report is attached.

Insurance Company Payroll Audit Each Enrolled Contractor and Enrolled Subcontractor is required to maintain payroll records for each Contract. Such records will allocate the payroll by Workers’ Compensation classification(s) code and exclude the excess or premium paid for overtime (i.e., only the straight time rate will apply to overtime hours worked). Furthermore, such records will limit the payroll for Executive Officers and Partners/Sole Proprietors to the limitations as stated in the state manual rules.

It is important that you properly classify payrolls, as these are reported to the rating bureau for promulgation of future Experience Modifiers for your firm. All Enrolled Contractors and Enrolled Subcontractors shall make available their payroll records, vouchers, contracts, documents, and records, of any and all kinds, to the auditors of the OCIP insurer(s) or the District’s representatives. Availability of records must be for the policy period, any extension, or during a final audit period as required by the insurance policies.

Note: Failure to submit the payroll reports as required may result in the withholding of contract progress payments or final payment until the reports are received as well as being barred from future opportunities with the District.



Change Order Procedures Change orders must also exclude the Enrolled Contractor's Costs of OCIP Coverage for the insurance coverages that are provided by the District in the OCIP.

Demolition / Abatement Work As respects to demolition on any structures of 4 (four) stories or greater in height, contractors should notify the Administrator (Aon) so that notification to Liberty Mutual can be made at least 4 (four) weeks in advance of the actual work beginning. Such notification shall give Liberty Mutual Loss Prevention the option to participate in the review, pre-planning and monitoring process for the demolition work.

For demolition projects totaling $1,000,000 or less, or projects with hazardous materials abatement of 10% or less of the total project costs, OCIP coverage will extend to all portions of work except for hazardous materials abatement. Contractors/subcontractors performing this type of work must provide and maintain a Pollution Liability Policy covering hazardous materials abatement. The contractor/subcontractor shall complete and submit the 00620 Certificate of Insurance for Hazardous Materials form as verification of insurance coverage for hazardous materials work.

Demolition projects with no hazardous materials abatement or disturbances that may be performed by properly trained personnel according to Specification Sections 13280 and 13282 are fully covered by the OCIP.

For demolition projects totaling above $1,000,000, or any project with hazardous materials abatement of more than 10% of total project costs, the contractor will be considered an “Excluded Party” for OCIP coverage. No portion of the project will be eligible for insurance coverage through the OCIP. Contractors will be required to provide evidence of Workers’ Compensation, General Liability, Excess/Umbrella Liability, Automobile Liability, and Pollution Liability insurance for all activities including both on-site and off-site activities as per the insurance specifications in the Contract.

The Owner Authorized Representative (OAR) assigned to the project shall ensure that the appropriate insurance is maintained by the contractor for the duration of the project.

Close Out and Audit Procedures The Enrolled Contractor and Enrolled Subcontractors must submit the Notice of Work Completion form (Aon-5), when a Contractor and/or a lower tier



Note that OCIP coverage will cease 60 days after the date of Substantial Completion is reached on the project.

Subcontractor has completed it’s Work at the LAUSD School Repair and Construction Program Project Site (s) and no longer has workers on Site. The

Aon-5 form will initiate the final payroll report and audit of payroll and worker-hours by the OCIP Insurer. The OCIP Insurer is the insurance company named on the policy or on the Certificate of Insurance that provides coverage for the OCIP. A copy of the Notice of Work Completion form, (Aon-5) with instructions on the proper method for completion is found in Section 7.

Issuance of final payment will not be authorized by the District until all necessary forms have been submitted to the OCIP Administrator. Any Safety Program Contributions for which the Contractor or Subcontractor of any tier is responsible will be considered at the time of close-out. Safety Program Contributions previously paid will not be considered as a part of the close out.


C L A I M R E P O R T I N G P R O C E D U R E S

Section

6 Claim Reporting Procedures This section describes the basic procedures for reporting various types of claims: Workers’ Compensation, Liability, and Damage to the Project (Builders’ Risk).

Workers’ Compensation Claims The main responsibility for any Contractor and Subcontractor is first to see that the injured worker receives immediate medical care. Next, you should immediately notify the OCIP Insurance Carrier in the event of a serious injury or accident.

A Claims Kit will be provided to all Contractors. It will include details about claim reporting and is intended for use at the job site.

To assist you in reporting an injury or accident, we have established a dedicated toll free telephone number. Please immediately report any injury using the toll free telephone number: 800-641-1723. You may report your WC First Reports of Injury 24 hours a day/365 days per year. When calling in you will need to know the project/school name, address, contractor, contract number, and contractor’s policy number.

When you report the Workers’ Compensation injury using the special reporting telephone number, the OCIP Insurance Carrier will complete the Employer's First Report of Injury (form 5020) and make the necessary filings. It is the employer's responsibility to provide the injured worker with the Employee's Claim (form DWC-1) within 24 hours of employer’s knowledge of injury. The employer must also send a copy of the employee's claim form and the Supervisor's Report of Injury form to the OCIP Insurance Carrier.

The OCIP Administrator will provide Claims Kits to all Enrolled Contractors and Enrolled Subcontractors. These kits will include appropriate claim forms and postings. Additional kits or claims forms can be obtained from the OCIP Administrator or the carrier’s claims coordinator. Also attached to this manual is the MPN notice. This Notice must be given to each employee to review and then must be signed for knowledge of receipt.



The District’s Workers’ Compensation insurer has arranged with authorized medical providers and facilities for treatment of all minor or non-life threatening injuries. The name, address and telephone number of the nearest authorized clinic and hospital for the designated school location will be on the Posting Notice, which is in the Claims Kit. The posting notice was also sent to you at the time Aon Risk Services advised you of the completion of the enrollment.

Contractors and Subcontractors must designate a representative at the site to take injured employees to the medical treatment center and to report the claim. This individual is to remain with the injured employee at the medical treatment center while he/she is being treated. The treating physician should provide a written description of whether or not the injured employee can return to work, a list of restrictions if any, and the estimated length of time the injured worker must be on modified duty. The District supports transitional modified work to keep injured workers gainfully employed during recovery.

The General Contractor will arrange with the local 911 emergency ambulance services for response to any serious traumatic life threatening injuries and will provide information in the Claims Kit.

Liability Claims Accidents at or around the Project Site(s) resulting in damage to property of others (other than your own work product), or personal injury or death to a student, faculty member or a member of the public, must be reported immediately to Liberty Mutual by calling the toll free telephone number: 800-641-1723 Do not voluntarily admit liability. Cooperate with the District and the OCIP insurer representatives in the accident investigation.

Report all Liability claims to Liberty Mutual.

Automobile Claims No insurance coverage is provided for automobile accidents under the OCIP. It is the sole responsibility of each Contractor and Subcontractor to report accidents/claims involving their automobiles to their own insurers.

Report all Auto claims to your insurance carrier and the OCIP Administrator.

However, all accidents occurring in or around the job site must be reported to the OCIP Administrator. The accident will be investigated to determine any liability arising out of the project construction activities that could result in future claims (i.e., due to the conditions of the roads, etc.). Each Contractor and Subcontractor shall cooperate in the investigation of all automobile accidents.



Pollution Claims The District's OCIP policies may provide coverage for certain pollution conditions. Incidents must be reported promptly in writing. Report incidents or possible claims by immediately notifying the OCIP Administrator of any known or suspected pollution incidents.

Builders Risk Claims All risk of direct physical loss or damage excluding earthquake and flood is subject to policy terms, conditions and exclusions. Driver Alliant is the broker for the Builders Risk program. To report claims contact:

Claims Manager – Robert Frey (415) 403-1445 (telephone) Driver Alliant Claims Office: (415) 402-0773 (fax) 600 Montgomery Street, 9th Floor [email protected] San Francisco, CA 94111


F O R M S


Forms This section contains the forms needed for enrolling into the OCIP, reporting claims, reporting payroll and overall administration of the OCIP.

This section contains the following forms:

Aon 1 Insurance Credit Worksheet

Aon 2 Insurance Summary

Aon 3 Enrollment Application

Aon 4 On-Site Payroll Report

Aon 5 Notice of Work Completion

Aon 6 On-site Worker Hours Incident Report

Exhibit 1 Sample Certificate of Insurance

Exhibit 2 Workers’ Compensation First Report of Injury or Illness

Exhibit 3 General Liability Notice of Occurrence/Claim

Exhibit 4 Property Loss Notice

Exhibit 5 Liberty Mutual Medical Provider Network Information

Note: For assistance in completing these forms, please

contact the LAUSD OCIP Administrator

Aon Risk Services (866) 226-1420

Section

7

LAUSD INSURANCE CREDIT WORKSHEET Form-1 Page 1 of 1(Instructions located on the following page)

1. Contractor Information: Federal ID No.:

u Business Information (headquarters) u Contact Information (address questions to..) Company Name & dba / Contact Name & Title:

Address: City, State Zip Code:

Telephone: Fax:

Bid Package No.:2. Bid Information:

Scope of Work: Proposed Contract Price: $ Amount of Self Performed Work: $

If Subcontractor, Contractor Are you a: identify under contract with: Subcontractor Workers’ Compensation Insurance Information:

3. State Class Code

4. Description

5. Rate (per $100 payroll)

6. Worker-hours

7. 8. WC Premium Payroll (Payroll * Rate / 100)

9. Totals Your Company’s Workers’ Compensation Experience Modifier: 10.

Modified Premium (Total WC Premium multiplied by line 10):11. 12. a) Employers Liability Rate: b) Employers Liability Cost = line 11 x line 12a:

b) Rate c) Amount a) Modification Premium Factors: Modifier 1:

13.

Modifier 2: d)Total Modified Amount:

14. Total Workers’ Compensation Premium (line 11 plus 12 minus 13): b) Based On: c) Rate factor: 15. _________ a) General Liab. Rate:

Payroll Per $100 GL Premium Cost:

Receipts Per $1,000 Other ____ __________

a) Builder’s Risk/Installation Floater Rate: b) Property Premium Costs:16. Not applicable b) Based On: c) Rate factor: 17. _________ a) Excess/Umbrella

Rate: Payroll Per $100 Excess/Umbrella Receipts Per $1,000 Premium Costs: Other ____ __________ d)

18. Total of all Insurance Premiums (total of lines 14, 15, 16 & 17):

Overhead & Profit on Insurance Prem. %: O/H & Profit Amount: 19.

20. Total Initial Insurance Credit (Total of lines 18 &19):

21. Initial Insurance Composite Rate (line 20 divided by total payroll in line 9):

Name: Date: (please print)

Title: Signature:

INSTRUCTIONS FOR INSURANCE CREDIT WORKSHEET (AON FORM-1) A separate form may be used for each contractor, known Subcontractor and trade not currently awarded to a Subcontractor. This form may be used to estimate the cost of insurance, which must be deducted from the bid. Duplicate this form as needed:

1. Contractor Information: Provide your company's Federal ID Number. Provide your Business Information including the Company Name, Address, City, State, Zip Code, Telephone and Fax

in the column. Provide the name of your employee that can answer insurance questions. If this person’s Business Address,

Telephone and Fax is different enter this information in the column provided.

2. Bid Information: Provide the Bid Package Number assigned by District. Provide a brief description of the work your firm will perform. Identify your proposed contract price. Identify the amount your firm will self-perform (100% if no subcontractors are used) Check the box that applies to your status on this bid. Identify with whom you are contracting (the District or the name of the contractor or subcontractor)

Workers’ Compensation Insurance Information:

Description of Worker’s Compensation Column Information 3. State Class Code – Provide the state Workers’ Compensation classification codes applicable to your scope of work. 4. Description – Provide the Workers’ Compensation class code description that applies to the code. 5. Rate – Enter the rate your firm pays for coverage for each class code. This information can be obtained from your

Workers’ Compensation policy. 6. Worker-hours – Provide your estimated worker-hours, by class code, for work that will be performed on-site. 7. Payroll – Provide your estimated payroll, by class code, for work that will be performed on-site. 8. WC Premium – For each classification you entered, multiply the Payroll by the Rate and divide by 100.

9. Totals – Calculate totals for columns numbered 8, 9 and 10. 10. Workers’ Compensation Experience Modifier - Enter your experience modification factor. This number is located on

your Workers’ Compensation policy or on the Bureau’s rating sheets. If you do not have an experience modifier, use 1.00.

11. Modified Premium – Multiply the total on line 9 by your Workers’ Compensation experience modifier. 12. Employers Liability Rate – (a) Enter your Employers Liability Rate located on your Workers’ Compensation policy and

(b) calculate by multiplying the Modified Premium by the rate. 13. Modification Premium Factors – Identify the premium modification factors that apply to your Workers’ Compensation

policy. These factors may include a “Scheduled Credit” or a “Premium Discount”. a) Identify the name of the Modifier, (b) enter the Rate , (c) compute the Amount by calculating the Modified Premium by the Rate. Total the amount computed in column 13.c). Enter the total in 13.d).

14. Total Workers’ Compensation Premium – Add the Modified Premium and the Employers Liability Premium (line 11 and 12). Subtract the Premium Modifications identified and totaled in line 13 d).

Other Insurance Items: 15. General Liability – (a) Enter the General Liability rate, (b) identify the basis the rate applies to by checking the box (if the

basis is other, identify in the space provided), (c) Check whether the rate factor is ($100 or $1,000). Compute the General Liability Premium by using the formula (rate basis * rate / rate factor).

16. Builder’s Risk/Installation Floater – (a) Enter the rate and (b) apply to the Proposed Contract Cost identified in the Bid Information Section.

17. Excess/Umbrella Liability – (a) Enter your Excess or Umbrella Liability rate, (b) identify the basis the rate applies to by checking the box (if the basis is other, identify in the space provided), (c) Check whether the rate factor is $100 or $1,000. Compute the Excess or Umbrella Liability Premium by using the formula (rate basis * rate / rate factor).

Total Insurance Premiums: 18. Total of all Insurance Premiums – Add lines 14, 15, 16 and 17. 19. Overhead & Profit – (a) Identify the percentage of Overhead & Profit included in your pricing structure, (b) apply the

percentage to Overhead & Profit to the Total of all Insurance Premiums. 20. Total Initial Insurance Credit – Add lines 18 and 19. 21. Initial Insurance Composite Rate - Divide the Total Initial Insurance Credit (line 20) by the Total Payroll (column 9).

LAUSD INSURANCE SUMMARY Form-2 Page 1 of 1

1. Name of Contractor: 2. Bid Package No.:

$ 3. Total Proposed Cost: A B C D

Contracting Parties & Trades Amount of Contract Estimated Worker-hours

Estimated Payroll Initial Insurance Credit

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8. Composite Rate for Contract: (line 7d divided by line 7c * 100)

INSTRUCTIONS FOR INSURANCE SUMMARY (AON FORM-2)

Make a separate entry on the Aon Form-2 for each contractor, known Subcontractor and trade not currently awarded to a Subcontractor. Duplicate this form as needed:

General Information 1. Name of Contractor – Enter the name of the Contractor or Subcontractor that is being summarized on the form. 2. Bid Package No. – Enter the Bid Package No. the District assigned to the bid. 3. Proposed Contract Cost – Enter the Proposed Contract Cost for the Contractor or Subcontractor being summarized.

Contractor Specific Information 4. Contractor – Enter the Contractor or Subcontract that is being summarized (include only self-performed work from the

Aon Form-1) b) Estimated Worker-hours (line 9 and column⊕) c) Estimated Payroll (line 9 and column∅) d) Initial Insurance Credit line 21).

5. Known Subcontractors – For each Subcontractor summarize their work and the work of lower level tiers. Information will be obtained from either an Insurance Summary Aon Form-2, if lower level tiers were used, or the Aon Form-1. The Aon Form-1 reference numbers are supplied below: a) Amount of Contract – The Proposed Contract Cost from Bid Information Section (2). b) Estimated Worker-hours – The work performed by the Subcontractor and all lower level subcontractors. Information

from line 9 and column 6. c) Estimated Payroll – The work performed by the Subcontractor and all lower level subcontractors. Information from

line 9 and column.7 d) Initial Insurance Credit – The work performed by the Subcontractor and all lower level tiers. Information obtained

from line 21. 6. Identified Trades NOT yet assigned to a Subcontractor – For each trade, not yet assigned to a Subcontractor, estimate the

amount of work and insurance costs on Aon Form-1s. a) Amount of Contract – The Estimated cost to subcontract the work. Information is obtained from the Proposed

Contract Cost from Bid Information Section (2). b) Estimated Worker-hours – The estimated on-site trade worker-hours. Information from line 9 and column 6. c) Estimated Payroll – The estimated on-site trade payroll. Information from line 9 and column 7. Initial Insurance

Credit – the computed insurance costs for the trade based on estimated subcontract cost, including Contract Amount, Worker-hours and Payroll. The OCIP Administrator is available to provide reasonable insurance rates for computing the insurance costs on the Aon Form-1. Information obtained from line 21.

7. Total Estimates for Contract – The total amount entered in column a, b, c, and d. 8. Composite Rate for Contract – The Total Initial Insurance Credit divided by the Total Estimated Payroll (line 7d / 7c).

LAUSD ENROLLMENT APPLICATION Form-3 (Instructions located on the following page) Page 1 of 2

It is suggested that you examine your current Workers’ Compensation and General Liability Policies or contact your Insurance Agent to assist you with completing this form. *** NOTICE *** Enrollment is not automatic and requires the satisfactory completion of the Aon Form-3. In addition, you must submit a Certificate of Insurance providing evidence of your off-site coverages and automobile liability insurance. Please refer to the Insurance Manual & Safety Standards for coverage requirements.

1. Contractor Information: Federal ID No.

u Business Information (headquarters) u Contact Information (address questions to …) Company Name & dba / Contact Name & Title:

Address: City, State Zip Code:

Telephone: Fax:

E-mail Address: Entity: Sole Proprietor Corporation

Partnership Other: __________________________________________

2. Provide your current Workers’ Compensation Information: Anniversary Rating Date: Experience Modification: Bureau File Number:

Your WC Insurance Carrier: Policy #: Effective Date: Expiration Date:

3. Contract Information: Contract #: Contract Description:

Sub–Subcontractor Location of Work:

Prime Status on Project: Other __________________ Subcontractor

Contract Award Date:

If you are a Sub, Identify who your contract is with:

Provide Payroll by Class Code in the following space provided (attach a separate sheet if necessary) Class State Description Worker-hours Payroll Code

Totals

Contacts: Position Name & Title Phone Fax e.mail address

Project Mngr: Safety Rep: Residnt Engnr: Contract Admin: Payroll: Claims:

Actual Actual Start Date: Completion Date: Estimated Estimated

Contract Amount:

LAUSD ENROLLMENT APPLICATION Form-3 (Instructions located on the following page) Page 2 of 2

4. Subcontract Information: List any Subcontractors that will be working for you on this project (complete the information in the following table). Use additional paper if necessary:

Subcontractor Address Subcontract $ Phone Contact Person

5. Will you have any off-site location(s) 100% dedicated to this project? Yes No If yes, please provide address:

6. If you are a subsidiary and/or division of another company, complete an ERM-14 Form. If you are a participant as a joint venture partner, also complete an ERM-14 form.

7. Please check if: Any aircraft will used on this project Any watercraft will used on this project 8. Does your firm participate in Alternative Dispute Resolution with the Union? Yes No

W A R R A N T Y Workers’ Compensation, General Liability and Excess Insurance coverages, as stated in the Contract Documents, are provided by the District. The undersigned agrees and warrants:

9. It is the Contractor’s responsibility to notify it’s own insurance carrier to exclude from its regular insurance all Work to be performed at the Project Site under this Contract

10. The statements in this insurance application are true to the best of my knowledge.

11. Contractor warrants that their cost of OCIP insurance and the cost of OCIP insurance for all subcontracted Work has been deducted from the bid.

12. Contractor agrees to be solely responsible for the cost of the non-OCIP insurance specified in the Contract.

13. The costs of premiums for the coverage provided by the OCIP shall be paid by the District. The District will receive or pay, as the case may be, all adjustments to such costs, whether by way of dividends, retrospective rating adjustments, return premiums, audits or otherwise. Each Contractor and each of its Subcontractors shall execute any instruments of assignment as may be necessary to permit the District to receive such adjustments, unless otherwise provided in the Contract Documents.

Date: Name: (please print) Title: Signature:

Mail to: LAUSD OCIP Administrator Fax to: LAUSD OCIP Administrator Aon Risk Services, Inc. Aon Risk Services, Inc. 1000 N. Milwaukee Ave. Fax (800) 363-6695 Glenview, IL 60025 Phone: (866) 226-1420

INSTRUCTION FOR ENROLLMENT APPLICATION (AON FORM-3)

This form must be completed and submitted by each Contractor and Subcontractor of any tier prior to Site mobilization for each contract awarded. The Contractor and Subcontractor will submit the completed forms to Aon Risk Services. Upon receipt of this form, Aon will issue, to the Contractor and Subcontractor, a Certificate of Insurance evidencing coverage in the Owner Controlled Insurance Program. The completed Certificate of Insurance and Workers’ Compensation insurance policy will be mailed to each Enrolled Contractor and Subcontractor.

1. Contractor Information – Supply the Federal ID Number, Legal Company Name (include the doing business as, dba if applicable), mailing address and phone numbers. Identify the individual that will answer insurance questions and be responsible for your OCIP Worker’s Compensation policy. Also identify the legal structure of your company by checking one of the boxes. If you choose Other, write the structure in the space provided

2. Provide your current Workers’ Compensation Information – a) Enter information concerning your Worker’s Compensation Experience Modifier in the table. Refer

to your copy of the Bureau’s Rating Calculation or contact your insurance agent or broker. i) The Anniversary Rating Date is the effective date of your unique Experience Modifier. Factor. ii) The Experience Modification Factor is calculated by the Rating Bureau based on your loss experience

and payroll. iii) The Bureau File Number is your identification number with the Bureau. It may also be referred to as

a Risk Identification Number. b) Enter information concerning your current Worker’s Compensation Policy. This information is

available on the Declarations or Information page. 3. Contract Information –

a) Provide the contract number that was assigned by the District or the party you contract with. b) Provide a brief description of your work under this contract number. c) Identify the location of your contract work. This could be an area, phase or sub-project. (Hobart

Elementary is example) d) Identify your status by checking one of the boxes provided. If you select other, identify what type of

a contractor you are. e) Identify the effective date of your contract. f) If you are a Subcontractor, identify with whom you have a contract. g) Contacts – Communication is key to a successful OCIP. Identify the key contacts for each function

listed and provide the information requested. If a single individual handles multiple job duties, be sure to list the functions that apply.

h) Provide the Start Date and the Completion Date. Identify if these are the actual dates or have been estimated.

i) Provide the amount of your contract. If you have a time and materials contract, provide a reasonable estimate of your anticipated activity.

4. Subcontract Information - List Subcontractors that will perform work on-site during the term of your Contract. Enrollment is NOT automatic. If you add or change subcontracting firms during the course of your contract, be sure to notify the OCIP Administrator.

5. Indicate if you have off-site location(s), including warehouses, that are dedicated to this project by checking the appropriate box. If the answer is yes, provide the address. If additional room is need, attach a separate sheet. Be sure to include the Address, City, State and Zip Code.

6. ERM-14 forms are available upon request. Please contact the OCIP Administrator. 7. Check the appropriate box if you will be using aircraft or watercraft. 8. Indicate if your company participates in Alternative Dispute Resolution with the Union. Read the Warranty statements completely. Sign the Aon Form-3 and return it to the OCIP Administrator using the information supplied at the bottom of the form. This form has been designed to fit in a standard window envelope for your convenience.

LAUSD ON-SITE PAYROLL REPORT Form-4 (Complete a Separate Form for Each Contract with the District) Page 1 of 1

Delay in providing this report may result in progress payments being withheld.

1. Period Beginning: Period Ending: Year:

2. Contractor:

3. Under Contract to:

4. Contract #:

6. Workers’ 5. State Compensation 7. Work Description 8. Worker-Hours 9. Reportable Payroll *

Class Code

TOTALS:

*Do not include premium (excess) overtime wages; use straight time wage rates only. I VERIFY THAT THE DATA SHOWN ABOVE IS CORRECT.

10. Signed: Title:( must be signed by an Officer of the Company)

Date:

CHECK IF THIS IS THE LAST PAYROLL REPORT

Mail to: or Fax to: LAUSD OCIP Administrator LAUSD OCIP Administrator Aon Risk Services, Inc. Aon Risk Services, Inc. 1000 N. Milwaukee Ave. Fax: (800) 363-6695 Glenview, IL 60025 Phone: (866) 226-1420

INSTRUCTION FOR ON-SITE PAYROLL REPORT (AON FORM-4) This form must be completed each month by every Enrolled Contractor and Enrolled Subcontractor of any tier performing work at the Project Site (s) for each Contract awarded. The Contractor/Subcontractor must send the completed report to Aon Risk Services. Contractors will be responsible for the submission of this form by their Subcontractors. Aon Risk Services can forward a supply of these forms to your company. COMPLETION INSTRUCTIONS

1. Reporting Period - Fill in the month ending date for which this report is supplying payroll information

2. Name of Contractor/Subcontractor - Your firm’s name

3. Your Contract with - The Contractor if you are a Subcontractor; your subcontractor if you are Sub-Subcontractor

4. Contract Number - Contract number of the Work you are performing

5. State – Identify the State in which the work occurred.

6. Workers’ Compensation Classification Code – Use the Classification Codes on Aon-3 form.

7. Work Description - Provide a brief description of the work. Refer to your Workers’ Compensation policy.

8. Worker-hours - List worker-hours for each class code.

9. Payroll – List payroll for each class code for on-site work.

NOTE: List only straight time/unburdened payroll (overtime as straight time). List one cumulative monthly figure for all employees who fall under each class code.

10. Signature - Please have appropriate officer of the company sign and date the completed form.

F O R M S

LAUSD NOTICE OF WORK COMPLETION Form-5 Page 1 of 1

1. Contractor Name:

2. CONTRACT #:

3. Description of Work:

4. Date On-Site Work Completed:

5. The following Subcontractors have completed their Work at the Site: (Add attachment if more space is needed)

NAME CONTRACT # DATE ON-SITE

WORK COMPLETED

6. Location of your payroll audit records:

Address: Contact/Phone #:

The undersigned acknowledges request for termination of coverage under the OCIP as of the date indicated above for the specified Contract. Should we return to the work Site, we will be working under our own insurance program and must provide the District with a Certificate of Insurance showing our own coverage as outlined in our contract.

7. SIGNED BY:

Title Date

8. APPROVED BY: Construction Manager Date

Mail to: LAUSD OCIP Administrator LAUSD OCIP Administrator OR FAX TO:

Aon Risk Services, Inc. Aon Risk Services, Inc. 1000 N. Milwaukee Ave. Fax: (800) 363-6695 Glenview, IL 60025 Phone: (866) 226-1420

F O R M S

INSTRUCTION FOR NOTICE OF WORK COMPLETION (AON FORM-5)

This form must be completed and returned to the OCIP Administrator by the Enrolled Contractor or Enrolled Subcontractor whenever work is completed for each Contract. The Contractor will receive the final payment after all Contractor and Subcontractor information is complete.

COMPLETION INSTRUCTIONS

1. Contractor Name: If you are a Subcontractor, the name of the Contractor. If you are a Sub-Subcontractor, the name of the Subcontractor.

2. Contract #: The Contract or Specification number(s) relating to the Work at the Project Site.

3. Description of Work Performed: Type of work performed under your Contract.

4. Date Work On-Site Completed: Fill in appropriate date.

5. Subcontractors of all tiers included in the Work:

Names Subcontractors of all tiers associated with the close-out.

6. Final Audits Payroll Records: List name of terminating Contractor and applicable Subcontractors.

7. Signature: The Signature of the Contractor Closing-out

8. Approved by: The Signature of the District or the Construction Manager.

F O R M S

ON-SITE WORKER-

HOURS/INCIDENT REPORT

LAUSD Form-6 Page 1 of 1

1. Contractor Name:

2. Under Contract to:

3. Contract #:

Period Ending: 4. Period Beginning: Year:

Totals Totals Information Description This Month Year-To- Comments Project-To-

Date Date 5. Total Hours Worked

6. Number of First Aid Cases

7. Number of OSHA Recordable Cases

8. Number of Lost Work Day Cases

9. Number of Lost Work Days

10. Number of Restricted Work Days

* Attach a copy of your OSHA 200 Log or complete items 6 through 8. If none, please state so. I VERIFY THAT THE DATA SHOWN ABOVE IS CORRECT.

11. Signed: Title:( must be signed by an Officer of the Company)

Date:

F O R M S

F O R M S

Liberty Mutual Group Medical Provider Network

For The State of California

IMPORTANT INFORMATION REGARDING YOUR WORKERS’ COMPENSATION BENEFITS

MEDICAL TREATMENT FOR WORK RELATED INJURIES

This letter serves as a notification and a reminder about the Liberty Mutual Group Medical Provider Network (MPN) and contains important information regarding workers’ compensation benefits and medical treatment for work related injuries. Recent changes in California’s workers’ compensation laws now allow insurers and self-insured employers to direct injured employees to a medical provider network (MPN) for medical treatment if they receive state approval for the network.

The State of California has certified the Liberty Mutual Group Medical Provider Network (MPN) under California Labor Code section 4616 et seq. and Division of Workers’ Compensation regulations to provide all necessary medical care, treatment and services for your work related injury.

The goals of the MPN program are to ensure that:

• You have access to prompt, efficient, and quality medical care, treatment and services for occupational injuries and illnesses.

• You have increased access to occupational health services and specialists.

• You receive ongoing medical review of treatment.

All rendered treatment will be consistent with recommended standards set forth in the American College of Occupational and Environmental Medicine (ACOEM) Occupational Medical Practice Guidelines, evidence based medical guidelines or with guidelines adopted by the DWC Administrative Director.

You may pre-designate your physician(s) prior to injury if:

• You have received care with the physician, and

• The physician agrees to be your primary treating physician.

If your physician does not agree to participate in this capacity, you will be required to seek medical care with a MPN provider.

Access to MPN Services The MPN shall ensure that a MPN primary care physician, a hospital, or a provider of all emergency health care services are located within thirty (30) minutes or fifteen (15) miles from your residence or work place. Other occupational health services and specialists must be within sixty (60) minutes or thirty (30) miles from your residence or work place. You may consult with your employer for physician, hospital or other medical care recommendations within the MPN.

F O R M S

Should you have a work-related injury, your supervisor will help to ensure that you receive prompt initial care and medical attention through a MPN provider.

• On the job injuries must immediately be reported to your supervisor.

• Upon being notified of an on the job injury, your supervisor will immediately direct you to a primary care MPN physician who will provide you with the necessary initial and subsequent medical care required for your injury. At the time of your referral for initial care, you will be informed of your right after your initial visit with a MPN provider to be treated by a physician of your choice within the MPN and how to obtain a directory of available MPN providers.

• The Liberty Mutual Group MPN physician/provider directory will be available to your employer, physician and you. You may contact your supervisor or Claims Case Manager to request a regional and/or full listing of the MPN provider network. Your employer or Claims Case Manager will provide you the options of receiving (a) an internet link and password to electronically access a regional and/or full listing of the MPN provider network via the Provider Referral Services (PRS) system; (b) a printed copy of the regional and/or full listing of the MPN provider network; and/or (c) a printed copy of a regional and or full listing of MPN providers by calling either the Liberty Provider Referral Line, 1-800-944-0443 or the Wausau Provider Referral line, 1-888-398-6333.”

• If you need emergency health care services, please proceed to the nearest hospital or emergency medical facility and notify your employer immediately but no later than within 48 hours of treatment. The Liberty Mutual Group MPN shall allow the emergency health care services by the hospital or medical facility until such time that your physician considers you to be in stable medical condition and recommends that you may return to your residence or your employer’s workplace. You will then continue your medical treatment with a MPN physician or provider under the provisions of the Liberty Mutual Group MPN.

• For non-emergency services, an appointment for initial treatment with a MPN physician will be available within three (3) business days of your request for treatment. For non-emergency specialist services to treat common injuries experienced at work, an appointment with a specialist within the MPN will be available within twenty (20) business days of your request for a referral.

• If you are temporarily working or traveling for work and require treatment outside the MPN service area and need emergency health care services proceed as stated above. If you require non-emergency medical treatment outside of the MPN service area, you should notify your supervisor of your need for medical treatment outside the MPN Service Area. The Claims Case Manager will assist you, if necessary, in obtaining appropriate medical treatment from a physician or other providers outside the MPN service area.

• If you require medical treatment in certain rural or unpopulated areas where health facilities are located at least 30 miles apart, you must notify your employer or Claims Case Manager. You may need to treat with a physician or provider outside of the MPN service area. If necessary, the Claims Case Manager will provide you with a MPN provider directory.

• If your physician prescribes durable medical equipment, home health services, or medications for you, please contact your Claims Case Manager who will contact the ancillary service provider. The service provider will contact you directly to arrange for service delivery.

• If you need transportation to your MPN physician or medical facility please contact your Claims Case Manager who will make the necessary arrangements. The service provider will contact you directly to arrange for service delivery.

• If you need language translation services provided to you at the time of your medical appointment please contact your Claims Case Manager who will make the necessary arrangements. The service provider will contact you directly to arrange for service delivery.

Changing Your Treating Physician Within the MPN • If you are not satisfied with the services of a MPN provider anytime after your initial medical evaluation, you will be

allowed to change to another provider of your choice within the MPN.

F O R M S

• Non-emergency treatment, incurred outside of the MPN may not be paid unless the request is received by a Claims Case Manager, in advance. This written request should also document the reason for the requested change.

Your supervisor or the Claims Case Manager can assist you in choosing a geographically convenient provider in the MPN and will be able to assist you to ensure that you receive the appropriate medical attention needed to get you back to work.

If you have difficulty scheduling an appointment with a MPN physician or provider you should notify the Claims Case Manager. The Claims Case Manager will contact the physician or provider on your behalf to schedule an appointment. If the physician or provider cannot accommodate your appointment request within the required timeframes the Claims Case Manager will notify you and when necessary, will provide to you a full listing and/or regional MPN directory of the names of physicians or providers who are accessible to you for you to choose another physician or provider.

Transfer of Ongoing Medical Care to MPN Provider If you are currently being treated for a work related injury or illness by a physician or other health care provider that becomes a provider in the MPN, you may continue treatment with your physician or health care provider through the MPN.

If you are being treated for a work related injury or illness by a physician or other health care provider that is not in the MPN, you may continue to receive treatment from your physician or provider for the duration of any acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a duration of not more than 30 days. Completion of treatment shall be provided for the duration of the acute condition.

For a serious chronic condition, you may complete treatment with your physician or other health care provider that is not in the MPN for a period of time, up to one year, necessary to complete the course of treatment approved by your insurer or employer and to arrange transfer to another provider within the MPN, as determined by your insurer or employer. A serious chronic condition is a medical condition due to disease, illness, catastrophic injury, or other medical problem or medical disorder that is serious in nature that persists without full cure or worsens over 90 days and requires ongoing treatment to maintain remission or prevent deterioration. The one year period for completion of treatment starts from the date of determination that the employee has a serious chronic condition.

You will continue to have coverage and may complete treatment with your physician or other health care provider that is not in the MPN for an incurable or irreversible condition for the duration of a terminal illness which is defined as an incurable or irreversible condition that has a high probability of causing death within one year or less.

You may have surgery or other procedures performed by your physician or other health care provider that is not in the MPN that were authorized by your Claims Case Manager or employer and were recommended and documented by your physician or other health care provider to occur within one hundred and eighty (180) days from the effective date of the MPN.

Your Claims Case Manager or employer will notify you and your primary treating physician in writing of the determination regarding completion of ongoing treatment. You may request a report from your treating physician if you disagree with the determination regarding transfer of ongoing care. If you disagree with the medical determination made by your treating physician regarding transfer of care, you may file a dispute under Labor Code section 4062. The transfer of care will go forward during the dispute resolution process only if your treating physician agrees with your MPN or employer’s determination.

Treatment Provided By A Specialist If you require treatment by a specialist, you may self-select an appropriate specialist or be referred to a specialist by your physician. Your Claims Case Manager can provide you with a full listing of the MPN provider network or a regional directory of the names of physicians or providers who are accessible to you within 60 minutes or 30 miles of your residence or workplace. Your physician has access to the MPN directory and can also refer you to a specialist within the MPN.

MPN Continuing Care Policy As a covered employee in the MPN you have certain rights concerning your medical care. Your rights include allowing you to receive and complete medical treatment for certain medical conditions with your physician who may not be in the MPN. If your physician is terminated from the MPN, on a case-by-case basis, you may be allowed to treat with a specialist who is

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not within the MPN. A copy of the MPN Continuing Care Policy is available from your Claims Case Manager.

Procedures for Selecting a Physician for a Second and Third Opinion If you dispute either the diagnosis or treatment prescribed by your treating physician, you may obtain a Second Opinion and a Third Opinion from other physicians within the MPN. During this process you have the option to continue ongoing treatment with your treating physician or change to another physician of your choice within the MPN pursuant to section 9767.6 of the Department of Workers’ Compensation regulations.

A Second Opinion is an opinion rendered by a MPN physician, after an in person examination, to address a dispute that you have over either the diagnosis or the treatment prescribed by your treating physician.

A Third Opinion is an opinion rendered by a MPN physician, after an in person examination, to address a dispute that you have over either the diagnosis or the treatment prescribed by either your treating physician or the physician that rendered a Second Opinion.

To obtain a Second Opinion, you must inform your supervisor or your Claims Case Manager verbally or in writing by letter, fax or electronic mail that you dispute your treating physician’s opinion and are requesting a Second Opinion. You may select a physician or specialist from a directory of available MPN providers provided to you by the Claims Case Manager for the Second Opinion. It is your responsibility to make the appointment with the Second Opinion physician within sixty (60) days and inform the Claims Case Manager of the appointment date. The Claims Case Manager will contact the Second Opinion provider in writing to notify that he or she has been selected for a Second Opinion, to describe the nature of the dispute, and provide necessary medical records prior to the appointment date. You will receive a copy of the letter to the Second Opinion physician. Upon your request, you may obtain a copy of your medical records. If the appointment is not made within sixty (60) days of your receipt of the directory of available MPN providers, then you may not obtain a Second Opinion for the disputed diagnosis or treatment of your treating physician. You and your treating physician will receive a copy of the Second Opinion physician’s written report within twenty (20) days of the date of your appointment or the receipt of results of any diagnostic tests made at your appointment, whichever is later.

To obtain a Third Opinion, you must inform your supervisor or your Claims Case Manager verbally or in writing by letter, fax or electronic mail that you dispute the second opinion physician’s diagnosis or treatment and are requesting a Third Opinion. You may select a physician or specialist from a directory of available MPN providers provided to you by the Claims Case Manager for the Third Opinion. At the time of the selection of the physician for a third opinion, the Claims Case Manager will notify you about the Independent Medical Review process and provide you with an “Application for Independent Medical Review” form as set forth in section 9768.10 of the Department of Workers’ Compensation regulations. The Claims Case Manager will fill out the “MPN Contact Section” of the form and list the specialty of the treating physician and an alternative specialty, if any, that is different from the specialty of the treating physician.

It is your responsibility to make the appointment with the Third Opinion physician within sixty (60) days and inform the Claims Case Manager of the appointment date. The Claims Case Manager will notify the Third Opinion provider in writing that he or she has been selected for a Third Opinion, describe the nature of the dispute, and provide necessary medical records prior to the appointment date. You will receive a copy of the letter to the Third Opinion physician. Upon your request, you may obtain a copy of your medical records. If the appointment is not made within sixty (60) days of your receipt of a directory of available MPN providers, then you may not obtain a Third Opinion for the disputed diagnosis or treatment of your treating physician. You and your treating physician will receive a copy of the Third Opinion physician’s written report within twenty (20) days of the date of your appointment or the receipt of results of any diagnostic tests made at your appointment, whichever is later.

If you disagree with the diagnosis or treatment recommended by the Third Opinion physician, you may file the application form with the California Division of Workers’ Compensation Administrative Director to request an Independent Medical Review. If you need assistance contact your supervisor or your Claims Case Manager.

Contact Information

For questions and concerns regarding the MPN program contact your supervisor, the Claims Case Manager, or the Liberty Mutual Group MPN Program Coordinator. The Claims Case Manager and the MPN Program Coordinator may be contacted during normal business hours of 8:00 AM - 5:00 PM PST, Monday through Friday. The MPN Program Coordinator may be contacted at 800-331-1133 x130. The Liberty Mutual Utilization Review Unit may be contacted during normal business hours of 8:30 AM - 6:30 PM PST Monday through Friday at 1-800-664-CARE (2273).

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Grupo Liberty Mutual Red de Profesionales de Servicios

Médicos para el

Estado de California

INFORMACIÓN IMPORTANTE ACERCA DE LOS BENEFICIOS DE COMPENSACIÓN DE SUS

TRABAJADORES

TRATAMIENTO MÉDICO PARA LESIONES RELACIONADAS CON EL TRABAJO

Notificación de la Grupo Liberty Mutual Red de Profesionales de Servicios Médicos para el Estado de California

Esta carta sirve como una notificación y recuerdo sobre el Grupo Liberty Mutual Red de Profesionales de Servicios Médicos (MPN) y contiene la información importante acerca de los beneficios de compensación de trabajadores lesionados y el tratamiento médico para lesiones relacionadas con el trabajo Los recientes cambios en las leyes de compensación de los trabajadores de California permiten ahora que las aseguradoras y los empleadores auto-asegurados envíen a los trabajadores lesionados a una red de profesionales de servicios médicos (medical provider network o MPN) para su atención si el estado les otorga la aprobación de esa red.

El Estado de California ha certificado a la Red de Profesionales de Servicios Médicos (MPN) del Grupo Liberty Mutual conforme al Código de Trabajo de California (California Labor Code) sección 4616 y subsecuentes, y a los reglamentos de la División de Regulaciones de Indemnización a Trabajadores (Division of Workers’ Compensation o DWC) para proporcionar toda la atención médica, tratamiento y servicios necesarios para su lesión relacionada con el trabajo.

Los objetivos del programa MPN son asegurar que: • Usted tenga acceso a atención y servicios médicos rápidos, eficientes y de calidad para lesiones de trabajo y

enfermedades.

• Tenga mayor acceso a servicios de salud y especialistas de la salud de trabajo.

• Reciba revisión médica progresiva del tratamiento.

Todo tratamiento que se proporcione será consistente con los estándares recomendados establecidos en los Lineamientos de la Práctica de la Medicina del Trabajo del Colegio Americano de Medicina Profesional y Ambiental (American College of Occupational and Enviromental Medicine o ACOEM) y en lineamientos médicos basados en la experiencia o los adoptados por el Director Administrativo de la DWC.

Usted puede predesignar a su(s) médico(s) antes de la lesión si:

• Ha recibido atención del médico y

• él/ella está de acuerdo en ser el médico que lo atienda principalmente.

Si su médico no está de acuerdo en participar de esta forma, se le pedirá que busque la atención médica de un profesional de la MPN acceso a los Servicios de la MPN

La MPN se asegurará que haya un médico de atención primaria de la MPN, un hospital o un profesional de todos los servicios de atención a la salud localizado a no más de treinta (30) minutos o quince (15) millas de su domicilio o lugar de

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trabajo. Otros servicios y especialistas de salud de trabajo deben estar a no más de sesenta (60) minutos o treinta (30) millas de su domicilio o lugar de trabajo. Usted puede consultar a su supervisor, para que le recomiende un médico, un hospital o le hagan otras recomendaciones sobre atención médica dentro de la MPN:

En caso de que usted tenga una lesión relacionada con el trabajo, su supervisor le ayudará a asegurarse que usted reciba atención inicial rápida y atención médica a través de un profesional de la MPN.

• Las lesiones en el trabajo deben reportarse inmediatamente a su supervisor.

• Al momento en que se le notifique una lesión de trabajo, su supervisor lo referirá de inmediato a un médico de atención primaria de la MPN quien le proporcionará la atención médica inicial y subsecuente que su lesión amerita. Al momento en que se le refiera para la atención inicial, se le informará de su derecho, después de una visita inicial con un profesional de la MPN, a ser tratado por el médico de su elección dentro de la MPN y cómo obtener un directorio de profesionales MPN disponibles.

• El directorio de médicos y profesionales de la MPN de Grupo Liberty Mutual estará disponible para su empleador, su médico y usted. Puede comunicarse con su supervisor o Administrador de Casos de Reclamación para solicitar un listado regional y/o completo de la red de proveedores de la MPN. Su empleador o el Administrador de Casos de Indemnización le proporcionará las opciones para recibir (a) un vínculo de Internet y una contraseña para tener acceso electrónico a un listado regional y/o completo de la red de proveedores de la MPN a través del sistema de Servicios de Referencia de Proveedores (PRS); (b) una copia impresa del listado regional y/o completo de la red de proveedores de la MPN; y/o (c) una copia impresa de un listado regional y/o completo de proveedores de la MPN al llamar a la Línea de Referencia de Proveedores Liberty, 1-800-944-0443 o la línea de Referencia de Proveedores Wausau, 1-888-398-6333.

• Si necesita servicios de atención a la salud de emergencia, por favor acuda al hospital más cercano o instalación médica de emergencia y comuníquese con su empleador inmediatamente, en un plazo que no exceda las 48 horas siguientes al tratamiento. La MPN del Grupo Liberty Mutual permitirá los servicios de atención a la salud en el hospital o instalación médica hasta que su médico considere que usted se encuentra estable y le recomiende regrese a su domicilio o al lugar de trabajo de su empleador. Entonces usted continuará su tratamiento médico con un médico o profesional de la MPN de acuerdo con las condiciones de la MPN del Grupo Liberty Mutual.

• Para los servicios que no sean de emergencia, se le dará cita para tratamiento inicial con un médico de la MPN dentro de los tres (3) días hábiles siguientes a su solicitud de tratamiento. Para los servicios que no sean de emergencia de un especialista para tratar lesiones comunes en el trabajo, se le dará cita con un especialista de la MPN dentro de los veinte (20) días hábiles siguientes a su solicitud de tratamiento.

• Si usted está trabajando temporalmente o en viaje de negocios y requiere tratamiento fuera del área de servicio de la MPN y requiere atención médica de emergencia proceda como se indicó arriba. Si usted requiere tratamiento médico que no sea de emergencia fuera del área de servicio de la MPN, usted debería notificar a su supervisor sobre su necesidad de recibir tratamiento médico fuera del área de servicio de la MPN. El Administrador de Casos de Indemnización lo ayudará, en caso de ser necesario, a obtener tratamiento médico adecuado por parte de médicos y profesionales fuera del área de servicio de la MPN.

• Si requiere tratamiento médico en ciertas áreas rurales o poco pobladas en donde las instalaciones sanitarias se encuentran apartadas entre si al menos a 30 millas de distancia, debe notificarlo a su empleador o a su Administrador de Casos de Indemnización. Usted podría tener que tratar con un médico o profesional fuera del área de servicio de la MPN. Si es necesario, el Administrador de Casos de Indemnización le proporcionará un directorio de profesionales de la MPN.

• Si su médico le prescribe equipo médico durable, servicios de salud a domicilio o medicamentos, por favor comuníquese con su Administrador de Casos de Indemnización quien hará lo propio con el profesional de servicio auxiliar. El profesional de servicio se comunicará directamente con usted para acordar la entrega del servicio.

• Si necesita transporte para ir a su médico o instalación médica de la MPN por favor comuníquese con su Administrador de Casos de Indemnización quien hará los arreglos necesarios. El profesional de servicio se comunicará directamente con usted para acordar la entrega del servicio.

Si necesita servicios de interpretación de idiomas al momento de su cita médica por favor comuníquese con su

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Administrador de Casos de Indemnización quien hará los arreglos necesarios. El profesional de servicio se comunicará directamente con usted para acordar la entrega del servicio.

Cambio de médico dentro de la MPN • Si usted no está satisfecho con los servicios de un profesional de la MPN en cualquier momento después de su

evaluación médica inicial, se le permitirá cambiar a otro profesional de su elección dentro de la MPN.

• El tratamiento que no sea de emergencia fuera de la MPN puede no ser pagado a menos que el Administrador de Casos de Indemnización reciba la solicitud previamente. Dicha solicitud escrita también debe documentar la razón para el cambio solicitado.

Su supervisor o el Administrador de Casos de Indemnización pueden ayudarle a elegir un profesional geográficamente conveniente en la MPN y podrá ayudarle a asegurar que usted reciba la atención médica adecuada que necesita para que vuelva al trabajo.

Si usted tiene alguna dificultad para concertar una cita con un médico o profesional de la MPN deberá notificarlo al Administrador de Casos de Indemnización. El Administrador de Casos de Indemnización se comunicará con el médico o profesional por usted para concertar una cita. Si el médico o profesional no puede acomodar su cita dentro de los límites de tiempo, el Administrador de Casos de Indemnización se lo hará saber y, si es necesario, le proporcionará un listado regional y/o completo de la red de proveedores de la MPN de los nombres de los médicos o profesionales que están disponibles para que usted elija otro médico o profesional.

Transferencia de la atención médica actual a un profesional de la MPN Si usted está siendo tratado actualmente por una lesión o enfermedad relacionada con el trabajo por un médico u otro profesional de atención a la salud que se convierta en un profesional en la MPN, usted puede continuar su tratamiento con su médico o profesional de atención a la salud a través de la MPN.

Si usted está siendo tratado actualmente por una lesión o enfermedad relacionada con el trabajo por un médico u otro profesional de atención a la salud que no esté en la MPN, usted puede continuar recibiendo tratamiento de su médico o profesional mientras haya alguna condición grave. Una condición grave es una condición médica que incluya una serie repentina de síntomas debidos a una enfermedad, lesión u otro problema médico que requiera atención médica rápida y que tenga una duración de no más de 30 días. Se proporcionará el tratamiento mientras dure la condición grave.

Para una condición crónica seria, usted puede completar el tratamiento con su médico o algún otro profesional de atención a la salud que no esté en la MPN por un período de tiempo, hasta un año, necesario para completar el curso del tratamiento aprobado por su aseguradora o empleador y para hacer la transferencia a otro profesional dentro de la MPN, como lo determina su aseguradora o empleador. Una condición crónica seria es una condición médica debida a un padecimiento, enfermedad, lesión catastrófica u otro problema médico o desorden médico que es de naturaleza seria y que persiste sin curarse totalmente o empeora durante 90 días y requiere tratamiento progresivo para mantener la remisión o prevenir el deterioro. El período de un año para que se complete el tratamiento comienza desde la fecha en que se determina que el empleado tiene una condición crónica seria.

Usted seguirá teniendo cobertura y puede completar el tratamiento con su médico u otro profesional de atención a la salud que no esté en la MPN para una condición incurable o irreversible por la duración de la enfermedad terminal que se define como una condición incurable o irreversible que tenga una alta probabilidad de causar la muerte dentro de un año o menos.

Su médico u otro profesional de atención a la salud que no esté en la MPN, que haya sido autorizado por su Administrador de Casos de Indemnización o su empleador y que haya sido recomendado y documentado por su médico u otro profesional de atención a la salud, puede practicarle cirugía u otros procedimientos dentro de los ciento ochenta (180) días siguientes a la fecha efectiva de la MPN.

Su Administrador de Casos de Indemnización o su empleador le notificarán a usted y al médico que lo atiende principalmente por escrito de la determinación sobre la continuación del tratamiento actual. Usted puede solicitar un reporte del médico que lo trata si no está de acuerdo con la determinación sobre la transferencia de la atención actual. Si usted no está de acuerdo con la determinación médica que hizo el médico que lo atiende sobre la transferencia de la atención usted puede presentar una disputa bajo el Código de Trabajo sección 4062. La transferencia de la atención continuará durante el proceso de resolución de la disputa sólo si su médico está de acuerdo con la determinación de la

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MPN o de su empleador.

Tratamiento proporcionado por un especialista Si usted requiere tratamiento de un especialista, usted puede seleccionar por sí mismo a un especialista apropiado o su médico puede referirle a un especialista. Su Administrador de Casos de Indemnización puede proporcionarle un listado completo de la MPN o un directorio regional de nombres de médicos o profesionales que están disponibles para usted a 60 minutos o 30 millas de su domicilio o lugar de trabajo. Su médico tiene acceso al directorio de la MPN y puede referirle a un especialista.

Política de atención continúa de la MPN Como empleado cubierto en la MPN usted tiene ciertos derechos referentes a su atención médica. Sus derechos incluyen permitirle recibir y completar el tratamiento médico para ciertas condiciones médicas con su médico quien puede no estar en la MPN. Si su médico es quitado de la MPN, dependiendo del caso, se le puede permitir a usted que trate con un especialista que no está dentro de la MPN. Hay una copia de la Política de Atención Continua disponible con su Administrador de Casos de Indemnización.

Procedimientos para seleccionar a un médico para una segunda y tercera opinión Si usted presenta una disputa, ya sea por el diagnóstico o el tratamiento que le prescribió el médico que lo trata, usted puede obtener una Segunda Opinión y una Tercera Opinión de otros médicos dentro de la MPN. Durante este proceso usted tiene la opción de continuar con su tratamiento actual con el médico que lo trata o cambiar a otro médico de su elección dentro de la MPN de conformidad con la sección 9767.6 del reglamento del DWC.

Una Segunda Opinión es una opinión proporcionada por un médico de la MPN, después de un examen en persona, para atender una disputa que usted tenga, ya sea sobre el diagnóstico o sobre el tratamiento que le prescribió el médico que lo trata.

Una Tercera Opinión es una opinión proporcionada por un médico de la MPN, después de un examen en persona, para atender una disputa que usted tenga, ya sea sobre el diagnóstico o sobre el tratamiento que le prescribió ya sea el médico que lo trata o el médico que proporcionó una Segunda Opinión.

Para obtener una Segunda Opinión usted debe informar a su supervisor o su Administrador de Casos de Indemnización verbalmente o por escrito, fax o correo electrónico que usted pone en disputa la opinión del médico que lo trata y que está solicitando una Segunda Opinión. Usted puede seleccionar a un médico o especialista de un directorio de profesionales MPN disponibles que le proporcione el Administrador de Casos de Indemnización para la Segunda Opinión. Es su responsabilidad concertar la cita con el médico de la Segunda Opinión dentro de los sesenta (60) días siguientes e informar al Administrador de Casos de Indemnización de la fecha de la cita. El Administrador de Casos de Indemnización se comunicará con el profesional de la Segunda Opinión por escrito para notificarle que ha sido seleccionado para una Segunda Opinión, para describirle la naturaleza de la disputa y proporcionar el historial médico necesario antes de la fecha de la cita. Usted recibirá una copia de la carta al médico de la Segunda Opinión. Si usted lo solicita, usted puede obtener una copia de su historial médico. Si no se hace la cita dentro de los sesenta (60) días siguientes a que usted reciba el directorio de profesionales MPN disponibles, usted no podrá obtener una Segunda Opinión del diagnóstico o tratamiento en disputa del médico que lo trata Usted y el médico que lo trata recibirán una copia del reporte escrito del médico de la Segunda Opinión dentro de los veinte (20) días siguientes a la fecha de su cita o la recepción de los resultados de cualquier prueba diagnóstica que se haya hecho en su cita, lo que suceda después.

Para obtener una Tercera Opinión usted debe informar a su supervisor o su Administrador de Casos de Indemnización verbalmente o por escrito, fax o correo electrónico que usted pone en disputa el diagnóstico o el tratamiento del médico de la segunda opinión y que está solicitando una Tercera Opinión. Usted puede seleccionar a un médico o especialista de un directorio de profesionales MPN disponibles que le proporcione el Administrador de Casos de Indemnización para la Tercera Opinión. Al momento de la selección de un médico para obtener la Tercera Opinión, el Administrador de Casos de Indemnización le notificará acerca del procedimiento de Revisión Médica Independiente y le proporcionará un formulario de "Solicitud de Revisión Médica Independiente" como lo dispone la sección 9768.10 del reglamento de la DWC. El Administrador de Casos de Indemnización completará la "Sección de Contacto de la MPN" del formulario y anotará la especialidad del médico tratante y una especialidad alternativa, si la hay, distinta a la especialidad del médico tratante.

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Es su responsabilidad concertar la cita con el médico de la Tercera Opinión dentro de los sesenta (60) días siguientes e informar al Administrador de Casos de Indemnización de la fecha de la cita. El Administrador de Casos de Indemnización se comunicará con el profesional de la Tercera Opinión por escrito para notificarle que ha sido seleccionado para una Tercera Opinión, para describirle la naturaleza de la disputa y proporcionar el historial médico necesario antes de la fecha de la cita. Usted recibirá una copia de la carta al médico de la Tercera Opinión. Si usted lo solicita, usted puede obtener una copia de su historial médico. Si no se hace la cita dentro de los sesenta (60) días siguientes a que usted reciba la lista de profesionales MPN disponibles, usted no podrá obtener una Tercera Opinión del diagnóstico o tratamiento en disputa del médico que lo trata Usted y el médico que lo trata recibirán una copia del reporte escrito del médico de la Tercera Opinión dentro de los veinte (20) días siguientes a la fecha de su cita o la recepción de los resultados de cualquier prueba diagnóstica que se haya hecho en su cita, lo que suceda después.

Si usted no está de acuerdo con el diagnóstico del tratamiento recomendado por el médico de la Tercera Opinión, puede presentar un formulario de solicitud dirigido al Director Administrativo de la División de Compensación a Trabajadores de California para solicitar una Revisión Médica Independiente. Si necesita ayuda, comuníquese con su supervisor o su Administrador de Casos de Indemnización.

Información de contacto Si tiene preguntas o inquietudes acerca del programa MPN comuníquese con su supervisor, con el Administrador de Casos de Indemnización o el Coordinador de Programas de la MPN del Grupo Liberty Mutual. Usted puede comunicarse con el Administrador de Casos de Indemnización y el Coordinador de Programas durante las horas normales de oficina de 8:00 AM a 5:00 PM PST, de lunes a viernes. Puede comunicarse con el Coordinador de Programas de la MPN al teléfono 800-331-1133 x130. Usted puede comunicarse con la Unidad de Revisión de Utilización de Liberty Mutual durante las horas normales de oficina de 8:30 AM a 6:30 PM PST de lunes a viernes al teléfono 1-800-664-CARE (2273).