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Carroll Volunteers - First Report of Injury

(PAID Staff are reported and processed through the individual departments)

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 hours, the "First Report of Injury" needs to be completed and submitted to CCVESA at the Carroll County Public Safety Training Center.  The packet includes:
    • The Employee's Report of Injury
    • The Supervisor's Accident Investigation Report
    • Any Witnesses should prepare individual Accident Witness Statement Reports
       
  • 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
    • EMAIL is the best option (Liaison can process outside business hours); if you need, you can FAX to - 410-875-0319

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 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

 

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?
  •  
 

 

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Carroll County
Emergency Services Association, Inc.

50 Kate Wagner Road
Westminster, MD 21157
Emergency Dial 911
Voice: 410-848-1488
Fax: 410-875-0319
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