Meadowbrook/Star/Williamsburg/Pro Century Insurance Group

FSIM is the program administrator for your workers’ compensation insurance.

What that means is FSIM works directly with the insurance carrier to:

• Receive your first report of injury
• Provide nurse case management services as needed
• Issue your policy
• Handle your monthly payroll reports and payments
• Provide safety consultations
• Review and monitor your claims
• Assist with final audits

Contact customerservice@fsim.us or call (916) 462-6600

Give all of your supervisors/foremen copies of the following

1. Refusal of Medical Treatment Forms
2. Employee Report of Injury (Body Part Chart) form
3. DWC1 to have on hand at all times
4. MPN Acknowledgement forms (have signed prior to injury)

• 5020 form (employer's report of injury)
• DWC-1 form
• Body part form with the injury spot circled, initialed and dated by the injured worker
• MPN Acknowledgement Receipt
• Wage earning report (52 weeks preceding the date of injury)
• First doctor’s report (if available)
• Additional Questions form – complete as much as possible

Report all injuries along with completed forms to FSIM:

• Online: FSIM Portal (log in required)
• Phone: (800) 951-1134
• Fax: (800) 397-7770
• Email: intake@fsim.us

• Employee signs the Refusal of Medical Treatment Form
• Employer gives them a copy of the DWC-1 form with the employer information filled out only (Keep refusal form and copy of DWC-1 form on file just in case you have to send to FSIM)

• DWC-7 form
• MPN Complete Written Notice in English and Spanish
• MPN Implementation Notice Medical Provider Network

• MPN Signature form – This should be signed prior to any injury. Suggestions – at time of hire or at safety meetings.
• Group Signature forms are available. Contact customerservice@fsim.us to request.

• Go to Find an MPN Doctor under the Announcements & Quick links tab on the FSIM Portal.
• Contact the FSIM Medical Management office – (800) 951-1134

• Payroll report and payment is due on the 10th of every month following the month in which the payroll is paid (i.e. February payroll is due on March 10th)
• You must complete a payroll report even if you have zero (0) payroll

Payroll reporting and online payments are available by logging into the FSIM Portal.

1. Click on My Policies
2. Click on blue drop down arrow in front of your active policy
3. Click “View Policy”
4. Click on the "Payroll" tab at the top of the screen
5. Click on the blue banner "Report Payroll"
6. Payment may be made electronically from the portal (ACH) or you may print your statement and mail the statement with a check

If you have questions or need help on the FSIM Portal contact customerservice@fsim.us

• Please direct all of your claims inquiries or status updates to your broker first.
• Call the FSIM Medical Management Dept. – (800) 951-1134.
• You may also send your inquiries to: intake@fsim.us

For any class code changes, please contact your broker and advise them of the change. Your broker and FSIM will work together to ensure that the correct class code(s) are on your next payroll report.

Please call or email our customer service staff at: (916) 462-6600 or email customerservice@fsim.us.

FSIM’s focus is from “dirt to table” which includes, growers, packers, shippers, wholesale distributors, custom harvesters, restaurants, grocers, and other selected classes. Contact customerservice@fsim.us for a complete class code list.

• Accounts must have 100% of exposures within California
• Account must have had continuous workers’ compensation insurance – No coverage lapses
• Minimum of one (1) year in business with reported payroll. No new ventures will be considered.
• Minimum Final Premium $10,000 (ten thousand dollars).
• Account must have Governing Classification in one of the FSIM Eligible Classifications
• Classifications in any other class is acceptable only if the payroll or the ineligible classification represents 15% or less of the total payroll for the account
• For a FSIM’s complete underwriting guidelines contact customerservice@fsim.us

Meadowbrook/Star/Williamsburg/Pro Century Insurance Group

Contact Matt Costa, Owner and Principal (916) 462-6600 to obtain an Agency Profile form to submit for Agency Appointment review.

• Agency Profile
• Copy of current E & O Declarations Page
• Copy of current CA state license
• Signed Agency Agreement

FSIM is an expert in workers’ compensation for the food and ag industry. Our experienced underwriters know exactly how to evaluate the risks associated with your accounts’ business activities and assist you in writing business. In addition to FSIM’s underwriting expertise, our brokers have the advantage of offering their customers and prospects, FSIM’s value-added services including a medical management team staffed by Spanish speaking employees, a loss control consultant who has a full understanding of our classes of business and a claims liaison who can help our brokers navigate the workers’ compensation claims process. Our excellent customer service to our brokers and accounts includes personal service which leads to higher retention for our brokers and FSIM.

• FSIM’s services include personal contact with each account through customer service representatives
• Loss control consultants
• Medical management services provided by a bi-lingual, bi-cultural staff
• Claims analysis and assistance through our claims liaison
• Assistance with the sales process where needed

Workers' compensation insurance is a way to pay for some of the costs for employees and their families when:

1. An employee is injured on the job
2. An employee is killed on the job
3. An employee has an occupational disease

Call (800) 951-1134, 8:00 am - 4:30 pm, M – F

You must report your injury or occupational disease to your employer immediately. Your employer must report the injury to FSIM. You will receive a copy of the DWC-1 and other claim reporting documents for your records.

You should notify FSIM and your employer of any change of address as soon as possible. This will help ensure you will receive your benefit checks and other important claim related information in a timely matter.