Claims (Patriot Risk Services) - Shomer Insurance Agency, Inc

Claims (Patriot Risk Services)

Claim Forms
New Claim Packet

Use: Employer should follow the claim protocol, and fill out the 5020 and Supervisor's Investigation Report. The rest of the forms should be given to the injured employee. Upon receipt of the forms from the employee, the employer should fill out the bottom section of the DWC-1, while the employee completes the Supervisor's Investigation Report. The paperwork should be reviewed to make sure it is completely and correctly filled out and then faxed to 954-252-3816 or emailed to claims@patriotrs.com. The 24hr call center can be reached at 866-993-0239

Declination of Medical Treatment Packet

Use: Some employees do not wish to pursue treatment for a variety of reasons, however, a DWC-1 must still be given to the employee. The declination is verification for employer records. If in the future the employee seeks Workers' Compensation benefits, the employee should then fill out the DWC-1 and notify the employer.

First Aid Packet

Use: In any incident where only first aid treatment is provided, the employer should review the first aid guidelines and reporting requirements, then fill out the 5020, Supervisor's Investigation Report and fax them to 954-252-3816 or emailed to claims@patriotrs.com. If the claim is a first aid it will not affect the experience modifier.

MPN

You may access the list of Network Providers through the following website: http://www.rockporthealthcare.com/SSL/Login.aspx?Userid=AVIZENT&pw=9572. You may search for providers by zip code, name or location.

	General and Professional Liability
	Workers Compensation
	Property
	Employment Practice Liability Insurance (EPLI)

Shomer Insurance Agency, Inc
Lic #OC79888
7461 Beverly Blvd Suite #306
Los Angeles, CA 90036

Phone: (323) 934-8160
Fax: (323) 934-8170
contact@shomerinsurance.com