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Carroll Volunteers - First Report of Injury
(PAID Staff injuries are reported through the individual department insurance policies and process)
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At Time of Incident:
- Within 24-48 hours, the "First Report of Injury (FROI)" needs to be completed and must be submitted to CCVESA at the Carroll County Public Safety Training Center. Do not send the FROI report directly to the Insurance Company. The packet includes:
- The Employee's Report of Injury
- The Supervisor's Accident Investigation Report
- Any Witnesses should prepare individual Accident Witness Statement Reports
- Social Security Number: I can't file a claim without the SS#. BUT, for security, do NOT enter on the form. Make sure I have a good email and phone number for the injured member and I will call the person to get the SS# over the phone. You can just add the email at the top of the injured members form.
- How to file the forms:
- Click on this link to download the form: Chesapeake Insurance Accident Injury Packet - (Can be completed on your computer and printed for required physical signature)
- Once the forms are complete, scan them to EMAIL to liaison@ccvesa.org
- PLEASE NO CELL PHONE PICTURES OF THE FORMS
- EMAIL is the best option (Liaison can process outside business hours); if you need, you can FAX to - 410-875-0319
- PLEASE - If at all possible, when filing the report, provide the email address of the Injured worker so the full claim details they will need can be sent directly to them.
Again, the forms are found here: Chesapeake Insurance Accident Injury Packet - (Can be completed on your computer and printed for required physical signature)
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After the First Report is Filed:
- Liaison or designee will call that report into the Insurance company to start the claim.
- That claim number will be provided to the Injured member and the supervisor submitting the reports.
- As soon as possible, notify those medical services that provided care that you have a claim number
- Give them the Policy Number and Claim Number Provided to you
- Give them this information for where the bills should be submitted
Send Medical bills to:
Chesapeake Employers' Insurance Company
PO Box 9899
Baltimore, MD 21284-9899
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Frequently Asked Questions:
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