Arnold Machinery Company

2975 West 2100 South
Salt Lake City, UT 84119
(801) 972-4000

Human Resources:	Rohana Parker
HR Assistant:	Tammy Coe
HR Assistant:	Angie Yates
Corp. Safety and Environmental:	Paul Prieto

REPORTING A WORK RELATED ACCIDENT, VEHICLE ACCIDENT, & PROPERTY DAMAGE

Arnold Machinery is currently covered by St.Paul/Travelers Insurance Company. Please note that there are two numbers to call for each claim category. Claims are categorized by:
1. Workers Compensation Claims
2. Automobile/Property/Liability claims.

There are Two (2) required forms to fill out:

WC Telephone Reporting Worksheet (This is also your First Report of Injury Form)- All Work Related Accidents that require medical attention.
Vehicle Accidents/Property Damage Form- All Vehicle accidents, vehicle collision, theft & property damage. Note: If the associate requires medical attention, a First Report of Injury Form will also be filled out.

CONDUCTING ACCIDENT INVESTIGATIONS:

To prevent similar accidents from re-occurring, both OSHA & MSHA requires that businesses conduct accident investigations and implement corrective actions. It is important that Managers/Supervisors take the time to conduct an Accident Investigation to determine the root cause. Attached is a copy of the Incident Investigation Report Form. This separate form should be faxed to the Corporate office- 801-974-4067 Attention: Paul Prieto

TO REPORT A WORKERS' COMPENSATION CLAIM
Workers Compensation Related injuries only:

When an Associate is injured, the most important thing is to secure appropriate medical treatment. Once this has been done, Fill out the WC Telephone Reporting Worksheet Form (First Report of Injury Form) The claim should be called into the Workers Compensation Telephone Reporting Center:

VEHICLE ACCIDENT/THEFT REPORTING/PROPERTY DAMAGE:

As soon as possible, fill out the Vehicle Accident/Property Damage Claim Form and notify via phone to:

Claims Offices in Arnold Machinery’s Operating Territory

Arizona & Colorado:

Nevada

Minnesota

Idaho, Montana, Oregon, Utah & Wyoming

A copy of the Vehicle Accident Forms must be submitted Via Fax to Paul Prieto/Kayden Bell ASAP 801-974-4067

JUST THE FACTS:
IMPORTANT WORKERS COMPENSATION INFORMATION:

Gather the facts.

Use the Workers Compensation WC Telephone Reporting Worksheet Form (First Report of Injury Form) for your convenience. The worksheet is a tool to help reduce the amount of time you are on the telephone. All the questions that will be asked by a Travelers representative will be on the worksheet. Remember, the objective is to report the claim quickly. All claims will be reported within 24 hours from the time of the accident or your Branch will be charged a late fee of $1,000. We need the associate's name, social security number and a description of the accident. Try to gather as much information as possible, but don't worry if you do not have the answers to every question. Please make sure that the appropriate location code is entered on the First Report of Injury. This will identify your Branch into the system. Attached with this memo is a list of location codes by branch.
Call the Customer Service Unit

When you call the toll-free number provided (1-800-832-7839), you will be greeted on the telephone by a customer service representative who will complete the state-specific notice of injury by asking you the necessary questions. The order of the questions will be the same every time you call.
The questions are grouped in three sections:
· General Questions
This section contains questions specific to you, your employee and the accident. These questions will be asked on every claim.
·State Specific Questions
If the jurisdiction requires data not covered in the general section, it will be covered here.
·Additional Comments and Information
If you would like to provide additional information not covered elsewhere, the Customer service representative will record this in a free form area.
Acquiring a Claim Number
Before you hang up, the customer service representative will give you a claim number. Using the claim number will help expedite handling the rest of the claim. It is very important that you include the claim number with all future correspondence, such as wage statements or medical bills. Please be sure that a copy of the First Report of injury claim form is faxed to our corporate office, Attn: Paul Te Prieto at 801-974-4067.
Drug Testing
Please make sure that you advise the clinic and the associate that they will be required to take a Drug Test. Please note that a drug and alcohol test is mandatory and this applies to both property damage, and vehicle accidents as well. Your branch will be charged a $1,000 penalty if the associate does not receive a drug test.

Please feel free to contact Paul Prieto at 801-972-4000 or 801-910-4896 if you have any questions.

ACCIDENT FORMS (Please click on the links below to download forms)

Worker's Compensation Telephone Reporting Worksheet (This is also your First Report of Injury Form)- All Work related Accidents that require medical attention.
Vehicle/Property Damage Accidents/Claim Information Data Sheet. All Vehicle accidents, vehicle collision, theft & property damage. Note: If the associate requires medical attention, a Worker's Compensation Telephone Reporting Worksheet (First Report of Injury Form will) also be filled out.
Incident Investigation Report Form- CONDUCTING ACCIDENT INVESTIGATIONS: To prevent similar accidents from re-occurring, both OSHA & MSHA requires that businesses conduct accident investigations and implement corrective actions. It is important that Managers/Supervisors take the time to conduct an Accident Investigation to determine the root cause. Attached is a copy of the Incident Investigation Report Form. This separate form should be faxed to the Corporate office- 801-974-4067 Attention: Paul Prieto

© 1999-2010 Arnold Machinery Company
P. O. Box 30020
Salt Lake City, UT 84130-0020
Phone: 801-972-4000
Fax: 801-974-4035

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