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Home My WebLink AboutCC RES 79-08310 11 12 13 14 1.5 16 17 18 1.9 20 21 22 23 24 25 26 27 28 29 30 31 32 RESOLUTION NO, 79'-83 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF TUSTIN, CALIFORNIA, ADOPTING SETTLEMENT PROCE- DURES FOR WORKERS COMPENSATION CLAIMS. WHEREAS, claims for damages against the City have formerly been processed Workers Compensation insurance carriers of the City; and WHEREAS, the City of Tustin is now self- insured for Workers Compen- sation claims for periods since inception of the City's self- insurance program; and WHEREAS, the City has the obligation to process claims and to provide legal defense for Workers Compensation claims and litigation filed against it; and. WHEREAS, the City has the need for the retention of adjusting services and legal counsel who shall be vested with certain limited authority to accomplish a favorable disposition of claims made against the City. NOW, THEREFORE, the City Council of the City of Tustin, does hereby resolve as follows: Section 1: A Workers Compensation reserve fund is hereby established in the amount of One Hundred Thousand Dollars ($100,000.00) f or the payment of claims made against the City. Said amount shall be maintained and provided for in the annual budget to insure that sufficient funds are on deposit to provide for payment of those amounts not covered by Workers Compensation insurance. The claims administration procedure for Workers Compensation claims, a copy of which is attached hereto and incorporated herein by this reference, is approved and the City Staff is directed to implement and administer the same. Section 2: Workers Compensation claims made against the City in an amount not to exceed Twenty Five Hundred Dollars ($2,500.00) per claimant, are authorized to be settled upon the approval of the City Adminnistrator, Finance Director, Personnel Director and /or City Attorney. Section 3: A committee comprised of the City Administrator, Finance Director, Personnel Director and City Attorney, is authorized to review and make settlement of Worker's Compenstion claims made against the City in an amount not to exceed Five Thousand Dollars ($5,000.00) per claimant. 1 . .. • ... ... ...... ..1. wn, ... q`: 'An'r:'• ns .. • .. . ap rI Ip10 � Ta•. .a � .a.. .. _.. V .... • I. •. a a .. ., .. .. ... .. i .r .. .r. •r a. VI. tr?• e � . :,.. w v •. ! .. Jh,. 1 1 2 3 5 6� 7� a N 10 12' 13' 1Z i 15 l6 t' 1.( T� ELI 18 Rl 19 20 ;I 21 � 22 23 24 25 26 27 28 � l 29 .I 30 31 32 C C. Section 4: All claims in amounts exceeding Five Thousand Dollars ($5,000.00) per claimant shall be approved by the City Council. Section 5: The City Attorney is authorized to retain the services of legal counsel for purposes of representing the City in the defense of any matters of litigation wherein he determines the specialized expertise or experience are desirable or that the workload requires the utilization of outside counsel. PASSED, APPROVED AND ADOPTED at a regular meeting of the City Council of the City of Tustin held on this 5th day of November , 1979. 4,1 MAYOF4 ATTEST: CITY�CLERK 6 JGR:se:D:10 /3/79 T /R /WC Claims D:16 2 .. .S •,6 ; f •R . `� . f � . � . 4 7l .Yrr. E WORKERS COMPENSATION CLAIMS ADMINISTRATION PROCEDURES 0 1. All claims made against the City shall be filed with the Personnel Department. Upon receipt of a claim the person in the Personnel Office receiving the claim shall immediately see that it is processed as follows: a) Check the employee's file for the Supervisor Injury Report and the Employee Injury Report. (Attachment PF -1, PF -2) b) Complete the Plan Administrator's Report with a copy of,the Doctor's First Report. (Attachment A) c) Forward to the Administrator of the Workers Compensation plan all medical information concerning that particular injury. d) Notify the department head of the injury. 2. The Personnel Department and Plan Administrator shall make the initial review of all claims and make recommendations to the Workers Compensation Board for its formal action on the claim. Upon formal action of the Board on a claim, Personnel shall: a) ;dotify the Council in a report of the action taken. 3. The Department head shall write a narrative report giving detailed information as known to the department and what, if any, corrective action is being or has been taken. 4. Bierly and Associates shall investigate the claim and provide a detailed written report of its investigation together with its recommendations for settlement, denial, etc. to the Personnel Director and the Finance Director. 5. Upon receipt of the report and recommendation of Bierly and Associates, the Personnel Director shall review and: a) May authorize settlements within the limitations provided herein, and make a report thereon to the Council /City Administrator, b) Make a report and recommendation to the Council, c) Settlements of claims for payments up to $1,000.00 per claimant may be approved by the City Administrator, Personnel Director or City Attorney. d) Settlement of claims by payment of up to $5,000.00 may be approved by action of a majority of the Workers Compensation Board, composed of the City Administrator, Personnel Director, Finance Director and City Attorney. e) Settlement of claims by payment in excess of $5,000.00 per claimant must be approved by the City Council. W Workers Compensation Claims Page 2 M f) Claims which have been approved as provided above shall be paid by City warrant and shall be transmitted to Bierly and Associates for delivery to the claimant after execution of proper releases of City. g) Obvious emergency situations shall also be immediately reported verbally to Bierly and Associates as well as to the Department. 6. Bierly and Associates shall provide all statistical and claims analysis reports with a copy to: a) Personnel Department b) Finance Department 7. Bierly and Associates shall provide City with a monthly computer report showing claims made and location code which identifies the department involved. 8. Bierly and Associates shall send quarterly reports to the Personnel Department showing all outstanding claims and all settlements made. pri City of Tustin • REPORT OF INVESTIGATION OF ACCIDEN ACCIDENT TO. CLASSIFICATION: DATE O: INJURY' DEPT NATUR= OF INYJRY: HO'N DID IT HAPPEN A- Eu?LCY __E ❑ 2. Eq! ; ; -rrt 5_cr as jaz"s. S- e':. ,:c:ided but net ____. Cog;l-s. but ac; .I^• +r`�r --53fe t001 .,. _CAi- 5. Horse-•:i, c _ ;Iing. 6. Ics ;r,.r.-ic:•; rules disregar_ =d 7.Ir.at:zr. >c u 9. Piiysi.al __ .d':Ion of erpicy 0 10.I -p 11. L ^pro _. _.aod of drug wc- ° ;. 12. Act c' 13. LOCATION OF TIME: ACCIOENT: LOST TIME: DIVISION: BASIC CAUSES 1. Poor light. ❑ (PLEASE CHECK A ?PROPRIATE BOXES) ❑ 3. Bad housAeepin3. C- UNSAFE EDUIPMENT B- SUPER71SI0,4 ❑ OR MATERIALS 1 -No job briefing. ❑ 1.Ineffeetivelyguardadequip- plate 11b analysis. ment. 3. Fules, stardards or instructions not ❑ 2. Unguarded equipment. enforced. ❑ 3. Defective materials. �. Personal safety devices not pro- ❑ 4. Defective tco s. vided on job (goggles, safety belts, n3sks; respifator5, etc) ❑ 5.Defective equipment (not 5. Correct or safe tools or equipment motor vehicles). not provided. ❑ 6. Defective motor vehicle E. Inadequate 1aspe6on cf equipment equipment. or jobs. ❑ .e equipment cr ma- 7. Unsa` 7.1- proper =;hod of doing work• m ' terial of contractor, r.on- 8. Poor job planning, emptoyea or customer. 9. Too muc`I risk. ❑ g. Inproper type or poor ❑ 10. Inadequate job training by foreman. design. 2. STATE IN D= -IL WHY YOU SELECTED THE ABOVE BASIC CAUSES. (Use reverse side) A. WHAT WAS Tr.E UNSAFE CONJIT:ON (IF ANY)? B. WHY C'D IT EXIST? C. WHAT'NAS THE UNSAFE ACT? D. WHY'NAS IT PERFORMED? BECAUSE OF JOB CIRCU%'STANCES ?. D- UNSAFE COHOITIO43 ❑ 1. Poor light. ❑ 2. Poor ventilation. ❑ 3. Bad housAeepin3. ❑ 4. Improper pilir.-7 or s1c ❑ 5. Tools, equipment or m ials scattered around. ❑ 6. Slippery floors or c . places. ❑ Mirisale conditions ca by other persons. BECAUSE OF THE SUPERVISION? _ __ __ .. __ ___ BECAUSE OF THE EMPLOYEE'S WORK HABITS • PHYSICAL CGNDITION ___, TRAINING ______. OUALIFICATION FOR THE JOB . OTHER - 3. TO PREVENT A RECURRENCE. WHAT HAVE YOU DONE OR WHAT DO YOU SUGGEST? �Yh:r:ESi Name 5. o. A) ScC'JENCE AND ANALYSIS OF EVENTS LEADING UP TO ACCIDENT: B) CEi := 7'ON OF ACCICc`.— .. __ `.G .,._URY. T �_c. C :':r.! L BE CO':❑ 7 _ D -:S A CCIDSNY AJJ�es; o: Cepartment :;O`.<...!c N -S: 0 • GlIRLY SCHEDULED WORKDAY BECAUSE OF THIS IN,IU.9Y7 9l T--.'-'_ .:'15E =t GF 7�= TO THIS Et1D' OYCE CI •'T': 'Ec= C= iVOJS'RI „! i% _J :ES TO THIS PART 0= THe BODY :;O`.<...!c N -S: 0 • pF2 Ask - INSTRUCTION'S: c: •" p: ::a 07;-, sdo of torm "d • W.::n: ^_ 3"1 DID CITY OF TUSTIN EMPLOYEE ACCIDENT ANALYSI5 REPORT INJUR=O EMPLOYEES REPORT - P -- _ .. c..>1 WHAT K.ND -'F INJURY? Your suggestion and id as on how 1j, prereni the reoccurrence of this accident are Tmporant : =T '�:'J -� �- 09 V. tiA' = _ '•:��! .RECO '•: E`:D REI %7 C3%- 70 PREVENT THE P.EOCCUnRECE OP THIS ACCIDENT? E a:dre �t C•�.� :jam. State pf California _�.1PLOYER'S- REPORT 0-c OCCUPATIONAL 1:1JU RY OR ILLNESS IIERLY AND' ASSOCIATES SELF- INSURANCE SPECIALISTS 1633 EAST FOURTH STREET, SUITE 23a • SANTA ANA, CA 92701 (714) 547 -6333 USI1A case or File No. 1. California law requires an employer to report within five days every industrial injury or occupational disease which: (a) Results in lost time beyond the day of injury, or Ihl r >quires medical treatment other tban first aid. In addition, if the injury results in death• a report must be made by telephone (4151557 -3962) or teleG,aoh to :he California Division of Labor Statistics & Research, San Francisco, within 24 hours after death. 1 Fwv N.Ai - z- m 5020 1 Prr. 21 FILING OF THIS REPORT 13 NOT AN AOMISSION OF LIABILITY IA. CERTIFICATE NUMilt,i PLEASE 00 Npl USE THIS COLUMN D 2 u>1LLY. AO.+`.A tTrna msluda city, 2rp1 2A. PHONE NUM3Ea 45f ND -iI ]. LOCA:I U'Y, Ii Cri Gi REYG FROM (FAIL Ap0Ai5 iw.ielfl rrLL a NACURF OF SCi :MESS 1r.3. 1u p..wl.alw, uS..l ,.rrbl S STATE U.M9pYhIEnT INSURANCE ACCT. tlUM3ERER UH)USTar NAME 2. SOCIAL SECURITY N.-T'-0 �•' -bra - - F HONE ADC P'>5 �.umhw ud lvwL Dry, Lpl CA. PHONE NUMEER f J3. .'l • 11. DATE OF eIRTA / / Monllr pry YM Ua. OAIE OF HIRE 5t. ❑ °•+ T10CP:PAT10YIRrydrrlehpgr, npnperLS SCOnryaumld rnluNl l ❑ f.ntlr IZ DEP >RR'Ea: 1Y N.41CH AEGUL44LY E.`MLO•`_] AGE CCC4aAlron on;N Op Yw - - 0 I CC• :'.11SSl O.Y OR PIECE WORK 13 WAGS$ pv Pt OYEE PAID ' I 345 S. OR PAID eDaRO OR LOOCING ALLONANCE? In. uNOER 1'Mai CLASS CODE CF YOUR POLICY WERE WAGES ASSIGNED? WEEKLY FaLf Yn No WHERE CID ACC12ENi OR EAPDSURE OLCUA' .amzv < :r wowryl 0;1 EMPLOYER S PRi.•AISEST 115 ❑Y., ❑Np CGUNY i. 64AT 1YA EN+JYEE ZING WHEN INJURE 11 1 larnhry la0,mpr mrterultL emPloYr. wn uxngl _ I• - ACCIDEnt TTIF 1 AGING ;1, NON +_- __i-E_YT OR EEPOSUR ? fan Nr neq „fill rerul; ed minlury of 9auprrmnJ dnuu i;Mah..... rnd IlownM1aiynad. T.<a,i av vp+ran sNnI if nr< ury) AGENCY Iasi • II I 1 AGIICY 1 MATURE DF Mass, J T hilrd pr lw>GUwd; :1. CRJECT CR : >YCi T.i>i DIRECTLY ItiO'.v -D i`aPI DYEi Lp.,Ibm¢hin: rmDtovo dr�e5.qumtor whi <h em<a him;IM1r.rpw pr pp.wnm Ihr i,% ,cd Nal rrra... hiaYn, in uva al Haim -Ih. th;., fra.n<Lltinp,pU :LnD, rtal TART GFgo.Y I IgURI Gafe 13. NATURE Cf IV:U9} OR ILLNESS AND PART OF EDGY AFFECTED _ 2] NAMi A.VD Ail. ?EL OF PHV TICIAN IT IF HOSPITALIZED, NAME AND ADDRESS OF HOSPITAL I.TENY OF Mvif S 22 DATE OF IY,UAY CA LLYESS ” 11-1 OF 0 >Y •^`• VP? Drr Yfa Pm. 2A. 1YAS EMPLOYEE WYAHLE M WORN ❑ Yg Z.F Plaid ON ANY DAY AFTER INJURY? E] No ISURAnC1 CARRH 24 HAS EMPLCI:E RETURNED TO WORAt ❑Yn, d.;. nN.nd ❑ Na, 1p4 off ..orY 26 DID 141PLOYEE 0167 (3 y., btr ❑ No afloat tAL • CGGfp p1 _iIo.Otad by 111Vi Gr Wins) $i,..t.,• Ti[IB Dan z- m 5020 1 Prr. 21 FILING OF THIS REPORT 13 NOT AN AOMISSION OF LIABILITY STATE OF CALIFORNIA ) COUNTY OF ORANGE ) SS CITY OF TUSTIN ) RUTH C. POE, City Clerk and ex-officio Clerk of the City Council of the City of Tustin, California, does hereby certify that the whole number of the members of the City Council of the City of Tustin is five; that the above and foregoing Resolution No. 79 -�was duly and regularly introduced, passed and adopted at a regular meeting of the City Council held on the 5th day of November 1979, by the following vote: AYES: NOES: ABSENT: COUNCILPSEN: SCHUSTER SALTARELLI SHARP, WELSH COU`iCIL ^CN: KENNEDY . CO'._;CII2.CN: None C. RUTH C. POE, City erk, Cito of Tustib, C lifo nia_