BPM006681_Sellmark_Work_Comp_Insurance.pdf

USS

PO Box 12058 Austin, TX 78711-2058

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ROACH HOWARD SMITH & BARTON INC

DBA: ROACH HOWARD SMITH & BARTON

1320 S UNIVERSITY DR STE 1000

FORT WORTH TX 76107-8000

Important Insurance Documents Enclosed

Please forward the Insured’s copy to them immediately.

CONFIDENTIALITY NOTICE: This communication may contain confidential, proprietary or privileged information and is intended only for the person to whom the communication is addressed. If you are not the intended recipient, please immediately notify Texas Mutual's information services center at (800) 859-5995 or information@texasmutual.com and destroy all copies of the communication as your use, disclosure, copying or storage of the communication is prohibited and may be a violation of state or federal law.

Important Notice: Your Texas Mutual policy provides coverage for claims made by Texas employees for Texas benefits only.

If you have employees that need workers' compensation coverage in other states, notify your agent immediately.

2024-10-03

WORKERS' COMPENSATION INSURANCE

USS

PO Box 12058 Austin, TX 78711-2058

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SELLMARK CORPORATION

2201 HERITAGE PKWY

MANSFIELD TX 76063-5628

Important Insurance Documents Enclosed

Please forward the Insured’s copy to them immediately.

CONFIDENTIALITY NOTICE: This communication may contain confidential, proprietary or privileged information and is intended only for the person to whom the communication is addressed. If you are not the intended recipient, please immediately notify Texas Mutual's information services center at (800) 859-5995 or information@texasmutual.com and destroy all copies of the communication as your use, disclosure, copying or storage of the communication is prohibited and may be a violation of state or federal law.

Important Notice: Your Texas Mutual policy provides coverage for claims made by Texas employees for Texas benefits only.

If you have employees that need workers' compensation coverage in other states, notify your agent immediately.

2024-10-03

PO Box 12058, Austin, TX 78711-2058 texasmutual.com | (800) 859-5995 | Fax (800) 359-0650 COVINSUR

10/3/24 Information From Your Underwriter Insured copy

Policy no.

0001242689

Regarding

SELLMARK CORPORATION

Policy period 9/25/24 to 9/25/25

Dear Policyholder, Thank you for placing your account with Texas Mutual Insurance Company. For your convenience, we are enclosing a copy of your workers’ compensation policy along with two claim-reporting forms you may use if one of your employees has a work-related accident.

You can also save time by reporting your injuries online at texasmutual.com. Our website also offers services that allow you to view your claim information, create your own customized loss reports, manage your workplace safety programs and stay up-to-date with Texas Mutual® news and events.

As the state’s leading provider of workers’ compensation insurance, we strive to set the standard in Texas for service, communication, and ease of doing business. If you have any questions, please email us at information@texasmutual.com or call us at (800) 859-5995.

Sincerely, WHITNEY GILLIGAN

Underwriting Team http://texasmutual.com texasmutual.com | (800) 859-5995 | Fax (800) 359-0650

10/3/24 Welcome Letter Insured copy

Policy no.

0001242689

Regarding

SELLMARK CORPORATION

Policy period 9/25/24 to 9/25/25

Dear Policyholder, Enclosed is our policyholder packet. Thank you for choosing Texas Mutual Insurance Company. We know you have a choice of workers’ compensation carriers, and we are determined to continue to earn your business. As a policyholder-owned mutual company, Texas Mutual is singularly focused on serving you and your employees.

We work hard to help you control your premium, fight workers’ compensation fraud and prevent workplace accidents. If your employees get injured on the job, our professionals are committed to helping them get well and return as productive members of the workforce.

Thank you again for your partnership. Please let us know if there is anything we can do to improve our service to you.

Sincerely, Jeanette Ward President & CEO texasmutual.com | (800) 859-5995 | Fax (800) 359-0650

Making the most of Texas Mutual services

Thank you for choosing Texas Mutual Insurance Company. This brief guide will help you get the most value from your Texas Mutual coverage.

Earn dividends Dividends reward loyal customers who share Texas Mutual’s commitment to preventing workplace accidents. Visit texasmutual.com/OwnershipPays to learn more about dividends

Understand your premium

Your annual premium is an estimate based on your payroll, the type of work your employees perform, your loss history, your safety programs and other factors. At the end of your policy period, we will review your account to determine your actual payroll and/or any operational changes during the policy year. If necessary, we will adjust your premium accordingly. You may get money back, or you may be billed.

Report injuries ● Report injuries the same day they happen, if possible. The fastest way to report injuries is at texasmutual.com. If you cannot report online, you may report by phone at (800) 859-5995, or send a completed DWC-1 form (available on our website – texasmutual.com) by fax to (877) 404-7999 or by mail to Texas Mutual Insurance Company, P.O. Box 12029, Austin, Texas 78711-2029.

● Give the employee a copy of the injury report and the “Employee’s Rights and Responsibilities” brochure. The brochure can be located on the Texas Mutual Website or The Texas Department of Insurance Website.

● Keep accurate records of the dates when you take any claim-related action, including when you file a Supplemental Report of Injury (DWC-6 form) or Employer’s Wage Statement (DWC-3 form). You are required to give a copy of these forms to the employee at the time of completion.

● You can complete the DWC-3 online by going to Texas Mutual Online (texasmutual.com) and clicking on the Employer Tab. This is the preferred method, but you can also complete the form manually and fax it to our office.

● If you have a network policy, you are required to give the employee a copy of the “Notice of Network Requirements” within three days of new employee hire and at the time of injury. The employer must provide employees with a notice of network requirements, which can be located on our website, in English, Spanish, or any other language common to employees. Additional network requirements can be located on our website.

Prevent workplace accidents

An investment in workplace safety is an investment in your employees and your bottom line.

By preventing accidents, you can reduce your workers' compensation costs and improve your productivity. Texas Mutual is your partner in safety. Whether you need help finding free safety resources on our website or advice on a specific safety issue, we are here to help. Simply call us toll-free at 844-WORKSAFE between 8 a.m. and 5 p.m. Central Standard Time (CST) to speak with a knowledgeable, responsive safety services support center representative. You also have access to a multimedia library of 2,000 free training materials in the safety resource center at texasmutual.com.

texasmutual.com | (800) 859-5995 | Fax (800) 359-0650

Launch a return-to-work process

When employees miss work due to on-the-job injuries, their employers must find a way to make up for lost production. Meanwhile, injured employees must contend with the depression and financial stress that often come with being away from work. Texas Mutual works with you to get your injured employees well and back on the job. Visit texasmutual.com/safety/rtwtools.shtm for more information and free tools.

Fight fraud Workers’ compensation fraud is bad for your business. Our investigators specialize in protecting your premium dollars from the trickle-down effects of fraud. Visit the Fighting Fraud section at texasmutual.com to learn how you can help us stop those who try to cheat the system.

Save time with Texas Mutual® online

You can handle most of your workers’ comp needs at texasmutual.com. Visit our website to report injuries, get free safety training materials, review claim detail reports, submit interim payroll reports and report suspected fraud.

Get Telephone assistance

Use our enhanced automated phone services at (800) 859-5995 between 6 a.m.

and 9 p.m. CST to:

● Verify quote and policy status, including issue date and policy period

● Check payment status, including amount and receipt date

● Retrieve return payment information, including check number and issue date

● Confirm deposit and/or premium amount due

● Verify claim number and assigned workers’ compensation specialist

● Get address and fax information

Representatives are available between 8 a.m. and 5:30 p.m. CST to help with:

● Interim and final audit information

● Information and enrollment for free policyholder workshops

● Access to password-protected online services and password reset

● Workers’ comp health care network information

● Any of your workers’ comp needs

Did someone get injured on the job?

We hope you never experience a workplace accident, but if you do, you need to know some basic information about the claims process. Visit the Employers section at texasmutual.com, and click on Claims to learn what to do if an employee gets injured on the job.

Register for our email newsletter

Texas Mutual’s free, monthly email newsletter includes tips on workplace safety, return-to-work, and other strategies for reducing your workers’ comp costs and improving your productivity. To register, visit texasmutual.com/news/phenews.shtm.

texasmutual.com | (800) 859-5995 | Fax (800) 359-0650 TMPNL

10/3/24 Privacy Notice Insured copy

Policy no.

0001242689

Regarding

SELLMARK CORPORATION

Policy period 9/25/24 to 9/25/25

Privacy Policy

The management and staff of Texas Mutual Insurance Company are committed to maintaining the confidentiality of non-public, personal information. We do not disclose any non-public, personal information about our customers to anyone, except as permitted by law. We do not sell any information about our customers to mailing list companies or mass marketing organizations.

What information is collected about our customers?

As a workers' compensation insurance carrier, we may collect non-public, personal information directly from our customers or their agents. We use this information only to serve our customers' insurance needs, conduct company business, and fulfill legal and regulatory requirements. For example, we collect information from our customers and their agents, such as:

● company name, address, and federal identification number;

● payroll, assets, and employee class codes; and

● loss runs (history of the number and severity of workplace injuries and illnesses).

We may obtain information from customer transactions and other dealings with us such as payment history and premium balance. From our customers’ injured workers, we may obtain contact information, health information, and information regarding wages and benefits. Also, depending on the nature of the transaction, we may collect information from other third parties, including health care providers, other insurance companies, government agencies, information clearinghouses, courts, and other public records.

Confidentiality and security measures We treat non-public, personally identifiable customer information, including information related to injured workers, as confidential, and we maintain physical, electronic and procedural safeguards to protect personal information. Texas Mutual Insurance Company employees and contractors who have access to our customers' non-public, personally identifiable information are those who need it for business purposes. We also instruct our employees on the importance of maintaining the confidentiality of our customers' information. We may share customer information with third-party vendors as necessary to perform our business operations.

At Texas Mutual Insurance Company, we respect our current and former customers' privacy. We are proud of the strong relationships we have built over the years, and we value your business.

texasmutual.com | (800) 859-5995 | Fax (800) 359-0650 TMPNL

Information we collect on our website Texas Mutual Insurance Company collects no personal information about you when you visit our website unless you choose to provide this information to us. However, we do collect and store general usage information about visitors coming to our website to help us improve the quality of our services and provide you with a positive experience, and we may combine your information with information we collect from third parties or public sources. We collect the Internet Protocol addresses (including the city, domain address, and service provider), the session identification, and we create an activity log.

We or third party online advertising and analytics companies may use tools and services to gather, analyze, and store information about users, including for statistical purposes, reporting, attribution, analytics, market research, interest-based advertising, ad delivery, and other purposes described in this Privacy Policy. These third parties use cookies, web beacons, and similar technologies that are placed on your computer to help analyze how you use online services. We use Google Analytics, a web analytics service provided by Google, Inc and, on Texas Mutual Online, we also use Acoustic Experience Analytics (Tealeaf) provided by Acoustic. Please use the following link to understand how Google Analytics collects and processes data https://www.google.com/policies/privacy/partners/.

United States only operations Texas Mutual controls and operates its websites from locations in the United States. By using Texas Mutual’s websites, you consent to the transfer of your personally identifiable information within and to the United States.

2200 Aldrich Street Austin, Texas 78723-3474 texasmutual.com | (800) 859-5995 | Fax (512) 224-3011 LPSERV

10/3/24 Safety Services Insured copy

Notice to Policyholder/Agent:

Pursuant to Texas Labor Code §411.066, Texas Mutual Insurance Company is required to notify its policyholders that accident prevention services are available from Texas Mutual Insurance Company at no additional charge.

These services may include surveys, recommendations, training programs, consultations, analyses of accident causes, industrial hygiene, and industrial health services. Texas Mutual Insurance Company is also required to provide return-to-work coordination services as required by Texas Labor Code §413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under Texas Labor Code §413.022.

If you would like more information, contact Texas Mutual Insurance Company at 844-WORKSAFE (967-5723) and safety@texasmutual.com for accident prevention services or 844-WORKSAFE (967-5723) and safety@texasmutual.com for return-to-work coordination services. For information about these requirements call the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) at 1-800-687-7080 or for information about the return-to-work reimbursement program for employers call the TDI-DWC at (512) 804-5000. If Texas Mutual Insurance Company fails to respond to your request for accident prevention services or return-to-work coordination services, you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.gov or by mail to Texas Department of Insurance, Division of Workers’ Compensation, MS-8, at P.O. Box 12050, Austin, Texas 78711.

In addition to the services above, Texas Mutual offers thousands of free materials in our Safety Resource Center at texasmutual.com. The resource center is home to an extensive library of free posters, handouts and online videos, many of which are available in Spanish. Texas Mutual regularly enhances the resource center to provide tools that meet your ever-changing needs. We understand, however, that you may need to speak with a professional about specific safety issues. With our safety services support center, help is just a phone call away.

Simply dial 844-WORKSAFE (967-5723) between 8 a.m. and 5 p.m. CST. Our knowledgeable, responsive representatives are ready to:

● Help you access streaming videos, interactive tools and other free safety resources at texasmutual.com

● Identify your industry’s top safety hazards and suggest best practices that address those hazards

● Conduct virtual surveys of your workplace

● Suggest specific safety programs that address your unique needs

Thank you for choosing Texas Mutual Insurance Company as your workers’ compensation carrier. We value your business and will work hard to continue earning it.

WW

WORKWELL,TX

Health care network information As of October 1, 2022

WORK SAFE, TEXAS®

Dear Employer, At Texas Mutual Insurance Company, we are committed to the safety of Texas workers. WorkWell, TX serves as an extension of that commitment, ensuring quality care for employees who are injured on the job.

WorkWell, TX is a workers' compensation health care network certified by the state of Texas. By choosing the network option from Texas Mutual, you keep your costs low with a network discount and our focus on getting injured workers well and back on the job. Our providers have been chosen to treat your employees because of their proven record of success with work-related injuries and illnesses.

A network that offers high-quality care, better results, and savings is a win-win for you and your employees.

To help introduce your employees to WorkWell, TX, this packet offers information and resources, which they must read and sign. Start by reviewing the checklist below to discover what you and your workforce will need to know and do in case an injury occurs.

Employer Checklist

1. Review this packet.

2. Post the Notice of Network Requirements in a common area where your employees will see it.

3. Distribute the Notice of Network Requirements to employees when you begin the program, within 3 days of hiring a new employee, and at the time of injury. Keep a record of how, when, where and to whom you delivered the Notice of Network Requirements.

4. Have all employees sign the Employee Acknowledgment form and keep it in the employee's personnel file. (An employee who refuses to sign remains subject to network requirements.

Document a refusal to sign the acknowledgment in the employee's personnel file.)

5. When an injury occurs, report it immediately to Texas Mutual and if necessary, provide or arrange transportation for the injured employee to the network provider, or emergency facility if appropriate.

6. Work-related injuries must be treated by network-approved physicians. Review the online provider directory on texasmutual.com for a list of network providers. If you or an injured employee needs help locating a provider, you may call WorkWell, TX at (844) 867-2338.

Thank you for choosing WorkWell, TX. If you have any questions, please contact us at

(844) 867-2338 or visit texasmutual.com.

Sincerely, WorkWell, TX Support Team

(844) 867-2338

WW

WW

Notice of Network Requirements

(Post in visible area for all employees)

Your employer has chosen WorkWell, TX as its certified workers' compensation health care network in partnership with Texas Mutual Insurance Company, a workers' compensation insurance carrier.

WorkWell, TX will manage the health care and treatment you may receive if you are injured on the job or diagnosed with an occupational illness while employed here. WorkWell, TX doctors are trained in treating work-related injuries and illnesses and getting people back to work and back to a productive life.

The information in this packet will help you to seek care for your injury and describes what to do if you are injured while on the job.

What to do if you are injured while on the job

If you are injured at work, tell your employer right away. Your employer will help with any questions you may have about seeking treatment through WorkWell, TX. You may also contact Texas Mutual if you have any questions about your treatment. Our shared goal with your employer is to return you to work as soon as it is safe to do so.

A list of network doctors in your service area is available on texasmutual.com or by downloading the WorkWell, TX mobile app. You may contact us at (844) 867-2338 or at the address below for assistance.

WorkWell, TX Attn: Network Services PO Box 12029 Austin, TX 78711-2029

In case of an emergency

If you are injured and it is an emergency, you should seek treatment at the nearest medical care facility immediately. This also applies if you are injured outside the service area. Emergency care does not require preapproval. Texas law defines "medical emergency" as a medical condition that comes up suddenly.

After you receive emergency care, you may need ongoing care. Select a network doctor from the WorkWell, TX network. The doctor you choose will oversee the care for your injury. You must obtain referrals to see another health care provider or specialist from your treating doctor, except for emergency care.

Non-emergency care

Report your injury to your employer as soon as you can. Find a network treating doctor on texasmutual.com or by downloading the WorkWell, TX mobile app. Go to that doctor for treatment.

Treatment prescribed by your doctor may need to be approved in advance. Your doctor needs to request approval from the network for a specific treatment before the treatment or service is provided. You may continue to need further care after completing the approved treatment.

Choosing a treating doctor

If you are hurt at work and it is not an emergency and you live in the network service area, you must choose a treating doctor from the WorkWell, TX network. This is required so that WorkWell, TX covers the costs for the care. If you belong to a health maintenance organization (HMO) at the time of your injury, you may choose your HMO primary care doctor as your treating doctor. You must have chosen the doctor as your primary care doctor before your injury. We will approve the choice of your HMO doctor if they agree to the terms of the network contract and to abide by applicable laws.

For a list of network doctors available in your area, please visit texasmutual.com or download the WorkWell, TX mobile app. The WorkWell, TX provider directory is updated monthly. Doctors who speak Spanish or who are no longer taking new patients will be flagged with an icon on their record.

If your treating doctor leaves the network, we will notify you in writing. You will have the right to choose another treating doctor from the network directory. If your doctor leaves the network and you have a life threatening or acute condition for which a disruption of care would be harmful to you, your doctor may request to continue your treatment for an extra 90 days.

If you live outside of the service area, you may request a service area review by calling Texas Mutual.

You should provide proof to support your request. Texas Mutual will inform you of its decision within seven days of receiving your request. If you disagree with Texas Mutual's final decision, you have the right to file Cca complaint with the Texas Department of Insurance. Your complaint must include your name, address, phone number, a copy of Texas Mutual's decision and any proof you sent to Texas Mutual for review. A complaint form is available on the Department's website.

When waiting for Texas Mutual to make a decision or for the Texas Department of Insurance to review your complaint, you are still expected to use the network for all health care. You may be required to pay for health care services received out of the network if it is decided you do live in the network's service area.

Changing doctors

If you are not satisfied with your first choice of a treating doctor, you can select a different treating doctor from the network directory. We will not deny your choice to see a different treating doctor.

Before you can change treating doctors a second time, you must get permission from the network by calling (844) 867-2338.

Referrals

You do not have to get a referral if you have an emergency. All other health care and specialist referrals should be made through your treating doctor. All health care services that you request will be made available by the network on a timely basis, as required by your medical condition. This includes referrals. All health care services, including referrals, will be made available within 21 days after your request.

Out-of-network approvals

WorkWell, TX must approve all of your treating doctor or specialist's out-of-network referrals before you visit the provider. If you need to request approval, please call (844) 867-2338.

Payment for health care

Network doctors have agreed to seek payment from Texas Mutual for your treatment. They will not look to you for payment. If you receive treatment from a doctor who is not in the network without prior approval from WorkWell, TX, you may have to pay for the cost of that care. Medical costs for treatment by non-network health care providers may be covered only if one of the following situations occurs:

e Emergency care is needed. You should go to the nearest hospital or emergency care facility.

e You do not live within the service area of the network.

e Your treating doctor or specialist refers you to an out-of-network provider or facility and

WorkWell, TX approves the referral.

e You have chosen your HMO primary care doctor. Your doctor must agree to abide by the network contract and applicable laws.

Preauthorization, adverse determination and independent review

A list of the procedures and services that need preauthorization is on texasmutual.com. The list in this packet is not intended to be all-inclusive; health care is an evolving science. Procedures and treatments requiring prior approval will also evolve. Treating providers should verify preauthorization requirements by referring to the updated list on texasmutual.com.

If WorkWell, TX denies the request, you or the requesting doctor may ask for a review of that decision. If still dissatisfied, you, your provider or a person acting on your behalf may request an independent review. The preauthorization agent will provide any relevant medical records related to the injury to the independent review group. They may also provide any treatment guidelines used and a list of the doctors who provided care to you.

Complaints

We take your concerns seriously. If you are dissatisfied, you can file a complaint with WorkWell, TX.

You may do this if you are not satisfied with any aspect of the network, including care you received.

You must file your complaint within 90 days after the date of the event that is the basis for the complaint.

If you have questions about the complaint process you can reach the Grievance Coordinator by phone at (844) 297-5723, by fax at (512) 224-8800, by email at wwtxcomplaints@texasmutual.com, or by mail at the address below.

WorkWell, TX Attention: Grievance Coordinator PO Box 12029 Austin, Texas 78711-2029

Texas law does not permit WorkWell, TX to retaliate against you if you file a complaint against the network. We will not retaliate if you appeal the decision of the network. The law does not permit us to retaliate against your treating doctor if they file a complaint against the network or appeal the decision of the network on your behalf.

You have the right to file a complaint with the Texas Department of Insurance. A complaint form is available on the Department's website.

WorkWell, TX Preauthorization List

Hospital/ASC All non-emergency hospital or ASC (inpatient, outpatient, and observation) admissions including principle scheduled procedures and length of stay. Preauthorization request should include specific hardware, implantables, external delivery system, etc. to be utilized.

Surgery/Procedures/Integral Devices All non-emergency surgeries represented by AMA CPT codes 10010-69990 and/or G codes which represent a surgical procedure performed in a setting or place of service other than the doctor's office [POS 11]. Preauthorization request should include specified hardware, implantables, external delivery system, etc. to be utilized.

e All botox injections e All spinal injections (including but not limited to):

» Epidural steroid injections » RFTC or cryotherapy/cryoablation

Sacral iliac joint injection Facet injection

» Medical branch block Trigger point injections (AMA CPT 20553) Bone growth stimulators Discograms Implantable drug delivery system Investigational or experimental procedures or devices as determined by ODG or listed as an AMA category III code. Stimulator devices (including, but not limited to):

» TENS units » Interferential units » Neuromuscular stimulators » Dual units » Spinal cord stimulator » Peripheral nerve stimulator » Brain stimulator

Physical Medicine e All chiropractic treatments e Manipulations under anesthesia (MUA) e All PT/OT (unless requestor or rendering provider/facility is participating through Align) Biofeedback

Diagnostics e All initial and repeat MRI and CT scans e Bone density scans e e Surface electromyography (EMG) Unless otherwise specified in this list, all repeat individual diagnostic studies (series) having a billed amount greater than $350.

Other e Durable medical equipment (DME), prosthetics and/or orthotics, greater than $500.00 billed (purchase or accumulated rental or combination of rental/purchase) Gym memberships Texas Department of Insurance, Division of Workers' Compensation (DWC) Pharmacy Closed Formulary per 28 TAC §134, Subchapter F.

Alternative Treatment e Acupuncture outside ODG e Acupressure e Yoga

Rehab Programs Work conditioning Work hardening Chronic pain management program Medical rehabilitation Brain and spinal cord rehabilitation Chemical dependency programs Weight loss programs

Nursing Home e Skilled nursing facility, including skilled care within the same facility e Convalescent care e Residential care e Assisted living/group homes

Psychological Testing and Psychotherapy e Subsequent evaluations e Subsequent tests or testing e Therapy

WorkWell, TX Service Area Map

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Employee Acknowledgment ofWorkers' Compensation Network

I have received information that informs me how to get health care under my employer's workers' compensation insurance.

If I am hurt on the job and live in a service area described in this packet, I understand that:

e I must choose a treating doctor from the list of doctors in the network. Or, I may ask my HMO primary care physician to agree to serve as my treating doctor. If I select my HMO primary care physician as my treating doctor, I will call Texas Mutual Insurance Company at

(844) 867-2338 to notify them of my choice.

e I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will refer me to a specialist. If I need emergency care, I may go anywhere.

e Texas Mutual will pay the treating doctor and other network providers for the treatment for my compensable injury.

e I may have to pay the bill if I get health care from someone other than a network doctor without prior network approval.

Knowingly making a false workers' compensation claim may lead to a criminal investigation that could result in criminal penalties such as fines and imprisonment.

Signature Date Printed name

City State Zip code

I live at:

Street address

Name of employer:

Name of network: WorkWell, TX

To the employer:

Each employee must sign this form when you begin the program or within 3 days of being hired, and at the time an injury occurs. Please indicate at which point this acknowledgment was completed.

o Initiating the network program (companywide) Initial employee notification (new hire) Injury notification (Date of injury: )

Keep this completed form in the employee's personnel file. It could be requested by Texas Mutual.

JA-1802-2210 » ©2022 Texas Mutual Insurance Company

First Fill Simplifying the prescription process and helping workers take the first step toward getting well

KH-1478-1903-BW2 • ©2019 Texas Mutual Insurance Company texasmutual.com | worksafetexas.com

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Texas Mutual’s First Fill Program enables your employees to get prescribed medication quickly after an injury occurs, even if you haven’t had the opportunity to file a claim. Injured workers can get a seven-day supply for each covered prescription with a maximum of $500 per prescription with just the First Fill form.

Complete the First Fill form on the back of this sheet and advise your employee to present it at a participating Optum pharmacy.

The form is valid for the first fill and cannot be used if the first prescription fill is being requested more than 10 days after the injury occurred.

If additional forms are needed, visit the employer forms section at texasmutual.com.

FILL OUT THE

FORM TO START

'TexasMatual

WORKERS' COMPENSATION INSURANCE

WORK SAFE, TEXAS

You

Optum | P.O. Box 152539 | , Prescription First Fill Form

Pharmacy Help Desk: 8 -

PLEASE NOTE: This form is only valid within 10 days of the injury date. Once your claim has been reviewed, you will be sent a new card in the mail. If you do not receive a pharmacy card, please call us at 8 - .

Issuance of this letter or dispensing of a prescription does not constitute acceptance of your claim.

Prescription First Fill Instructions

Participating Optum pharmacies include Walgreens, CVS, Walmart, Kroger, Target, Costco, Sam’s Club, Brookshire, HEB and Tom Thumb. To locate other participating pharmacies, visit www.texasmutual.com/hcn or .

Complete the form and take to the pharmacy along with your prescription from the provider.

This form allows you to fill your initial prescription(s) with a maximum cost of $500 per covered prescription and a maximum day supply.

If you have questions, please call us at 866 599-5426, available 24 hours a day, seven days a week.

Bin #: PCN#: CAL Group Number: TXSMFF

Member ID:

Member Name:

Employer Name:

Date of Injury:

Date of injury + SSN combined as follows: YYMMDD123456789

Injured worker’s first last name

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Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee.

*Employers - Do not send this form to the Texas Department of Insurance, Division of Workers’ Compensation, Unless the Division specifically requests a direct filling. CLAIM # ______________________________________

CARRIER'S CLAIM #

EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS

1. Name (Last, First, M.I.) 2. Sex

F M

15. Date of Injury (m-d-y)

16. Time of Injury

: am pm

17. Date Lost Time Began (m-d-y)

3. Social Security Number

4. Home Phone

5. Date of Birth (m-d-y)

18. Nature of Injury* 19. Part of Body Injured or Exposed*

6. Does the Employee Speak English? If No, Specify Language

YES NO

20. How and Why Injury/Illness Occurred*

7. Race White

Black Asian

8. Ethnicity Hispanic

Native American Other

21. Was employee doing his YES regular job? NO

22. Worksite Location of Injury (stairs, dock, etc.)*

9. Mailing Address Street or P.O. Box

City State Zip Code County

23. Address Where Injury or Exposure Occurred Name of business if incident occurred on a business site

Street or P.O. Box County

10. Marital Status Married Widowed Separated Single Divorced

City State Zip Code

11. Number of Dependent Children 12. Spouse's Name 24. Cause of Injury(fall, tool, machine, etc.)*

13. Doctor's Name 25. List Witnesses

14. Doctor's Mailing Address (Street or P.O.Box)

City State Zip Code

26. Return to work date/or expected (m-d-y)

27. Did employee die?

YES NO

28. Supervisor's Name

29. Date Reported (m-d-y)

30. Date of Hire (m-d-y)

31. Was employee hired or recruited in Texas?

YES NO

32. Length of Service in Current Position

Months Years ______

33. Length of Service in Occupation

Months Years ______

34. Employee Payroll Classification Code 35. Occupation of Injured Worker

36. Rate of Pay at this Job

$ Hourly $ Weekly

37. Full Work Week is:

Hours Days

38. Last Paycheck was:

$ for Hours or Days

39. Is employee an Owner, Partner, or Corporate Officer?

YES NO

40. Name and Title of Person Completing Form 41. Name of Business

42. Business Mailing Address and Telephone Number Street or P.O. Box Telephone

43. Business Location (If different from mailing address) Number and Street

City State Zip Code City State Zip Code

44. Federal Tax Identification Number 45. Primary North American Industry Classification System Code:(6 digit)

46. Specific NAICS Code (6 digit)

47. Texas Comptroller Taxpayer No.

48. Workers' Compensation Insurance Company 49. Policy Number

50. Did you request accident prevention services in past 12 months?

YES NO If yes, did you receive them? YES NO

51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING)

X Date ________________________________________

DWC FORM-1 (Rev. 10/05) Page 3 DIVISION OF WORKERS’ COMPENSATION

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DWC FORM-6 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION

CLAIM #

Carrier #

SUPPLEMENTAL REPORT OF INJURY

Part I EMPLOYER INFORMATION

1. Employer business name 2. Employer phone #

3. Employer mailing address

4. Insurance carrier name

5. Does the employer have return to work (RTW) opportunities available based on the injured worker’s current capabilities? yes no If so, identify contact person and phone #

6. Has the insurance carrier provided RTW coordination services within the past 12 months? yes Date no

7. Has the employer requested RTW training from DWC or the insurance carrier? yes no

8. Has the insurance carrier provided accident prevention services in the past 12 months? yes Date no

9. Has the employer requested accident prevention services from the insurance carrier? yes no

Part II REASON FOR FILING THIS REPORT (deadlines vary, see instructions)

10. a. The injured worker returned to work in either a full or limited capacity: File this report within 3 days.

b. The injured worker is earning more or less than the pre-injury wage because of the injury: File within 10 days.

c. The injured worker returned, then later had additional lost time or reduced wages as a result of the injury: File within 3 days.

d. The injured worker resigned or was terminated from employment: File within 10 days.

Part III INJURED WORKER INFORMATION

11. Injured worker name 12. SSN (last 4 digits) xxx-xx-

13. DOI

14. Injured worker mailing address and phone #

15. First day of lost time or reduced wages for this injury (mm/dd/yyyy)

16. First day of additional lost time or reduced wages (mm/dd/yyyy)

17, Has the injured worker experienced 8 days (cumulative) of lost time or reduced wages as a result of the injury? yes no If yes, the date of the 8th day (mm/dd/yyyy)

18. Date of most recent RTW

19. Has the injured worker resigned, been terminated or died? yes no

Full duty, full pay date of resignation date of termination date of death

Limited duty, full pay 19a. Reason for resignation/termination

Limited duty, reduced pay 19b. Was the injured worker on limited duty when terminated? yes no

20. Hours the injured worker was working during the pay period of 21. Weekly/hourly earnings for the pay period of to : hours per week to : $ weekly or $

Indicated hours are: Indicated wages are:

Increase from pre-injury Increase from pre-injury wage

Same as pre-injury Same a pre-injury wage

Decrease from pre-injury Decrease from pre-injury wage

This form to be filed with: The employer’s insurance carrier and the injured worker in the timeframe as noted in Part II.

22. To the best of my knowledge the information provided in this report is accurate and may be relied upon for evaluation of eligibility for benefits.

Submitted by: Employer Injured Worker (If no longer working for the employer where injury occurred.)

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NOTICE TO EMPLOYEES CONCERNING

WORKERS’ COMPENSATION IN TEXAS

COVERAGE:

SELLMARK CORPORATION has workers’ compensation insurance coverage from Texas Mutual Insurance Company in the event of work-related injury or occupational disease. This coverage is effective from 9/25/24. Any injuries or occupational diseases which occur on or after that date will be handled by Texas Mutual Insurance Company. An employee or a person acting on the employee’s behalf, must notify the employer of an injury or occupational disease not later than the 30th day after the date on which the injury occurs or the date the employee knew or should have known of an occupational disease, unless the Texas Department of Insurance, Division of Workers’ Compensation (Division) determines that good cause existed for failure to provide timely notice. Your employer is required to provide you with coverage information, in writing, when you are hired or whenever the employer becomes, or ceases to be, covered by workers’ compensation insurance.

EMPLOYEE ASSISTANCE:

The Division provides free information about how to file a workers’ compensation claim. Division staff will answer any questions you may have about workers’ compensation and process any requests for dispute resolution of a claim. You can obtain this assistance by contacting your local Division field office or by calling 1-800-252-7031. The Office of Injured Employee Counsel (OIEC) also provides free assistance to injured employees and will explain your rights and responsibilities under the Workers’ Compensation Act.

You can obtain OIEC’s assistance by contacting an OIEC customer service representative in your local Division field office or by calling 1-866-EZE-OIEC (1-866-393-6432).

SAFETY VIOLATIONS HOTLINE:

The Division has a 24 hour toll-free telephone number for reporting unsafe conditions in the workplace that may violate occupational health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any employee because he or she in good faith reports an alleged occupational health or safety violation. Contact the Division at 1-800-452-9595.

Notice 6 (01/13) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.101(e)(1)

COVERED EMPLOYER

Texas Workers’ Compensation Rule 110.101(e)(1) requires employers who are covered by workers’ compensation through a commercial insurance company to advise their employees that they do have workers’ compensation insurance coverage and to advise their employees of…