A business of Marsh McLennan
City of Austin
Rolling Owner Controlled
Insurance Program VIII
(Insert Project Description)
Location Code: (Insert Project #)
Austin, Texas
ROCIP VIII CLAIMS KIT TEMPLATE
Presented By:
(Insert Month, Year)
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Accident Reporting and Claims
Procedures
A. General Procedures:
This section describes basic procedures for reporting various types of Claims:
• Workers’ Compensation (Worker/Employee Injury)
• General Liability (Third Party Bodily Injury or Property Damage)
• Automobile (notice only) and Pollution (notice only).
The immediate reporting of all accidents or circumstances which might lead to or involve a
Claim is required. Report all injuries, occupational-related illnesses, third party bodily injury or
property damage to the General Contractor Claim Contact immediately. All Parties will
instruct employees and other personnel to report, in writing, within 24 hours all Accidents and
Occurrences of any type to the General Contractor Claim Contact.
Overview of Claims Reporting Process
Action Required:
Responsible Party:
1. Accident/Injury occurs
2. On-Site Supervisor is notified
Parties involved
3. Claim form is completed
On-Site Supervisor
4. If injury, worker is sent for medical treatment with
authorization form
On-Site Supervisor
Injured Worker
5. Claim form is provided to GC Claim Contact within
24 hours
On-Site Supervisor
6. GC Claim Contact reports claim to insurance carrier
immediately by phone to:
Liberty Mutual
1-800-362-0000
Account Number for ROCIP VIII: 6067424
GC Claim Contact
7. Completed form email to:
Lynn Miller, ROCIP Safety @
Lynn.Miller@Austintexas.gov
Kevin McClelland, ROCIP Claims Advocate @
Kevin.McClell[email protected]
GC Claim Contact
City of Austin
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Please refer to section B. Workers’ Compensation and C. General Liability for step-by-
step procedures on the following pages.
The General Contractor Claim Contact will immediately contact the ROCIP VIII Safety
Representative, Lynn Miller and Kevin McClelland, ROCIP Claim Advocate in the event
of any of the following “serious accidents”, incidents and injuries:
Any injury for which an ambulance is called
• Injury to head or neck
• Possible injury to back or spinal cord
• Unconscious employee
• Possible blindness
• Amputation of limbs
• Fatality
• Heart attack or stroke
• Hospitalization
• Property damage estimated over $1,000
Investigation Assistance:
All Parties will assist in the investigation of any accident or occurrence involving injury to
persons or property. All Enrolled Parties will cooperate with the companies involved in
adjusting any claim by securing and giving evidence and obtaining the participation and
attendance of witnesses required for the investigation and defense of any claim or suit.
When in doubt, refer all questions regarding the reporting of a claim to the General
Contractor Claims Contact and/or ROCIP VIII Claim Advocate
(INSERT GENERAL CONTRACTOR (GC)
CLAIM CONTACT)
(INSERT GC NAME)
Kevin McClelland
Marsh USA, Inc.
(INSERT GC ADDRESS)
1717 Main St., Ste 4400
Dallas, TX 75201-7357
(INSERT GC CITY, STATE, ZIP)
Phone: 214-303-8330
Phone: (INSERT CONTACT PHONE #)
Cell: 214-926-5983
(INSERT GC CONTACT EMAIL )
kevin.mcclelland@marsh.com
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B. Workers’ Compensation Claims Reporting Procedures:
These procedures apply to ALL employees covered by ROCIP VIII for this project.
Immediately notify the ROCIP VIII Safety Representative in the event of a serious injury or
accident. Contractors’ on-site personnel will follow these procedures if any employee is
involved in an accident or occurrence resulting in bodily injury:
1. Contact the Injured Worker’s On-Site Project Supervisor immediately and transport the
injured worker to the on-site first aid or medical facility, as necessary. An Authorization
for Medical Treatment Form is to be sent with the Injured Worker prior to the first
medical treatment, which includes the request for mandatory post accident drug testing.
2. Report all injuries or occupational-related illnesses to the General Contractor Claim
Contact immediately.
3. Project Supervisor must complete a WC Claim Report Form and return to the General
Contractor Claim Contact within 24 hours of employee's notice of injury/claim. The
General Contractor Claim Contact will call the injury/claim into the Insurance Carrier
immediately.
4. The General Contractor Claim Contact will fax a copy of the WC Claim Report Form to
Lynn Miller, ROCIP VIII Safety Representative at 512-974-3411 and Kevin McClelland,
ROCIP Claim Advocate at 214-303-8330.
5. An accident investigation is to be completed as soon as possible by all contractors
involved in the accident. An Incident Investigation Report must be completed by the
General Contractor Supervisor and provided to Lynn Miller and Kevin McClelland, ROCIP
Claim Advocate at 214-303-8330.
6. All “serious accidents”, incidents and injuries will be reported immediately by phone to
Lynn Miller at 512-828-1761 and Kevin McClelland, ROCIP Claim Advocate at 214-303-
8330.
7. If possible, Contractor and its lower-tier Subcontractor(s) may provide for Modified
Alternate Duty based upon the work abilities given to the Injured Party from the treating
physician.
8. Immediately send all subsequent return to work notes, inquiries or correspondence about
an Injured Party to the General Contractor Claim Contact.
9. No Injured Party will be allowed on a job site unless they have provided the General
Contractor Claim Contact with the proper return to work note, either full duty or
modified duty, as well as verification that post accident drug testing was completed.
C. General Liability & Property Damage Claim Reporting Procedures:
Contractors must immediately report all Accidents at the Project Site involving death, injury,
or damage to property of non-employee personnel (the public, tenants, and visitors) to the
General Contractor Claim Contact. As soon as the onsite personnel become aware of the
accident or occurrence, they must:
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1. Take appropriate emergency measures to prevent additional injury or damage, including
contacting police and fire authorities as required by law.
2. Complete and submit a GL Claim Report Form to the General Contractor Claim Contact
within 24 hours of the incident. The General Contractor Claim Contact will call the claim
into the Insurance Carrier immediately.
3. The General Contractor Claim Contact will email a copy of the GL Claim Report Form to
Lynn Miller, ROCIP VIII Safety Representative Lynn.Miller@austintexas.gov and Kevin
McClelland, ROCIP Claim Advocate at Kevin.McClell[email protected].
4. An accident investigation is to be completed as soon as possible by all contractors
involved in the accident. An Incident Investigation Report must be completed by the
General Contractor Supervisor and provided to Lynn Miller ROCIP VIII Safety
Representative at 512-828-1761 and Kevin McClelland, ROCIP Claim Advocate at 214-
303-8330.
5. All Serious accidents, incidents and injuries will be reported immediately by phone to the
City of Austin ROCIP VIII Safety Representative, Lynn Miller, at 512-828-1761 and Kevin
McClelland, ROCIP Claim Advocate at 214-303-8330.
6. Immediately send all subsequent inquires or correspondence about an insured loss or
claim, including a summons or other legal documents, to the General Contractor Claim
Contact immediately.
The first five thousand dollars ($5,000) of any insurable general liability property damage loss
will be the responsibility of and paid by the Contractor and deducted from the contract
amount.
D. Automobile Liability Claims Procedures:
No coverage is provided for automobile accidents under the ROCIP VIII. It is the sole
responsibility of each Party to report accidents/claims involving their automobiles to their own
insurers.
However, all accidents occurring in or around the Project site must be reported to the
General Contractor Claim Contact. Accident investigations will occur and focus on 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 Party shall cooperate in the investigation of all
automobile accidents.
E. Pollution Claims Procedures:
No coverage is provided for pollution incidents under the ROCIP VIII. It is the sole
responsibility of each Party to report accidents/claims involving pollution coverage to their
own insurers. However, all accidents occurring in or around the Project site must be
reported to the General Contractor Claim Contact. Accident investigations will occur and
focus on liability arising out of the Project construction activities that could result in future
claims involving Bodily Injury or Property Damage not deemed to have been caused by a
pollution event. Each Party shall cooperate in the investigation of all pollution incidents.
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F. Loss Runs:
An enrolled contractor may obtain loss runs for their own on-site experience by requesting, in
writing on their company letterhead, directed to the ROCIP VIII Administrator. Please note
that the loss information is also available from the ROCIP VIII Insurance Carrier.
G. Alcohol & Drug Testing:
Please refer to the ROCIP Project Safety Manual for the Controlled Substances Safety Policy
& Procedures.
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Click for Fillable
ROCIP WC Claim Form.pdf
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Click for Fillable
ROCIP GL Claim Form.pdf
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City of Austin
ROCIP VIII
AUTHORIZATION FOR MEDICAL TREATMENT
SEND WITH INJURED WORKER TO HAND TO MEDICAL PROVIDER
PRIOR TO THE FIRST MEDICAL TREATMENT
FACSIMILE TRANSMITTAL SHEET
TO: FAX NUMBER:
Medical Provider
FROM: PHONE:
TOTAL NO. OF PAGES INCLUDING COVER: DATE:
RE:
Injured Worker
CITY OF AUSTIN ROCIP VIII
Project Name & Site Code: (INSERT PROJECT # AND DESCRIPTION)
Enrolled Contractor Name & Address:
_Contractor WC Policy Number:
Contractor Main Contact Person: Phone:
Employee Name/Injured Worker: DOB:
Date of Incident: Description of Incident:
Which of the following test(s) will be administered to the injured worker?
Drug Screen Breath Alcohol X Drug Screen & Breath Alcohol Urine Collection Only
ALL DRUG SCREEN/BREATH ALCOHOL TEST RESULTS & BILLS WILL BE SENT TO:
(INSERT GC CLAIM CONTACT INFO – FROM CLAIM CONTACT SECTION)
TO MEDICAL PROVIDER:
Send Medical Bills only and Reports to ROCIP VIII Insurance Carrier:
Liberty Mutual Group
Central Billing Unit Phone: 1-800-300-0110 for inquiries or pre-authorization
P.O. Box 7203 ROCIP VIII Account Number: 6067424
London, KY 40742