Carroll Volunteers - First Report of Injury

(This process is NOT for DFEMS Employees or Department corporate staff. DFEMS employees use their County provided form/process.  Department Employees' injuries are reported through the individual department insurance policies and process)

At Time of Incident:

• First and foremost, assist the member to get any urgent medical treatment necessary. 
• If possible, tell the receiving facility that the injury is Work Related and charges for services should be billed here:

  Chesapeake Employers' Insurance Company
  PO Box 9899
  Baltimore, MD 21284-9899

• 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. Volunteer injuries are NOT sent to the DFEMS Incident email.  Also, 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#. 
  • Please include the injured worker's email address at the top of the form (form does not have a specific line for this)
     
• 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)

After the First Report is Filed:

• Liaison or designee will call or go online to submit that report to the Insurance company.
• 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:
  • 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

Frequently Asked Questions:

• What is the difference between IWIF and Chesapeake Employer's Insurance Company?
   
  • Nothing - IWIF is the OLD name of the company.  They changed their name in 2013 to Chesapeake Employers Ins Co.  Some of the forms still have the old logo IWIF on them next to the Chesapeake logo.
    
     
• What do I do if I recieve a bill from my medical provider for services rendered?
   
  • Usually, every medical bill has a toll-free phone number listed for you to call with questions or updates.  Please do not wait, call that number and make sure they know that the provider knows the Workers Compensation Claim Details.   You may need to give them the same information again:
     
    • 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
       
• Where can I get all the forms?
  • Forms can be found here:  Chesapeake Insurance Accident Injury Packet  -   (Can be completed on your computer and printed for required physical signature)
     

• Is social security number required?

  • Yes.  A Workers Comp claim is just like any other medical insurance claim that requires the SS#.