I O R T O C O M P L E T I N G I T I have been informed of my responsibilities under WV Workers’ Compensation Law and agree to abide by such in the administration of services provided by BrickStreet Insurance. I am aware the law provides for severe penalties for providing false statements or information. Initials o f E mployer Representative: 1. BrickStreet Insurance policy number: FEIN or SSN: 2. Industrial code: 3. Name of employer as listed with BrickStreet: Address of employer: Phone nu.
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How to fill out the BrickStreet Insurance BI-3 online
Filling out the BrickStreet Insurance BI-3 form is an essential task for employers reporting workplace injuries. This guide provides clear, step-by-step instructions to help you navigate the process efficiently and accurately.
Follow the steps to complete the BrickStreet Insurance BI-3 form online.
- Press the ‘Get Form’ button to access the BI-3 form and open it for editing.
- Begin by entering the claim number, team assigned, and ICD9 if applicable. This information helps in tracking and managing the claim.
- Input the BrickStreet Insurance policy number and the employer’s FEIN or SSN, which verifies your identity and accountability.
- Fill in the industrial code, name of the employer as listed with BrickStreet, and the employer's address. Include the phone number and city for direct communication.
- Provide the injured employee's SSN, county of residence, and state. Don't forget the date of injury as it is critical for claims processing.
- Enter the injured employee's name, marital status, and detailed job title or description.
- Complete the employee's address, including city, county, state, and telephone number to maintain accurate records.
- Indicate the injured employee's date of birth and gender, selecting the appropriate options for full-time, part-time, or leased employment.
- If applicable for leased employees, fill in the name and policy number of the client employer and the date the injured worker was assigned.
- Record the date the employee first started working, and indicate if they stopped work due to the injury, along with related dates and times.
- Establish whether the disability is expected to last longer than four days. This affects claim outcomes.
- Answer if there is a BrickStreet approved Return-To-Work program, and if the employee returned, specify if it was alternate or modified work.
- State the daily rate of pay on the date of injury, including hours worked per week.
- Clarify if the injury occurred on employer property and provide the address where it took place.
- Detail the nature, body part, and type of injury sustained, using precise vocabulary.
- Answer if you have reason to question this injury and whether an incident report was completed.
- Provide the initial medical contact information and indicate if there is a previous injury to the affected body part.
- Certify the accuracy of the information provided by signing and dating the form.
- Make a copy of the completed form for your records and return it to BrickStreet Mutual Insurance at the specified address.
Start completing the BrickStreet Insurance BI-3 form online today for seamless reporting.
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Get answers to your most pressing questions about US Legal Forms API.
What is the former name of Encova Insurance?
The former name of Encova Insurance is BrickStreet Mutual Insurance Company. This transition occurred in 2018 as part of their growth strategy to better serve customers with diverse insurance needs. The rebranding to Encova allows for a modern approach while retaining popular products like BrickStreet Insurance BI-3. Customers can expect the same dedication to service with the added benefit of new offerings.
Did Encova buy BrickStreet?
Encova Insurance did not buy BrickStreet; rather, BrickStreet Mutual Insurance Company became Encova through a rebranding process. This strategic move was made to broaden their market presence and enhance their services. Now, customers can benefit from a wider range of products, including BrickStreet Insurance BI-3, under the Encova name. The transition highlights their growth and evolution in the industry.
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What did Encova insurance used to be?
Encova Insurance was formerly known as BrickStreet Mutual Insurance Company before it rebranded in 2018. This change marked a new beginning for the company, expanding its offerings beyond workers' compensation. The rebranding reflects their commitment to providing comprehensive coverage, including BrickStreet Insurance BI-3. Customers can trust in their resilience and adaptability in the insurance marketplace.
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