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A.I.M. Mutual Insurance Company Associated Employers Insurance Company Massachusetts Employers Insurance Company Employers Insurance Company

in Claim Kit partnership with you On behalf of the A.I.M. Mutual Insurance Companies, I welcome you as a policyholder.

As your new workers compensation insurance carrier, we ask that you report all accidents to us as soon as possible after they occur. Your prompt notification together with a complete accident report will help us to handle your claims fairly and efficiently.

Enclosed is a supply of the necessary forms along with instructions for their use. Please feel free to contact us at any time with your questions or service requests.

Sincerely,

Laura Parsons, WCLA, FCLA Director of Claim 54 Third Avenue, Burlington, MA 01803 Workers Compensation Claim Reporting Options In the event of a serious accident, call us immediately at 1-866-270-3354 (toll free 24-hour/7 day a week claim reporting) Choose from several different ways to report your workers compensation claims to us:

By Fax: For all claims, complete and fax the Employer First Report of Injury (Form 1) to us at 1-781-270-5599. Form 1 should be filed as soon as possible after knowledge of an employee’s job-related injury or disease but no later than 72 hours thereafter. We will file Form 1 with the State of Vermont Department of Labor. Even if the claim is for first-aid only injury claims, submit the Form 1 to us. We will file this form with the Vermont Department of Labor.

On-Line, over the Internet: Log on to www.aimmutual.com. Select Policyholder Tools / Report A Claim / VT Claim Page.

You will be prompted to answer a series of questions similar to the information necessary to complete a Form 1. After answering all of the questions and clicking on SEND, you will receive a message stating your claim has been submitted. It will also state that a Claim Acknowledgement letter containing the claim number and assigned claim representative will be mailed to your company after registration has been completed. Click Print for a copy of the information you sent. We will file Form 1 with the State of Vermont Department of Labor. Even if the claim is for first-aid only injury claims, submit the Form 1 to us. We will file this form with the Vermont Department of Labor.

By Phone: Report claims by calling toll free: 1-866-270-3354.

This line is established for reporting new claims only and facilitates the initial claim reporting process. Please have your policy number on hand prior to calling. You will receive a completed Form 1 and a confirmation letter, followed by a claim acknowledgment letter including the name of the Claim Representative assigned to your case. We will file Form 1 with the State of Vermont Department of Labor. Even if the claim is for first-aid only injury claims, submit the Form 1 to us. We will file this form with the Vermont Department of Labor.

After the initial claim report: Please direct ongoing claim and service inquiries to your Claim Representative at our toll free telephone number: 1-800-876-2765

By Mail: Mail the completed Form 1 to A.I.M. Mutual Insurance Companies, Attn: Claim Department, 54 Third Avenue, P.O. Box 4070, Burlington, MA 01803-0970

State of Vermont Workers Compensation Claim Reporting Procedures

IT IS IMPORTANT THE INSTRUCTIONS IN THESE PROCEDURES BE FOLLOWED EXACTLY AS OUTLINED. Prompt filing of the correct forms with all the necessary information helps speed necessary claim investigations and the proper payments of benefits when due. LATE FILINGS OR LATE PAYMENTS MAY ALSO RESULT IN PENALTIES IMPOSED ON YOUR COMPANY AND/OR A.I.M. MUTUAL INSURANCE COMPANIES AS YOUR INSURER.

Keep in mind:

 If it’s a serious accident, call us immediately: 1-866-270-3354  We will file the Employer First Report of Injury (Form 1) with the State of Vermont Department of Labor.

If you need additional forms, they may be requested from A.I.M. Mutual Insurance Companies at 1-800-876-2765, Claim Services Department or downloaded from the Vermont Department of Labor (DOL) website: www. http://labor.vermont.gov/forms/#comp

Applicable Forms include: For any job-related claim:

1. Form No. 1 Employer First Report of Injury

Additional forms for any lost time claim:

1. Form 7 Workers’ Compensation Medical Authorization 2. Form 8 Notice of Intent to Change Health Care Provider 3. Form 10 Certificate of Dependency and Concurrent Employment 4. Form 25 Wage Statement

1 Reporting First Aid Injuries and/or Loss of Time Claims

Complete Employer’s First Report of Injury (Form No. 1)

You need to complete the Employer’s First Report Injury (Form No. 1) as soon as possible after knowledge of an employee’s job-related injury or disease, but no later than 72 hours thereafter. The timing of the filing of Form No. 1 is very important. Please file this report with us within 72 hours of the injury or disease, or immediately upon your receiving notice. We will file Form 1 with the State of Vermont Department of Labor. If you phone in or report a new claim over the Internet, a completed Form 1 will be sent to you. Report a claim at www.aimmutual.com

(If a first-aid claim only claim becomes a lost time claim, notify A.I.M. Mutual immediately. You will then be required to complete Form 25-Wage Statement which we will then file with the Vermont Department of Labor.)

Mail or Fax to:

A.I.M. Mutual Insurance Cos. Claim Department 54 Third Avenue P.O. Box 4070 Burlington, MA 01803-0970 Fax: 781-270-5599

For lost time claims, be sure to give the injured employee a copy of Notice of Intent to Change Health Care Provider-Form 8 and a completed copy of Form 1.

Employers’ Responsibility for Reporting an Injury Vermont Department of Labor

1. You must report any injury that results in medical care or an absence of work within 72 hours of notice of the injury to A.I.M. Mutual Insurance Companies (A.I.M. Mutual, AEIC). Filing a First Report does not make you liable for the injury.

2. First-aid only injury claims also must be reported using Form 1. Complete and submit Form 1 to A.I.M. Mutual Insurance Companies and we will report the claim to the Vermont Department of Labor on your behalf.

3. A.I.M. Mutual will assign an adjuster to investigate your claim and either accept or deny it within 21 days of your having notice or knowledge of the injury. Send any information that you have regarding the injury or incident directly to your A.I.M. Mutual adjuster to assist him or her in the investigation.

4. You may direct the injured employee to a company doctor for his or her first visit or to a Best Doctors Occupational Health Institute medical care facility. The employee may change doctors after that by filing a Change of Health Care provider-Form 8.

5. Once you have been notified that the injured worker has a work capacity, keep A.I.M. Mutual aware of any available work that you have for the injured employee. Be sure to notify A.I.M. Mutual as soon as the injured employee returns to work.

2 A.I.M. Mutual Insurance Companies

Internet Claim Reporting VERMONT

Form 1 (Rev. 9/11) DEPARTMENT OF LABOR – ATTN: WORKERS’ COMPENSATION (Approved for use as OSHA 101 and 301) PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 State File No. EMPLOYER FIRST REPORT OF INJURY

Answer every question fully and report promptly to avoid a penalty. Employer’s Federal ID Number and Employee Social Security Number MUST be provided.

1. Legal Name: 2. Business E Name: M 3. Mail Address: No. and Street City State Zip P L O 4. Location (if different from Mail Address): 5. Telephone Number, Extension and Contact Person.: Y E 6. Nature of Business (list principal products or service of 7. Do you regularly employ 10 or more 8. Federal ID No.: R concern): employees? Yes No 9. Name: First Name Middle Initial Last Name 10. Social Security No.: 11. Date of Birth: E M 12. Home Address: No. and Street 13. Home Phone No.: 14. Work Phone No: 15. Age: P L City State Zip 16. Job Title: 17. Sex: O M F Y E 18. Wages $ Hours Per Day 19. If board, lodging, etc. were 20. Was employee hired in 21. Date of Hire E furnished in addition to wages, state VT? estimated value: Per Days Per Week $ Yes No 22. Date of Accident: Accident Time: Began Shift: 23. Location of Accident: Town or State A City C AM PM AM PM C 24. Machine, tool, object, motor vehicle or substance directly causing injury: I D E 25. On employer’s premises? Yes No If yes, name of department: N 26. Describe what employee was doing: Was this the employee’s regular occupation? Yes No T 27. How did accident occur? Describe events leading up to the accident:

28. Describe the injury and the part of the body injured. 29. Was this a first-aid only injury: I Yes No N J 30. Any Lost Time? If yes, date disability Last date paid in 31. Employee returned to If yes, date Medical Only Incident: U began full: work? R Yes No Yes No Yes No Y 32. Did injury result in death? If yes, date of death. Yes No 33. Name and address of Physician: 34. Name and address of Hospital: Remained Overnight Yes No 35. Insurance Company Named on Workers’ Compensation Policy 35A. Claim Administrator I N Name in full: Company Name S Policy No. Phone Number Signed by:

Employer or Representative Title Date

Equal Opportunity is the Law DOL Form 4 Rev 9/11 Department of Labor State File No. Workers’ Compensation Division Ins. Co. File No. PO Box 488 Date of Injury Montpelier, VT 05601-0488 Soc. Sec. No. (802) 828-2286

REPORT OF FATAL ACCIDENT

IMPORTANT: This report is to be used only when a work related injury results in a fatality. In all such cases, the Employer’s First Report of Injury (Form 1) also must be filed.

1. Name of Employer:

2. Address of Employer:

3. Nature of Business:

4. Name of Injured Person:

5. Residence of Injured Person at Time of Death:

6. Date of Accident:

7. Date of Death:

8. Place where Injured Person Died:

9. Single Married Civil Union Widower Widow Divorced

10. Number of Children under Eighteen years of age:

11. If no Spouse or Reciprocal Beneficiary or Children Survive, State Other Relatives Dependent Upon Deceased:

12. Relationship of Dependents:

Dated this day of 20 (year)

Employer

By Official Position

FORM 7 (Rev. 1/17)

State File No.:

Ins. Co. File No.:

VERMONT WORKERS’ COMPENSATION MEDICAL AUTHORIZATION

NOTE: Title 21 VSA §655a requires all providers to utilize and comply with this medical release authorization form when seeking or providing medical information relative to a workers’ compensation claim. Workers’ Compensation claims are expressly exempted from the terms and provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR 164.512(1).

A copy of 21 VSA §655a is included with this form (see Page 2 of 2).

TO: (Physician, Hospital or other medical practitioner)

This, or a photocopy, will authorize you to release to (Insurance Carrier, Employer and/or its counsel of record) at the following address:

All relevant medical information you may have relating to the treatment or diagnosis of my work related injury claim that involves injury to my:

(enter body part(s) or health condition) that occurred on or about , 20

RELEVANT MEDICAL INFORMATION INCLUDES records relating to a past history of complaints or treatment of a condition similar to that presented in the work injury claim or other conditions related to the same body part and may include:

(1) Minimum data to justify services and payment, including that on the standard paper 1500 form or electronic 837 form. (2) Office visit notes, diagnostic reports, medical evaluations relating to the injury diagnosis or treatment. (3) Any other relevant provider records contained in the file.

Name: (Print Claimant/Patient Name) Date of Birth:

Signature Date

Page 1 of 2 Page 2 of 2

Title 21: Labor Chapter 9: EMPLOYER'S LIABILITY AND WORKERS' COMPENSATION 21 V.S.A. § 655a. Release of relevant medical records by health care providers; department to oversee release and use of relevant medical information

§ 655a. Release of relevant medical records by health care providers; department to oversee release and use of relevant medical information (a) Health care providers examining or attending the examination of an injured worker pursuant to this chapter shall provide relevant medical records and reports as requested by the injured worker, the employer, or the department regarding the diagnosis, condition, or treatment of the worker, permanent impairment, or any restrictions or limitations on the worker's ability to work upon receiving a written medical release authorization from the injured worker. The authorization shall be on a form approved by the department. If the relevance of any medical information is disputed, the department shall determine whether the requested medical information is relevant. (b) Medical information relevant to the specific claim includes a past history of complaints or treatment of a condition similar to that presented in the claim or other conditions related to the same body part. Information that may be requested includes: (1) Minimum data to justify services and payment, including that on the standard paper 1500 form or electronic 837 form. (2) Office notes of the examination relating to the injury diagnosis or treatment. (3) Any other relevant provider records contained in the file. (c) An injured worker shall only be obligated to sign a medical record release authorization approved by the department. (d) Any medical information received by the employer or the insurance carrier that is found not to be relevant to the claim may not be used to deny or limit a claim. The commissioner may order that specific disclosure requests be denied or rescinded and may make such other interim orders as are appropriate. (e) Any medical information received in conjunction with a claim shall be used only for the purpose of advancing or defending a claim relating to the injury or of investigating a claim of false representation or of ensuring compliance with the workers' compensation statutes and rules. (Added 2011, No. 50, § 4.) Vermont Department of Labor Form 10 (rev 9/11) Workers’ Compensation State File # PO Box 488 Ins. Co. File # Montpelier, VT 05601-0488 Date of Injury (802) 828-2286

www.labor.vermont.gov

Certificate of Dependency and Concurrent Employment

Employee:

Employer:

TO THE EMPLOYEE: This form MUST be completed in every workers’ compensation case in which an injured worker has lost time from work as the result of a work-related injury. The form must be completed even when the injured worker has no dependents. The information must be supplied and the form signed by the injured worker. This information is required to determine the employee’s right to additional weekly compensation of $10.00 for each dependent child under the age of twenty-one (21) years.

List below your dependent child(ren) up to 21 years old that have not already been declared by your spouse on his/her current workers’ compensation claim.**

Name of Dependent Date of Birth Relationship

Concurrent employment: If you were working for more than one employer on the date of injury indicated above please provide the following information.**

Name of Employer Employer’s Address Employer’s Phone Number Date of Hire

I hereby certify that the above is a true, complete and accurate statement of my dependents and concurrent employment.

Employee Signature Date Signed Address

Telephone Number City/State/Zip

**Attach additional sheets if necessary and return this to the insurance carrier DOL FORM 25 (Rev. 9/13) STATE OF VERMONT Department of Labor State File No. Workers’ Compensation Ins. Co. File No. 5 Green Mountain Drive, PO Box 488 Date of Injury Montpelier, VT 05601-0488 Fed. ID No.

WAGE STATEMENT – For Injuries on or after July 1, 2008

Employee:

Employer:

Wage Rate: $ per Number of Days Hired Number of Hours to Work: Hired to Work:

Week Ending Number Gross Wages Extras (as in 6 or 7) INSTRUCTIONS: of Please indicate what the Read Carefully Month Day Year Hours extra is, for example, or Days $1000.00 bonus 1. Enter GROSS wages of employee Worked for 26 weeks before date of accident 1 (NOT take home pay). 2. Do not include the week of the 2 accident. 3 3. Leave blank those weeks where the 4 employee had excused absences for which he/she was not paid for more 5 than ½ of a work week. 6 4. Leave blank those weeks where you had reduced operations or a shutdown 7 of the plant for which he/she was not 8 paid for more than ½ of a work week. 9 5. Do not enter those weeks where an employee was on vacation for more 10 than ½ of a work week. 11 6. If room, board, lodging or other “extras” (electricity, fuel, etc.) are 12 provided in addition to monetary 13 wages, break it down into a weekly 14 value, include and describe this income in column marked “EXTRAS.” 15 This includes tips if not included in 16 gross wages. 17 7. Include any bonuses and commissions paid to the employee in 18 addition to wages in the column 19 marked “EXTRAS.” 8. Enter the dates when your normal 20 work week ends (not the date a check is 21 given to the employee) and the number 22 of hours or days worked.

23 24 25 26

When did the employee begin losing time? Was the employee paid in full for the day of the accident?

Are employee’s wages subject to any child support withholding order? Yes No If yes, in what amount? $ per

Day of the week the check will be mailed to the claimant or deposited in the claimant’s account

This is a correct statement of the employee’s earnings as taken from the employer’s payroll records.

By: Position Title: Signature of Preparer

Print Name: Date:

Mail to: DOL Form 8 Rev. 9/11 Insurance Carrier Name: A.I.M. Mutual Insurance Companies State File No. Insurance Carrier Address: 54 Third Avenue, P.O. Box 4070 Ins. Co. File No. Insurance Carrier City/State/Zip: Burlington, MA 01803-0970 Date of Injury Insurance Carrier Adjuster:

NOTICE OF INTENT TO CHANGE HEALTH CARE PROVIDER

Note: An employee has the right to change health care providers from the one suggested or assigned to them by their employer, regardless of the reasons for the change, at any time during the course of treatment after the first appointment.

Employee Name: Address: City/State/Zip: Home Telephone: E-mail Address: Work Telephone:

I am changing my medical care for my work-related injury from the first treating health care provider selected by my employer to the provider of my choice.

FIRST TREATING PROVIDER NEW TREATING PROVIDER

Name: Name: Address: Address: City/State/Zip: City/State/Zip:

I am changing because: I would rather treat with my family health care provider. I believe another health care provider is better able to treat my symptoms. I have previously treated with another health care provider. Other (please describe below):

This notice should be presented to the employer/insurance carrier prior to changing health care providers to fulfill the requirements of Vermont law, [21 V.S.A. § 640(b)]. Notice is not required for subsequent changes of provider after the first change of provider form is submitted.

Print Employee Name

Employee Signature Date

Workers’ Compensation Division, PO Box 488, Montpelier, VT 05601-0488 Employer’s guide to the Best Doctors Occupational Health Institute

What you need to know

The treatment of work-related injuries requires physicians who are not only expert in the care of musculo-skeletal injuries, but they also must understand the importance of helping your employees return to rewarding productive lives. The quality of care your employee receives in the first few weeks of injury will have a tremendous influence on whether he or she is able to return to work safely or suffers from a prolonged disability.

About the Best Doctors Occupational Health Institute of Northern New England (BDOHI-NNE)

BDOHI-NNE is a medical community of physicians and allied health professionals who have been selected by their peers for clinical excellence and an understanding of productivity issues so important to work-related injuries. The mission of BDOHI-NNE is to help your injured employees get the best care possible and to assure a safe recovery and a prompt return to productivity.

How to help your employees benefit from the Best Doctors Occupational Health Institute-NNE

• Identify and encourage the use of the most convenient BDOHI-NNE Primary Occupational Health Center for your employees. For emergent situations dial 911.

• Display the A.I.M. Mutual/BDOHI-NNE poster with the name, address and phone number of the most convenient Primary Occupational Health Center in a public viewing area. The poster is available at www.aimmutual.com in our Forms Library.

• In the event of a serious injury please call us immediately at 1.866.270.3354. Please report all other injuries through our website www.aimmutual.com. Click on Report a Claim.

• If your employee requires specialty care he or she can call the assigned A.I.M. Mutual claim handler at 1.800.876.2765 for several recommendations.

Remember…

Your employees are your most important resource. Our mission is to help you, help them when injured on the job.

A.I.M. Mutual Insurance Cos. / 54 Third Avenue / P.O. Box 4070 / 800-876-2765 / Fax: 781.270.5599 Best Doctors® and the Star-in-cross logo are trademarks of Best Doctors, Inc, in the United States and other countries Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE VERMONT

BARRE RUTLAND

Concentra Medical Center* ClearChoice MD Urgent Care* 654 Granger Road 173 South Main Street Barre, VT 05641 Rutland, VT 05701 Tel: (802) 223-7499 / Fax: (802) 223-4120 Tel: (802) 772-4165 / Fax: (802) 855-8489

Occupational Health Partners, LLC BENNINGTON 9 Commons Street Rutland, VT 05701 Southwestern VT Medical Center Tel: (802) 747-1753 / Fax: (802) 747-4061 Occupational Health 120 Hospital Drive Bennington, VT 05201 SOUTH BURLINGTON Tel: (802) 447-5317 Champlain Medical Urgent Care 150 Kennedy Drive BERLIN South Burlington, VT 05403 Tel: (802) 448-9370 / Fax: (802) 448-1414 Central Vermont Medical Center 244 Granger Road ClearChoice MD Urgent Care* Berlin, VT 05602 1200 Williston Road Tel: (802) 225-3942 / Fax: (802) 225-3959 South Burlington, VT 05403 Tel: (802) 448-8205 / Fax: (802) 448-8206 ClearChoice MD Urgent Care* 798 US RT 302 Concentra Medical Center* Berlin, VT 05641 7 Fayette Drive Tel: (802) 744-0138 / Fax: (802) 622-0836 South Burlington, VT 05403 Tel: (802) 658-5756 / Fax: (802) 865-0042

BRATTLEBORO ST. ALBANS Brattleboro Memorial Hospital Occupational Health Services ClearChoice MD Urgent Care* 17 Belmont Avenue 178 Swanton Road Dunham Building St. Albans, VT 05478 Brattleboro, VT 05301 Tel: (802) 528-5100 / Fax: (802) 528-5793 Tel: (802) 257-8235 Northwestern Occupational Health ClearChoice MD Urgent Care* 260 Crest Road, Suite 204 1154 Putney Road St. Albans, VT 05478 Brattleboro, VT 05301 Tel: (802) 524-1223 / Fax: (802) 524-1095 Tel: (802) 490-2100 / Fax: (802) 579-1280

ST. JOHNSBURY ESSEX JUNCTION Northeastern Vermont Regional Hospital Champlain Sports Medicine Occupational Medicine Services 67 Lincoln Street 1290 Hospital Drive Essex Junction, VT 05452 St. Johnsbury, VT 05819 Tel: (802) 878-1003 Tel: (802) 748-4393

*Affiliation pending

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. Aug 2016

Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE VERMONT

NEW HAMPSHIRE

BELMONT

ClearChoice MD Urgent Care* 96 Daniel Webster Highway Belmont, VT 03220 Tel: (603) 267-0656 / Fax: (603) 267-0657

LEBANON

ClearChoice MD Urgent Care* 410 Miracle Mile Lebanon, NH 03756 Tel: (603) 276-3260 / Fax: (603) 727-4044

Dartmouth Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03756 Tel: (603) 653-3850 / Fax: (603) 650-0928

Occupational Health at Alice Peck Day 125 Mascoma Street Lebanon, NH 03766 Tel: (603) 448-7459 / Fax: (603) 448-7469

PORTSMOUTH

ClearChoice MD Urgent Care* 750 Lafayette Road Portsmouth, NH 03801 Tel: (603) 427-8539 / Fax: (603) 294-0976

*Affiliation pending

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. Aug 2016 Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE

AMESBURY BOSTON Anna Jacques Hospital Occupational Health Working Well Clinic @ Boston Medical Center 24 Morrill Place, Amesbury, MA 01913 Doctors Office Building Tel: (978) 834-8190 / Fax: (978) 834-8188 720 Harrison Avenue, Suite 703, Boston, MA 02118 Contact: Pat Powers, Manager Tel: (617) 638-8400 / Fax: (617) 638-8406 For appointments: Wendy Schlessinger, front desk Contact: Amalia Gonzalez, Practice Mgr (617) 638-8821 For appointments: (617) 638-8400

AMHERST New England Baptist Occupational Health 125 Parker Hill Ave., Boston, MA 02120 AEIOU Occupational Health & Urgent Care Tel: (617) 754-5620 / Fax: (617) 754-6453 170 University Dr., Suite 102, Amherst, MA 01002 Contact: Kathy Lehan, NCM, (617) 754-6786 Tel: (413) 461-3530 / Fax: (413) 461-3532 For appointments: (617) 754-5246 Contact: Lisa Rhoades, Practice Manager For appointments: (413) 461-3530 OccMed Consulting & Injury Care, LLC 10 Hawthorne Place, Suite 114, Boston, MA 02114 ATTLEBORO Tel: (617) 314-2018 / Fax: (877) 529-0181 Contact: Emily Burress (617) 314-2018 Sturdy Occupational Health For appointments: (617) 314-2018 211 Park St. 2nd floor, Attleboro, MA 02703 Tel: (508) 236-7500 / Fax: (508) 222-0796 BROCKTON Contact: Sue Higgins, Practice Manager For appointments: (508) 236-7500 Tristan Medical Express Care 1340 Belmont St., Brockton, MA 02301 Tel: (508) 583-1400 / Fax: (508) 583-3400 AUBURN Contact: Donna Chase, (508) 824-0243 x100 For appointments: (508) 583-1400 Reliant Medical Occupational Health 35 Millbury St., Auburn, MA 01501 Tel: (508) 832-9621 / Fax: (508) 832-9025 CAMBRIDGE Contact: MaryBeth Colarusso,(508) 852-0600 x51352 For appointments: (508) 853-2854 CareWell Urgent Care 1400 Cambridge St. (at Inman Square) Cambridge, MA 02139 AYER Tel: (617) 714-4534 / Fax: (617) 714-4962 Nashoba Valley Occupational Health Contact: Courtney Kelliehan, Practice Manager 200 Groton Road, Ayer, MA 01432 Tel: (978) 784-9328 / Fax: (978) 784-9666 CareWell Urgent Care Contact: Marcia Estes, (978) 784-9633 601 Concord Ave., Cambridge, MA 02138 For appointments: (978) 784-9328 option #5 Tel: (857) 706-1107 / Fax: (857) 706-1108 Contact: Courtney Kelliehan, Practice Manager

BEVERLY Mount Auburn Hospital Occupational Health 725 Concord Ave, Suite 5100, Cambridge, MA 02138 Quadrant Health Strategies Tel: (617) 354-0546 / Fax: (617) 868-4497 500 Cummings Center, Suite 4350 Contact: Bob Benoit, (617) 499-6722 Beverly, MA 01915 For appointments: (617) 354-0546 Tel: (978) 532-2428 / Fax: (978) 532-0616 Contact: Diane Talbot, (978) 998-3173 For appointments: (978) 532-2428

BILLERICA CareWell Urgent Care 510 Boston Road, Billerica, MA 01821 Tel: (978) 362-2443 / Fax: (978) 362-8799 Contact: Kim Brown, Practice Manager

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. (BDOHI Primary Occ Health-BDOHI-10/17) 1 Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE

DEDHAM FITCHBURG

Davis Occupational Health CareWell Urgent Care 200 Providence Highway, Suite 202-203 **COMING FALL 2016 ** Dedham, MA 02026 380 John Fitch Highway, Fitchburg, MA 01420 Tel: (781) 255-0778 / Fax: (781) 255-0857 Contact: Dr. Agustino Iarrobino, MD/Practice Manager For appointments: (781) 255-0778 FRAMINGHAM *Insured required to have an account* CareWell Urgent Care **Employer must call ahead, walk-ins not accepted** 50 Worcester Road (Route 9), Unit 3 ***Not accepting new patients/accounts*** Framingham, MA 01702 Tel: (508) 861-7375 / Fax: (508) 861-3952 Contact: Robert Hubbard, Practice Manager New England Baptist Outpatient Care Center 40 Allied Dr., Dedham, MA 02026 Tel: (617) 754-5620 GREENFIELD Contact: Kathy Lehan, NCM, (617) 754-6786 AEIOU Occupational Health and Urgent Care For appointments: (617) 754-5246 489 Bernardston Rd, Greenfield, MA 01301 Tel: (413) 773-1394 / Fax: (413) 773-1398 EAST LONGMEADOW Contact: Lisa Rhoades, Practice Manager For appointments: (413) 773-1394 Occu-Health 200 North Main St., Suite 5 Baystate Franklin Medical Ctr Workplace Health East Longmeadow, MA 01028 157 High St., Greenfield, MA 01301 Tel: (413) 525-6003 / Fax: (413) 525-9009 Tel: (413) 773-2182 / Fax: (413) 773-2165 Contact: Chris Parent, Owner Contact: Cindy Johnson, Practice Manager For appointments: (413) 525-6003 For appointments: (413) 773-2458 (for reception)

HADLEY FAIRHAVEN Occu-Health Southcoast Health System Urgent Care 106 Russell St. Hadley, MA 01035 208 Mill Rd, Fairhaven, MA 02719 Tel: (413) 584-6104 / Fax: (413) 586-6513 Tel: (508) 973-2432 / Fax: (508) 973-2435 Contact: Chris Parent, Owner Contact: Filomena Pimentel, (508) 973-7195 For appointments: (413) 584-6104

Tristan Medical Express Care (Urgent Care) HARWICH 210 Washington St., Fairhaven, MA 02719 Tel: (508) 992-5546 / Fax: (508) 990-0391 Cape & Islands Occupational Medicine Contact: Donna Chase, (508) 824-0243 x100 Fontaine Medical Center 525 Long Pond Drive, Harwich, MA 02645 FALL RIVER Tel: (508) 771-5770 / Fax: (508) 771-5774 Contact: Tom Martin Southcoast Occupational Health @ Charlton Hospital For appointments: (508) 771-5770 (Mon appts only) 534 Prospect St., Fall River, MA 02720 Tel: (508) 973-7044 / Fax: (508) 973-7098 Fontaine Outpatient Center - Urgent Care (Walk-in) Contact: Filomena Pimentel, (508) 973-7195 525 Long Pond Dr., Harwich, MA 02645 For appointments: (508) 973-7044 Tel: (508) 432-4100 / Fax: (508) 432-8951 Contact: Joe Camelio, Manager Trumed Inc. 528 Newton St., Fall River, MA 02721 HOLYOKE Tel: (508) 675-1522 / Fax: (508) 676-5647 Contact: Lisa Souza, Practice Manager Work Connection at Holyoke Hospital For appointments: (508) 675-1522 575 Beech St., Holyoke, MA 01040 Tel: (413) 534-2546 / Fax: (413) 534-2663 Contact: Christine Machos, Manager For appointments: (413) 534-2576

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. (BDOHI Primary Occ Health-BDOHI-10/17) 2

Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE

HYANNIS MILFORD

Cape & Islands Occupational Medicine TeamWork Occupational Health - Milford Hospital 130 North St., Lower Level, Hyannis, MA 02601 115 Water St., 2nd Floor, Milford, MA 01757 Tel: (508) 771-5770 / Fax: (508) 771-5774 Tel: (508) 422-2761 / Fax: (508) 634-8732 Contact: Tom Martin Contact: Melissa Paquette For appointments: (508) 771-5770 For appointments: (508) 422-2761

Mid Cape Medical Center at Tristan Medical MILTON 489 Bearses Way, Hyannis, MA 02601 Beth Israel Deaconess Hospital- Milton Occ Health Tel: (508) 771-4092 / Fax: (508) 771-9466 199 Reedsdale Rd., 2nd Floor, Brooks Wing Contact: Nicole Dacunha, Operations Manager Milton, MA 02186 For appointments: (508) 771-4092 Tel: (617) 313-1681 / Fax: (617) 313-1566 Contact: Jeanne Donahue, Clinical Supv (617) 313-1684 LAWRENCE For appointments: (617) 313-1681

Work Health at Lawrence Hospital NEEDHAM Marston Medical Center 25 Marston St, Suite 204, Lawrence, MA 01841 Beth Israel Deaconess Hospital - Needham Tel: (978) 683-4000 / Fax: (978) 946-8296 Occupational Health Contact: Janet Sheehan, Manager 148 Chestnut St., Needham, MA 02492 For Appointments: (978) 683-4000 X2010 Tel: (781) 453-3041 / Fax: (781) 453-3645 Contact: Karen Foulkrod, Administrative Director LEOMINSTER For appointments: (781) 453-3041

Take Charge Occupational Health CareWell Urgent Care 510 North Main St., Leominster, MA 01453 922 Highland Ave, Needham, MA 02494 Tel: (978) 248-8880 / Fax: (978) 534-3875 Tel: (781) 400-1383 / Fax: (781) 400-5914 Contact: Kathleen Kusmarik, Practice Manager Contact: Mike Dotolo, Practice Manager For appointments: (978) 248-8880 NEW BEDFORD

LEXINGTON Southcoast Occupational Health at St Luke’s Hospital

CareWell Urgent Care 101 Page St., New Bedford, MA 02740 58 Bedford St. , Lexington, MA 02420 Tel: (508) 973-5469 / Fax: (508) 973-5472 Tel: (781) 538-4526 / Fax: (781) 538-4531 Contact: Filomena Pimentel, (508) 973-7195 Contact: Mike Dotolo, Practice Manager For appointments: (508) 973-5469

Tristan Medical Occupational Health & Primary Care LOWELL 140 Nauset St., New Bedford, MA 02746 Tel: (508) 990-8260 / Fax: (508) 990-0347 Lowell General Hospital Urgent Care Center Contact: Donna Chase (508) 824-0243 x100 **For Initial Treatment/Urgent Care Only** 1230 Bridge St., Lowell, MA 01850 NORTH ATTLEBORO Tel: (978) 459-2273 Contact: Elizabeth Cunningham, Practice Manager Tristan Medical North Attleboro Care Center 465 S. Washington St., North Attleboro, MA 02760 MARLBOROUGH Tel: (508) 316-0725 / Fax: (508) 316-1685 Contact: Cheryl Quinn, (508) 316-0725 CareWell Urgent Care For appointments: (508) 316-0725 757 Boston Post Road East, Marlborough, MA 01752 Tel: (508) 630-8989 / Fax: (508) 8981 NORTH CHELMSFORD

MedWorks Occupational Health Lowell General Hospital Occupational Medicine UMass Memorial at Marlborough Hospital 10 Research Place, Suite 200, 157 Union St., Marlborough, MA 01752 North Chelmsford, MA 01863 Tel: (508) 486-5711 / Fax: (508) 229-1201 Tel: (978) 458-6868 / Fax: (978) 458-3735 Contact: Annette Casco, Practice Mgr (508) 486-5901 Contact: Barbara Kay, Practice Manager For appointments: (508) 486-5711 For appointments: (978) 458-6868

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. (BDOHI Primary Occ Health-BDOHI-10/17) 3

Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE

NORTH EASTON SANDWICH Care Central Urgent Care Cape & Islands Occupational Medicine 382 Depot Street, North Easton, MA 02356 18 Route 6A, Building 2, Sandwich, MA 02563 Tel: (508) 297-1665 Tel: (508) 771-5770 / Fax: (508) 771-5774 Contact: Dr. Renee Wilson, Owner Contact: Tom Martin For appointments: (508) 771-5770 (Appts vary by week) NORTHBOROUGH SEEKONK CareWell Urgent Care 333 Southwest Cutoff. Unit 202 CareWell Urgent Care Northborough, MA 01532 **COMING SOON ** Tel: (508) 466-8677 / Fax: (508) 466-8678 1088 Fall River Ave., Seekonk, MA 02771 Contact: Alissa Ashley-High, Practice Manager SHREWSBURY NORTON Reliant Medical Occupational Health Tristan Medical Occupational Health & Primary Care 222 Boston Turnpike, Shrewsbury, MA 01545 184 West Main St., Norton, MA 02766 Tel: (508) 853-2854 / Fax: (508) 853-4354 Tel: (508) 824-0243 / Fax: (508) 828-1810 For appointments: (508) 853-2854 Contact: Donna Chase, (508) 824-0243 x100 For appointments: (508) 824-0243 SOMERVILLE Cambridge Health Alliance Occupational Health NORWELL Assembly Square Mall st CareWell Urgent Care 5 Middlesex Ave, 1 Floor, Somerville, MA 02145 42 Washington St., Norwell, MA 02061 Tel: (617) 591-4660 / Fax: (617) 591-4693 Tel: (781) 421-3503 / Fax: (781) 421-3512 Contact: Bill Greene, Business Ops Manager, (617) 591-4673 Contact: Susan Courage, Practice Manager For appointments: (617) 591-4660

PEABODY CareWell Urgent Care 349 Broadway, Somerville, MA 02145 CareWell Urgent Care Tel: (617) 996-6987 / Fax: (617) 996-6989 229 Andover St. (Rte 114), Peabody, MA 01960 Contact: Tahari James, Practice Manager Tel: (978) 826-5950 / Fax: (978) 826-5951 Contact: Ann Keating, Practice Mgr, (978) 826-5953 SOUTH DENNIS CareWell Urgent Care PITTSFIELD Patriot Square, 484 Route 134, S. Dennis, MA 02660 Berkshire Medical Center Occupational Health Tel: (508) 694-7901 / Fax: (508) 694-7898 610 North St., Pittsfield, MA 01201 Contact: Sarah McLain, Practice Manager Tel: (413) 447-2684 / Fax: (413) 447-2805 Contact: John McLean, Client Serv (413) 447-2029 SOUTHBOROUGH For appointments: (413) 447-2684 Reliant Medical Occupational Health 28 Newton St., Southborough, MA 01772 PLYMOUTH Tel: (508) 460-3228 / Fax: (508) 486-4404 Contact: Mary Beth Colarusso, (508) 852-0600 x51352 Beth Israel Deaconess Hospital – Plymouth For appointments: (508) 853-2854 Jordan on the Job Occupational Health 45 Resnick Rd., Suite 201, Plymouth, MA 02360 Tel: (508) 732-0401 / Fax: (508) 732-0354 SOUTHBRIDGE Contact: Ted Harrington (508) 732-0127 CompreCare Occupational Health For appointments: (508) 732-0401 Harrington Hospital 32 Oakes Ave., 1st Floor, Southbridge, MA 01550 RAYNHAM Tel: (508) 765-3093 / Fax: (508) 765-3047 Contact: Arlene Smith, Practice Manager Tristan Medical Urgent Care Center For appointments: (508) 765-3093 675 Paramount Dr., Suite 203, Raynham, MA 02767 Tel: (508) 880-0012 / Fax: (508) 880-0032 Contact: Donna Chase, (508) 824-0243 x100

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. (BDOHI Primary Occ Health-BDOHI-10/17) 4 Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE

SPRINGFIELD WOBURN Pioneer Valley Occupational Medicine at Family Care Medical Center All One Health 1515 Allen St., Springfield, MA 01118 600 West Cummings Park, Suite 3400, Tel: (413) 783-9114 / Fax: (413) 782-0960 Woburn, MA 01801 Contact: Pat Gallant, Practice Manager Tel: (781) 935-8581 / Fax: (781) 938-4678 For appointments: (413) 783-9114 Contact:, Regional Ops Manager For appointments: (508) 655-9766 WorkWise at Mercy Hospital Weldon Center at 233 Carew St., Springfield, MA 01104 Tel: (413) 748-6869 / Fax: (413) 748-6877 Contact: Barbara Haswell, Clinic Manager, opt #5 For appointments: (413) 748-6869 opt #2 WORCESTER

CareWell Urgent Care STOUGHTON 348 Greenwood St., Worcester, MA 01607 Care Central Urgent Care Tel: (774) 420-2103 / Fax: (774) 420-2104 286 Washington St., Stoughton, MA 02072 Contact: Jay Paquette, Practice Manager Tel: (781) 341-2800 / Fax: (781) 341-2828 Contact: Dr. Renee Wilson, Owner CareWell Urgent Care 500 Lincoln St., Worcester, MA 01605 Tel: (774) 420-2111 / Fax: (774) 420-2112 TEWKSBURY Contact: Nicole Troy, Practice Manager

CareWell Urgent Care Webster Square Medical 345 Main St., Tewksbury, MA 01876 255 Park Ave., Suite 400, Worcester, MA 01609 Tel: (978) 851-4683 / Fax: (978) 710-5054 Tel: (508) 755-9776 / Fax: (508) 831-7861 Contact: Mike Chamberlain, Practice Manager Contact: Judy Gedman, x228 For appointments: (508) 755-9776 opt #1 WALTHAM

Newton-Wellesley Urgent Care Center – Waltham Children’s Hospital Building 9 Hope Ave. Waltham, MA 02453 RHODE ISLAND Tel: (617) 243-5590 / Fax: (617) 243-6126 Contact: Joan Millian, Site Manager (617) 243-5594 NORTH SMITHFIELD

WAREHAM Landmark Medical Occupational Health 116 Eddie Dowling Highway, N. Smithfield, RI 02896 Southcoast Health Systems Urgent Care Tel: (401) 769-5400 / Fax: (401) 767-1739 Wareham Crossing 2421 Cranberry Highway, Wareham, MA 02571 PAWTUCKET Tel: (508) 273-1810 Contact: Filomena Pimentel, (508) 973-7195 Armistice Urgent Care and Occupational Health 209 Armistice Blvd., Pawtucket, RI 02860 WILMINGTON Tel: (401) 725-4100 / Fax: (401) 728-5010

Concentra Urgent Care & Occupational Medical Ctr WARWICK 66 B Concord St., Wilmington, MA 01887 Tel: (978) 657-3826 / Fax: (978) 657-6155 CareWell Urgent Care Contact: Anita Nagle, Asst Ops Manager 535 Centerville Rd., Suite 102, Warwick, RI 02886 For appointments: (978) 657-3826 Tel: (401) 773-7220 / Fax: (401) 773-7221 Contact: Mike Lord, Practice Manager

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. (BDOHI Primary Occ Health-BDOHI-10/17) 5

Primary Occupational Health Centers BDOHI Credentialed Affiliates in BLUE

NEW HAMPSHIRE LITTLETON

BERLIN Littleton Hospital Occupational Health 600 St. Johnsbury Rd., Littleton, NH 03561 Coos County Health Services Tel: (603) 444-9294 / Fax: (603) 444-9025 133 Pleasant St., Berlin, NH 03570

Tel: (603) 752-2040 / Fax: (603) 752-7797

MANCHESTER

CONCORD Bedford Occupational & Acute Care/ExpressMED 1 Highlander Way, Manchester, NH 03103 Merrimack Valley Occupational Health Tel: (603) 625-2622 / Fax: (603) 626-1816 171 Pleasant St., Concord, NH 03301 Tel: (603) 228-3500 / Fax: (603) 228-3503 NASHUA

CONWAY St. Joseph Business & Health Saco Medical Group 166 Kinsley Street, Suite 201, Nashua, NH 03061-2013 7 Greenwood Ave., Conway, NH 03818 Tel: (603) 595-7371 Tel: (603) 447-3500 / Fax: (603) 447-5568 NEWPORT

EXETER Newport Health Center 11 John Stark Highway, Newport, NH 03773 Center for Occupational and Employee Health Tel: (603) 863-4100 / Fax: (603) 863-3585 6 Hampton Rd, Exeter, NH 03833 Tel: (603)-580-6635/ Fax: (603)-580-6579 PORTSMOUTH Contact: Rose Phillips Practice Manager (603) 580- 7323 Access Sports Medicine and Orthopedics For appointments: Alena Ciriello (603)-580-6635 x1 875 Greenland Rd., Portsmouth, NH 03801 Tel: (603) 431-3575 / Fax: (603) 778-9680 The Bakie Ctr at Access Occupational Medicine Access Health Building Occupational Health Services of Portsmouth Hospital 1 Hampton Rd, Exeter, NH 03833 Pease International Tradeport Tel: (603) 775-7575 Ext 3001 / Fax: (603) 778-9680 25 New Hampshire Avenue, Suite 105 Portsmouth, NH 03801 Tel: (603) 430-9675 / Fax: (603) 334-6088 HAMPTON SALEM Occupational Health Services of Portsmouth Regional Hospital Bedford Occupational & Acute Care/ExpresMED at Salem 55 High St., Suite 103, Hampton, NH 03842 159 North Broadway, Salem, NH 03079 Tel: (603) 929-7571 / Fax: (603) 929-4428 Tel: (603) 898-0961 / Fax: (603) 898-0964

KEENE SOMERSWORTH

Cheshire Medical Center Occupational Health SeaCoast Redicare 580 Court St., Keene, NH 03431 396 High Street, #1, Somersworth, NH 03878 Tel: (603) 354-6585 / Fax: (603) 354-6584 Tel: (603) 692-6066 / Fax: (603) 692-4815

LEBANON TILTON Dartmouth Hitchcock Medical Center Occupational Health Center Merrimack Valley Occupational Health One Medical Center Dr., Lebanon, NH 03756 614 Laconia Road, Rte 3, Tilton, NH 03276 Tel: (603) 653-3850 / Fax: (603) 650-0928 Tel: (603) 717-7020 / Fax: (603) 717-7011

Occupational Health at Alice Peck Day 125 Mascoma St., Lebanon, NH 03766 Tel: (603) 448-7459 / Fax: (603) 448-7469

Best Doctors® and the star-in-cross logo are trademarks of Best Doctors, Inc. in the United States and other countries. (BDOHI Primary Occ Health-BDOHI-10/17) 6

TM A.I.M. Works

Express Scripts Pharmacy Program for Injured Workers

As part of our workers compensation medical management services, we ask injured workers to use a pharmacy program through Express Scripts, Inc. (ESI). ESI is a pharmacy benefit management company that is uniquely set up to provide prescription medications for work-related injuries.

Injured employees will be notified by mail about the pharmacy program and how it works shortly after their claim has been approved. They will also receive a prescription identification card; the card is valid only for prescriptions related to the specific, approved work injury. Injured employees will be asked to use an Express Scripts affiliated pharmacy to fill their injury-related prescriptions.

Express Scripts also offers a mail service program, which employees will find convenient for refilling maintenance (long-term) prescription medications. I’m sure you are familiar with the cost benefits of a mail order prescription program, and we ask that you encourage injured workers to take advantage of this service. Most prescriptions are filled within 48 hours of receipt and mailed directly to the injured employee’s home. Injured employees can sign up for the mail service program through ESI by phone or by mail.

Additional benefits of the program include 24-hour access to a registered pharmacist via a toll-free number and an extensive network of pharmacies to choose from. Express Scripts offers significant savings of up to 35% over fee schedules and usual and customary charges, and the program will expedite claim processing and payment. Injured employees will incur no out-of-pocket expenses.

A list of Express Scripts affiliated pharmacies in the Northeast is included in this claim kit. Injured workers will receive a condensed list of chain pharmacies in the network on their prescription card information sheet. If their pharmacy is not on the list, they can call Express Scripts at 1-800-945-5951 to verify if their pharmacy is part of the network. While injured employees may use a non-affiliated pharmacy, we strongly recommend they use a pharmacy within the Express Scripts network and the mail order service to realize the program benefits.

Please call the Express Scripts Workers Compensation Service Center at 1-800-945-5951 with any questions you may have. The toll free service is available 24 hours a day, seven days a week. As always, thank you for working with us to enhance our claim service.

Sincerely,

Laura Parsons, WCLA, FCLA Director of Claim

To the Injured Worker:

On your first visit, please give this notice to any pharmacy listed on the back side to speed processing your approved workers’ compensation prescriptions (based on the guidelines established by your employer). Questions or need assistance locating a participating AIM WORKS retail network pharmacy? Call the Express Scripts

Patient Care Contact Center at 800.945.5951.

Atencion Trabajador Lesionado: Este formulario de identificación para servicios temporales de prescripción de recetas por Thank you for using a participating retail network compensación del trabajador DEBERÁ SER pharmacy. Even though there is no direct cost to you, PRESENTADO a su farmacéutico al surtir su(s) it’s important that we all do our part to help control the receta(s) inicial(es). rising cost of healthcare.

Si tiene cualquier duda o necesita localizar una Please see other side for a list of participating retail farmacia participante, por favor contacte al área de network pharmacies.

Atención a Clientes de Express Scripts, en el teléfono

800.945.5951.

To the Supervisor: Please fill in the To the Pharmacist: information requested for the injured worker. Express Scripts administers this workers’ compensation prescription program. Please follow the steps below to submit a claim. Standard claim limitations include quantity exceeding 150 pills or a day supply exceeding 14 days. This form is valid for up to 30 days from DOI. Limitations may vary. For assistance, call Express Scripts at 888.786.9640.

Pharmacy Processing Steps

Step 1: Enter bin number 003858 Step 2: Enter processor control A4 Step 3: Enter the group number as it appears above

Step 4: Enter the injured worker’s nine-digit ID number Step 5: Enter the injured worker’s first and last name Step 6: Enter the injured worker’s date of injury

(enter in PA field in the format YYYYMMDD)

A & P Drug Emporium Major Value Schnucks Acme Pharmacy Drug Fair Marsh Drugs Scolari’s Albertson’s Drug Town Medic Discount Sedano Albertson’s/Acme Drug World Medicap Shaw’s Albertson’s/Osco Eckerd Medistat Shop ‘N Save Albertson’s/Sav-On Econofoods Meijer Shopko Amerisource EPIC Pharmacy Minyard ShopRite Bergen Network NCS HealthCare Snyder Anchor Pharmacies FamilyMeds Neighborcare Stop & Shop Arrow Farm Fresh Network Sun Mart Aurora Farmer Jack Pharmaceuticals Super Fresh Bartell Drugs Food City Northeast Super Rx Bigg’s Food Lion Pharmacy Services Target Bi-Lo Fred’s Osco Texas Oncology Bi-Mart Gemmel P & C Food Srvs BJ’s Wholesale Giant Markets The Pharm Club Giant Eagle Pamida Thrifty White Brooks Giant Foods Park Nicollet Times Brookshire Brothers Hannaford Pathmark Tom Thumb Brookshire Grocery Harris Teeter Pavilions Tops Bruno H-E-B Price Chopper Ukrop’s Carrs Hi-School Publix United Drugs Cash Wise Pharmacy Quality Markets United Coborn’s Hy-Vee Raley’s Supermarkets Costco Jewel/Osco Randalls Vons Cub Kash n Karry Rite Aid Waldbaums CVS Keltsch Rosauers Walgreens D&W Kerr Rx Express Wal-Mart Dahl’s Kmart RXD Wegmans Dierbergs Knight Drugs Safeway Weis Discount Drugmart Kroger Sam’s Club Winn Dixie Doc’s Drugs LeaderNet (PSAO) Sav-On Dominicks Longs Drug Store Save Mart

NOTE: This form is not valid in the state of Ohio. For all other states, liability of a workers’ compensation claim is not assumed based on the dispensing of medication(s) to a patient.

Express Scripts Network

Vermont For additional locations by state, please refer to online listings at aimmutual.com/forms-library/index.html EXPRESS SCRIPTS (WORKERS COMPENSATION PHARMACIES)

BARRE LUDLOW

PRICE CHOPPER BRATTLEBORO RITE AID PHARMACY RITE AID VERMONT PHARMACY 158 CHERRY ST MAIN ST 214 NORTHSIDE DR BRATTLEBORO BURLINGTON, VT 05401 ENOSBURG FALLS, VT 05450 BENNINGTON, VT 05201 PHARMACY (802)862-1562 (802)933-7756 BARRE (802)447-9951 413 CANAL ST BRATTLEBORO, VT 05301 VERMONT FAMILY ESSEX JUNCTION HANNAFORD FOOD AND RITE AID (802)254-7777 PHARMACY DRUG 194 NORTH ST 1219 NORTH AVE CVS 456 S BARRE RD RITE AID BENNINGTON, VT 05201 BURLINGTON, VT 05408 7 ESSEX WAY BARRE, VT 05641 896 PUTNEY RD UNIT 6 (802)442-2240 (802)658-9664 ESSEX JUNCTION, VT 05452 (802)479-0432 BRATTLEBORO, VT 05301 THE PHARMACY (802)257-5592 WALGREENS (802)879-7438 HARRY'S DISCOUNT 205 NORTH ST 514 FARRELL ST PHARMACY RITE AID HANNAFORD FOOD AND BENNINGTON, VT 05201 BURLINGTON, VT 05401 DRUG 921 US ROUTE 302 STE 1 499 CANAL ST (802)442-5602 (802)651-0597 21A ESSEX WAY BARRE, VT 05641 BRATTLEBORO, VT 05301 ESSEX JUNCTION, VT 05452 (802)479-2521 WAL-MART (802)257-4204 210 NORTHSIDE DR CAMBRIDGE (802)878-0119 KINNEY DRUGS THE HOTEL PHARMACY BENNINGTON, VT 05201 KINNEY DRUGS KINNEY DRUGS 800 US ROUTE 302 20 ELLIOT ST STE 1 (802)442-6822 155 S MAIN ST 82 PEARL ST BARRE, VT 05641 BRATTLEBORO, VT 05301 CAMBRIDGE, VT 05444 ESSEX JUNCTION, VT 05452 (802)476-6659 (802)254-2303 BERLIN (802)644-8811 (802)878-5351 MEDICINE SHOPPE WALGREENS OSCO PHARMACY PRICE CHOPPER PHARMACY 467 CANAL ST 160 PAINE TPKE N COLCHESTER PHARMACY 20 S MAIN ST BRATTLEBORO, VT 05301 BERLIN, VT 05602 90 CENTER RD BARRE, VT 05641 (802)254-5633 COMMUNITY HEALTH (802)223-8599 PHARMACY ESSEX JUNCTION, VT 05452 (802)479-3381 (802)879-4155 WAL-MART 158 BRENTWOOD DR STE 7 RITE AID BRISTOL 282 BERLIN MALL RD STE 1 COLCHESTER, VT 05446 RITE AID 355 N MAIN ST BERLIN, VT 05602 RITE AID (802)893-1120 75 PEARL ST BARRE, VT 05641 (802)229-8049 1 PRINCE LN ESSEX JUNCTION, VT 05452 (802)476-4311 COSTCO BRISTOL, VT 05443 50 MOUNTAIN VIEW DR (802)878-3369 BETHEL (802)453-2367 COLCHESTER, VT 05446 BARTON RITE AID (802)655-3156 RITE AID 9 SUSIE WILSON RD KINNEY DRUGS BURLINGTON 1823 FLETCHER ALLEN OP ESSEX JUNCTION, VT 05452 16 CHURCH ST BETHEL, VT 05032 FLETCHER ALLEN OP PHARMACY (802)872-1800 BARTON, VT 05822 (802)234-5289 PHARMACY 792 COLLEGE PKWY (802)525-4098 1 S PROSPECT ST COLCHESTER, VT 05446 FAIR HAVEN BURLINGTON, VT 05401 BOMOSEEN (802)847-7461 BELLOWS FALLS (802)847-3784 RITE AID RITE AID 62 WASHINGTON ST GREATER FALLS CASTLETON HEALTH FLETCHER ALLEN OP CENTER PHCY 1184 PRIM RD STE 2 FAIR HAVEN, VT 05743 PHARMACY PHARMACY 275 ROUTE 30 N COLCHESTER, VT 05446 (802)265-3760 78 ATKINSON ST 111 COLCHESTER AVE BOMOSEEN, VT 05732 (802)863-2048 BELLOWS FALLS, VT 05101 BURLINGTON, VT 05401 (802)468-5800 HARDWICK (802)460-2634 (802)847-2821 SHAWS PHARMACY KINNEY DRUGS 66 MOUNTAIN VIEW DR RITE AID RITE AID HANNAFORD FOOD AND ROUTE 30 COLCHESTER, VT 05446 82 ROUTE 15 WEST 112 ROCKINGHAM ST DRUG BOMOSEEN, VT 05732 (802)655-2536 HARDWICK, VT 05843 BELLOWS FALLS, VT 05101 1127 NORTH AVE STE 11 (802)468-5777 BURLINGTON, VT 05408 (802)472-6961 (802)463-9910 DERBY (802)862-7752 BRADFORD RITE AID HINESBURG BENNINGTON KINNEY DRUGS KINNEY DRUGS 4408 US RTE 5 KINNEY DRUGS CVS 789 PINE ST 901 LOWER PLN DERBY, VT 05829 10212 ROUTE 116 8 KOCHER DR BURLINGTON, VT 05401 BRADFORD, VT 05033 (802)334-2313 HINESBURG, VT 05461 BENNINGTON, VT 05201 (802)864-8154 (802)222-9292 (802)482-4886 (802)442-8369 LAKESIDE PHARMACY DERBY LINE 242 PEARL ST EXTENDED CARE BRANDON BROWNS DRUG STORE LONDONDERRY PHARMACY BURLINGTON, VT 05401 40 MAIN ST 207 NORTH ST BRANDON COMMUNITY (802)862-1491 GREEN MOUNTAIN DERBY LINE, VT 05830 BENNINGTON, VT 05201 PHARMACY PHARMACY PRICE CHOPPER (802)873-3122 (802)442-4600 420 GROVE ST PHARMACY 5700 RTE 100 UNIT C-10 BRANDON, VT 05733 595 SHELBURNE RD LONDONDERRY, VT 05148 HANNAFORD FOOD AND (802)465-0011 ENOSBURG FALLS (802)824-3344 DRUG BURLINGTON, VT 05401 141 HANNAFORD SQ RITE AID (802)651-9835 ENOSBURG HM LUDLOW BENNINGTON, VT 05201 1 CARVER ST RITE AID PHARMACY (802)442-3642 BRANDON, VT 05733 1024 NORTH AVE 366 MAIN ST SOUTH LUDLOW PHARMACY (802)247-8050 BURLINGTON, VT 05401 ENOSBURG FALLS, VT 05450 57 POND ST STE 3 (802)865-7822 (802)933-9200 LUDLOW, VT 05149 (802)228-2500

 Pharmacy is open 24 hours

April 2013 Pharmacy directory is subject to change without notice. Please contact your local pharmacy for more information. EXPRESS SCRIPTS (WORKERS COMPENSATION PHARMACIES)

LUDLOW WEST RUTLAND

RITE AID RITE AID HANNAFORD FOOD AND RITE AID SPRINGFIELD PHARMACY 213 MAIN ST 29 MAIN ST DRUG 502 RAILROAD ST 264 RIVER ST LUDLOW, VT 05149 MONTPELIER, VT 05602 318 S MAIN ST SAINT JOHNSBURY, VT SPRINGFIELD, VT 05156 (802)228-8477 (802)223-4787 RUTLAND, VT 05701 05819 (802)885-6400 (802)775-5858 (802)748-5210 LYNDONVILLE MORRISVILLE PRICE CHOPPER STOWE SHELBURNE KINNEY DRUGS HANNAFORD FOOD AND PHARMACY HERITAGE DRUGS RTE 5 MEMORIAL DR DRUG 38 RUTLAND SHOPPING PLZ KINNEY DRUGS 1878 MOUNTAIN RD LYNDONVILLE, VT 05851 80 FAIRGROUNDS PLZ RUTLAND, VT 05701 47 EXECUTIVE DR STOWE, VT 05672 (802)626-3779 MORRISVILLE, VT 05661 (802)747-7887 SHELBURNE, VT 05482 (802)253-2544 (802)888-9894 (802)985-0008 RITE AID RITE AID 412 BROAD ST KINNEY DRUGS 7 WEST ST RITE AID SWANTON LYNDONVILLE, VT 05851 97 MORRISVILLE PLZ RUTLAND, VT 05701 30 SHELBURNE SHOPPING (802)775-0131 SWANTON REXALL (802)626-4365 MORRISVILLE, VT 05661 PARK DRUGS (802)888-5244 RUTLAND PHARMACY SHELBURNE, VT 05482 44 MERCHANTS ROW (802)985-2610 MANCHESTER RITE AID 75 ALLEN ST SWANTON, VT 05488 RUTLAND, VT 05701 EQUINOX 48 CONGRESS ST (802)868-3338 (802)775-2545 SOUTH BURLINGTON COMPOUNDING MORRISVILLE, VT 05661 PHARMACY (802)888-2226 WALGREENS HANNAFORD FOOD AND TOWNSHEND 34 WAYS LN 10 WOODSTOCK AVE DRUG MESSENGER VALLEY MANCHESTER, VT 05255 NEWPORT RUTLAND, VT 05701 217 DORSET ST PHARMACY (802)367-1096 (802)773-6980 SOUTH BURLINGTON, VT 170 GRAFTON RD KINNEY DRUGS 05403 WAL-MART TOWNSHEND, VT 05353 55 SHATTUCK HILL RD (802)863-1378 MANCHESTER CENTER NEWPORT, VT 05855 1 RUTLAND PLZ (802)365-4117 RITE AID (802)334-1600 RUTLAND, VT 05701 HANNAFORD FOOD AND DRUG 4993 MAIN ST STE A (802)773-1600 VERGENNES RITE AID 218 HANNAFORD DR MANCHESTER CENTER, VT 59 WATERFRONT PLZ STE 2 WILCOX HOME INFUSION KINNEY DRUGS 05255 SOUTH BURLINGTON, VT NEWPORT, VT 05855 250 STRATTON RD 05403 115B MONKTON RD (802)362-2230 (802)334-6785 RUTLAND, VT 05701 (802)863-1842 VERGENNES, VT 05491 (802)775-2808 (802)877-3148 MIDDLEBURY KINNEY DRUGS NORTHFIELD WILCOX PHARMACY 1653 WILLISTON RD MARBLE WORKS HANNAFORD FOOD AND NORTHFIELD PHARMACY 252 STRATTON RD SOUTH BURLINGTON, VT PHARMACY DRUG 14 DEPOT SQ RUTLAND, VT 05701 05403 187 MAIN ST 260 COURT ST UNIT 6 NORTHFIELD, VT 05653 (802)775-3351 (802)860-0714 VERGENNES, VT 05491 MIDDLEBURY, VT 05753 (802)485-4771 WILCOX PHARMACY LTC (802)877-1190 (802)388-6349 RITE AID 252 STRATTON RD 39 HINESBURG RD KINNEY DRUGS RANDOLPH RUTLAND, VT 05701 SOUTH BURLINGTON, VT WAITSFIELD 40 COURT ST (802)747-1994 05403 KINNEY DRUGS KINNEY DRUGS MIDDLEBURY, VT 05753 (802)862-5722 5091 MAIN ST STE 7 (802)388-0973 151 S RANDOLPH, VT 05060 SAINT ALBANS SHAWS PHARMACY WAITSFIELD, VT 05673 MARBLE WORKS (802)728-6284 HANNAFORD FOOD AND 570 SHELBURNE RD (802)496-2345 PHARMACY SOUTH BURLINGTON, VT RITE AID DRUG 99 MAPLE ST STE 19 05407 WATERBURY 12 N MAIN ST 277 SWANTON RD MIDDLEBURY, VT 05753 SAINT ALBANS, VT 05478 (802)860-3311 (802)388-3784 RANDOLPH, VT 05060 KINNEY DRUGS (802)728-3722 (802)524-2217 80 S MAIN ST RITE AID KINNEY DRUGS SOUTH HERO WATERBURY, VT 05676 263 COURT ST RICHFORD 164 SWANTON RD MCGREGORS SOUTH (802)244-8458 MIDDLEBURY, VT 05753 SAINT ALBANS, VT 05478 HERO PHARMACY (802)388-9573 NOTCH PHARMACY SHAWS/OSCO (802)524-6543 334 ROUTE 2 PHARMACY 44 MAIN ST STE 201 SOUTH HERO, VT 05486 820 WATERBURY STOWE RD RICHFORD, VT 05476 PRICE CHOPPER MILTON (802)372-5377 WATERBURY, VT 05676 (802)255-5530 PHARMACY KINNEY DRUGS 170 SWANTON RD (802)241-4115 3 CENTRE DR SAINT ALBANS, VT 05478 SPRINGFIELD RUTLAND MILTON, VT 05468 (802)524-2918 PETE'S PHARMACY WELLS RIVER (802)893-7459 BEAUCHAMP AND 242 RIVER ST STE 9 O'ROURKE PHCY RITE AID WELLS RIVER PHARMACY RITE AID SPRINGFIELD, VT 05156 62 WOODSTOCK AVE 153 N MAIN ST 41 MAIN ST N 201 ROUTE 7 S (802)885-4222 RUTLAND, VT 05701 SAINT ALBANS, VT 05478 WELLS RIVER, VT 05081 MILTON, VT 05468 (802)775-4321 (802)524-2141 RITE AID (802)757-2244 (802)893-2717 2 CHESTER RD STE 2 CVS SAINT JOHNSBURY SPRINGFIELD, VT 05156 WEST RUTLAND MONTPELIER 31 MAIN ST (802)885-5311 RUTLAND, VT 05701 KINNEY DRUGS RITE AID MONTPELIER PHARMACY (802)775-6736 957 MEMORIAL DR RIVER ST PHARMACY 294 MAIN ST 69 MAIN ST SAINT JOHNSBURY, VT 100 RIVER ST STE 2 WEST RUTLAND, VT 05777 MONTPELIER, VT 05602 05819 SPRINGFIELD, VT 05156 (802)438-6186 (802)223-4633 (802)748-2778 (802)885-6800

 Pharmacy is open 24 hours

April 2013 Pharmacy directory is subject to change without notice. Please contact your local pharmacy for more information. EXPRESS SCRIPTS (WORKERS COMPENSATION PHARMACIES)

WHITE RIVER JCT WOODSTOCK

WHITE RIVER JCT WOODSTOCK PHARMACY 19 CENTRAL ST CORNER DRUG STORE WOODSTOCK, VT 05091 213 MAPLE ST (802)457-1306 WHITE RIVER JCT, VT 05001 (802)295-2501

WILLISTON CVS 2466 ST GEORGE RD WILLISTON, VT 05495 (802)872-8840 HANNAFORD FOOD AND DRUG 78 MARSHALL AVE WILLISTON, VT 05495 (802)878-0388 KINNEY DRUGS 600 BLAIR PARK RD STE 195 WILLISTON, VT 05495 (802)878-9116 RITE AID 108 CORNERSTONE DR WILLISTON, VT 05495 (802)878-1118 SHAWS PHARMACY 71 BOXWOOD ST WILLISTON, VT 05495 (802)878-9056 WAL-MART 863 HARVEST LN WILLISTON, VT 05495 (802)878-5533

WILMINGTON RITE AID 1 E MAIN ST WILMINGTON, VT 05363 (802)464-7575

WINDSOR RITE AID 52 MAIN ST WINDSOR, VT 05089 (802)674-2334

WINOOSKI MCGREGORS MEDICINE ON TIME 321 MAIN ST STE B WINOOSKI, VT 05404 (802)655-3544 RITE AID 321 MAIN ST WINOOSKI, VT 05404 (802)655-2444

WOODSTOCK SHIRE APOTHECARY 13 ELM ST WOODSTOCK, VT 05091 (802)457-2707

 Pharmacy is open 24 hours

April 2013 Pharmacy directory is subject to change without notice. Please contact your local pharmacy for more information.