Policyholders

To us, you’re more than a monthly premium

To order a loss run for your account, please complete and submit the form below.

Useful Documents & Links

Waiver Instructions

Instructions for completing an Application for Waiver of Workers’ Compensation Insurance.

Download

Waiver Application

Blank Application for Waiver. Made available by the State of Maine and State of New Hampshire workers’ compensation boards.

Download

Letter of Authority

Sample letter template, authorizing Great Falls Insurance Company to obtain information on behalf of your business.

Download

No Known Loss Letter

Letter Document Template describing there are no known claims.

Download

ERM 14

Blank ERM-14 Form – Confidential Request for Ownership Information.

Download

Labor Posters

Link to Free Labor Posters from the Department of Labor for both Maine and New Hampshire policyholders.

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Medical Referral Form - Maine

This form can be faxed or hand carried by employee to their medical appt.

Download

Medical Referral Form - New Hampshire

This form can be faxed or hand carried by employee to their medical appt.

Download

First Injury Report - Maine

WCB-1 for Full SS# is to be used for the first report of injury in Maine.

Download

First Injury Report - New Hampshire

Form to be used for the first report of injury in New Hampshire.

Download

OSHA Reporting Requirements

Fatality, Severe Injury, and Illness Reporting Requirements for the public sector (including public schools), as of 1/1/15.

Fatalities: Employers are required to report each fatality within 8 hours of the death, for all fatalities.

Hospitalizations:Employers are required to report each in-patient hospitalization within 24 hours of the hospitalization, for all hospitalizations. In-patient hospitalization defined as a formal admission to the in-patient service of a hospital or clinic for care or treatment.

Amputations: Employers are required to report each amputation within 24 hours of the amputation, for all amputations.  Amputation is the traumatic loss of all or part of a limb or other external body part. This would include fingertip amputations with or without bone loss; medical amputations resulting from irreparable damage; and amputations of body parts that have since been reattached.

Loss of an Eye: Employers are required to report each loss of an eye within 24 hours of the loss of an eye, for all losses of an eye.

Fractures: Employers are required to report all fractures within 24 hours of knowledge.

Knowledge of an Event: Employer is required to report if an event (fatality, in-patient hospitalization, amputation, loss of an eye) is reported to employer or employer’s agent(s).

Employers can report these events by telephone to the nearest OSHA Area Office during normal business hours or the 24-hour OSHA hotline 1-800-321-OSHA [6742], or electronically at www.osha.gov/report_online.

telephone-586266_640

For public sector & public schools
Maine Department of Labor
Workplace Safety and Health Division
45 State House Station
Augusta, Maine 04333-0045
Phone: (207) 623-7900, Fax: (207) 623-7934

Or call Larry Winship at GFIC, 207-402-0806, [email protected]

Please choose Maine or New Hampshire to view a list of Occupational Health Providers.

Maine Occupational Health Providers

Town/City Provider Address Phone Fax Contact Name Practitioners Hours
Auburn WorkMed – St.Mary’s 15 Gracelawn Road 753-3080 753-3088 Dr.Jonathan Torres, Cathy Long NP 7am-5pm M-F
Augusta Work Place Heath 15 Enterprise Drive 621-7550 621-7551 Hicks MD, Ward MD 7:30-4:30 M-F
Augusta Concentra 219 Capitol Street, Suite 2 629-5005 629-5220 Christina Harmon 8am-5pm M-F
Bangor EMMC- Occupational Medicine 885 Union Street, Suite 215 973-7380 973-7081 Dr.Howard Jones (Walk-in-clinic 7am-7pm, 7 days) 7am-4pm M-F
Bangor Workwell – St. Joseph’s Hospital 900 Broadway, building 1 907-3010 907-3011 Bev Young Dr.C Curtis, M.Rizzo NP, L.Willard, NP., A. Nesbit, N.P. 8am-5pm M-F
Bath Occupational Health 270 State Road, West Bath 442-8625 442-8318 Patricia Barber Dr.Mesrobian, L.Muller, NP, N.Porr, NP
Biddeford SMHC WorkWell One Medical Center Drive 283-7600 283-7606 Dr.Paul Upham, Dr.Lonstaff, A. Dessano Rubinoff NP 7am-4:30pm
Belfast Coastal Medical Care 116 Northport Ave, Suite 114 338-8412 930-2599 Dr.Howard Jones, T Robinson PA
Bridgton Concentra 10 Hospital Drive 647-6063 647-6013 Kristen Searles T am & F pm
Brunswick US Healthworks 11 Medical Center Drive 725-2697 729-4719 Chip Bloomgren Dr.Mason, Dr.Stephen Cook 8am-5pm, M-F
Dover-Foxcroft Workwise – Mayo Regional Hospital 43 Dwelley Avenue 564-4338 564-4370 NP or Warren MacDonald, M.D. M, W, F only
Farmington Franklin Memorial Occ Health 111 Franklin Health Commons 779-2620 779-2624
Harrington Harrington Health Center 50 E Main Street 483-4502 483-4778 Dr.Steven Blair (Walk ins accepted) 8am-5pm M-F
Harrington Coastal PT (for PT and fitness center only) 1110 Main Street 483-4022 483-9722 Heather Anderson, PT
Houlton Katahdin Valley Occupational Health 59 Bangor Street 521-0022 532-1090
Jonesport Arnold Memorial Medical Center (family) 70 Snare Creek Lane 497-5614 497-5554 Dr.Weisberger
Lewiston Concentra 59 East Avenue 784-1680 783-9649 M-F
9am-1pm Sat & Sun
Machias Down East Community Medical Assoc. Reid Emery Building, 11 Hospital Drive 255-4567 255-5688 S.Blythe, D.O., C.. Moulton FNP
Machias Health Ways (family practice) 893 Main St, Machias 255-0102 255-4645 Dr.Mercedes Ang
Machias Down East Community Hospital (for PT) 11 Hospital Drive 255-0258 255-0439
Millinocket Health Access Occ Health 200 Somerset St., Suite 2 794-6700 723-8001
Norway Concentra 176 Main St. Suite 2 743-7399 743-1589 Kristen Searles Dave Davidson PA closed Thurs.
Pittsfield Sebasticook Valley Work Health 125 Main Street 487-3726 487-5725 Dr.Howard Jones 8am-4pm M-F
Portland Bayside Employee Health 50 Sewall St, Suite 301 780-6631 780-6320 7:30am-5pm M-F
Portland WorkHealth Mercy Hospital 195 Fore River Parkway, Suite 200 879-3466 879-3066 Gerald Lebel, NP Dr.Howard Jones Fri..- Gerald Lebel, NP 7am-4pm M-F
+ express hours
Presque Isle Occupational Health and Wellness  23 North Street, Suite 4A 768-4568  764-6459  Darcy Walsh  Dr.Howard Jones
Presque Isle Pines Health Services 66 Spruce Street, Suite 4 769-2025 764-0629 Lori Loggans, R.N.
Raymond Raymond Redicare 1278 Roosevelt Trail 655-6181 655-6188 Raymond Wilkins, DO
Rockland Coastal Medical Clinic 32 Birch Street 593-7925 593-7635 Susan Paxson Charlotte Campbel NP 9am-3:30pm M, T & Thurs, 10am-3:30pm Wed, 9am-1:30pm Fri
Rockport Health Connections 756 Commercial Street 921-5566 921-5341
Rumford Swift River Family Medicine 430 Franklin Street 369-0146 364-8626 8am-5pm M-F
Sanford SMHC WorkWell/Goodall 13 July Street 490-7099 490-5560 8:30am-5pm M-F
Skowhegan Health Connections 51 Fairview Avenue 474-7005 474-7013 8am-4pm M-F
Somersworth, NH Seacoast Redicare 396 High Street, Suite 1 603-692-6066 603-692-4815 Skip Moore Dr. Jay Burns M-S (Sat: closes at 2pm)
South Portland Concentra 85 Western Avenue, Suite 6-8 774-7751 828-5140 acquired CMPH 3/2016, also open 7:30am-7pm M-F
9am-1pm Sat & Sun
South Portland US Healthworks 400 Southborough Drive 761-1100 761-3700 Chip Bloomgren Dr.Hawkins, Dr.Mason 8am-5pm M-F
Waterville Workplace Health 30 Chase Avenue 872-4260 872-4034
Wells Wells Urgent Care / owned by York Hospital 114 Sanford Road 646-5211 641-8151

New Hampshire Occupational Health Providers

PROVIDER ADDRESS CITY State ZIP COUNTY PHONE FAX
Belnap/Merrimack Valley Occupational Health, LLC 614 Laconia Road, Unit#2 Tilton NH 03276 Belknap 603-717-7020 (603)-717-7011
Clear Choice MD – Urgent Care 96 Daniel Webster Highway Belmont NH 03220 Belknap 603-267-0656 (603)-267-0657
Saco River Medical Group- Occupational Medicine 7 Greenwood Avenue Conway NH 03818 Carroll 603-447-3500 (603)-447-5568
Saco River Medical Group- Occupational Medicine 15 US Route 302 Glen NH 03838 Carroll 603-383-3005 (603)-447-5568
Clear Choice MD – Urgent Care 448 West Street, Unit#4 Keene NH 03431 Cheshire 603-876-6115 (603)-876-6116
Convenient MD 351 Winchester Street Keene NH 03431 Cheshire 603-352-3406 (603)-352-3416
Dartmouth-Hitchcock Medical Center- Occupational Medicine 580-590 Court Street Keene NH 03431 Cheshire 603-354-6585 (603)-354-6584
Androscoggin Valley Hospital 47 Church Street Groveton NH 03582 Coos 603-752-2200 (603)-752-1836
AVH Occupational Health Services 59 Page Hill Road Berlin NH 03570 Coos 603-326-5738 (603)-326-5747
Weeks Medical Center- Emergency Care 173 Middle Street Lancaster NH 03584 Coos 603-788-4911 (603)-788-5069
Weeks Medical Center- Emergency Care 43 Main Street N. Stratford NH 03590 Coos 603-922-5039 (603)-922-3434
Weeks Medical Center- Emergency Care 8 Clover Lane Whitefield NH 03598 Coos 603-788-4911 (603)-788-5236
Alice Peck Day Memorial Hospital- Occupational Medicine 123 Mascoma Street Lebanon NH 03756 Grafton 603-448-7459 (603)-448-7469
Clear Choice MD – Urgent Care 410 Miracle Mile Lebanon NH 03756 Grafton 603-276-3261 (603)-727-4044
Dartmouth-Hitchcock Medical Center- Occupational Medicine 1 Medical Center Drive Lebanon NH 03766 Grafton 603-653-3850 (603)-650-0928
Littleton Regional Hospital Occupational Health Department 600 St. Johnsbury Road Littleton NH 03561 Grafton 603-444-9294 (603)-444-9025
Bedford Occupational & Acute Care/Express Med 1 Highlander Way Manchester NH 03103 Hillsborough 603-625-2622 (603)-626-1816
Catholic Medical Center- Urgent Care 5 Washington Place, Suite#1B Manchester NH 03110 Hillsborough 603-314-4567 (603)-314-4544
Concentra 14A Broad Street Nashua NH 03063 Hillsborough 603-889-2354 (603)-889-2793
Concentra 1276 South Willow Street Manchester NH 03103 Hillsborough 603-644-3330 (603)-644-3332
Bedford Occupational/ExpressMED 1 Highlander Way Manchester NH 03103 Hillsborough 603-625-2622 (603)-625-
Convenient MD 2 Dobson Way Merrimack NH 03054 Hillsborough 603-471-6069 (603)-471-6068
Convenient MD 565 Amherst Street Nashua NH 03063 Hillsborough 603-578-3347 (603)-578-3387
Dartmouth-Hitchcock Medical Center- Occupational Medicine 2300 Southwood Drive Nashua NH 03063 Hillsborough 603-577-4000 (603)-577-4165
Elliot Occupational Health Services 185 Queen City Avenue Manchester NH 03104 Hillsborough 603-625-1655 (603)-626-4686
Nashua Primary Care, Travel, & Occupational Health 155 Main Dunstable Road Nashua NH 03060 Hillsborough 603-943-7064 (603)-943-7067
Southern NH Medical Center- Occupational Medicine 460 Amherst Street Nashua NH 03063 Hillsborough 603-577-8400 (603)-577-8405
St. Joseph Business & Health – Occupational Health 166 Kinsley Street, Suite#203 Nashua NH 03060 Hillsborough 603-595-7371 (603)-595-6943
Concentra 1 Pillsbury Street Concord NH 03301 Merrimack 603-223-2300 (603)-228-9730
Concord Hospital- Occupational Health Services 60 Commercial Street Concord NH 03301 Merrimack 603-230-1220 (603)-230-1225
Convenient MD 8 Loudon Road Concord NH 03301 Merrimack 603-226-9000 (603)-226-2268
Dartmouth-Hitchcock Medical Center- Occupational Medicine 253 Pleasant Street Concord NH 03301 Merrimack 603-226-2200 (603)-229-5314
LRG Healthcare-Franklin Regional Hospital 15 Aiken Avenue Franklin NH 03235 Merrimack 603-934-2060 (603)-671-0009
Merrimack Valley Occupational Health 171 Pleasant Street Concord NH 03301 Merrimack 603-228-3500 (603)-228-3503
Access – Occupational Medicine Clinic 1 Hampton Road Exeter NH 03833 Rockingham 603-775-7575 (603)-778-9680
Access – Occupational Medicine Clinic 155 Borthwick Ave, Suite#102 Portsmouth NH 03801 Rockingham 603-431-3575 (603)-431-4730
Access – Occupational Medicine Clinic 6 Freetown Road Raymond NH 03077 Rockingham 603-895-6224 (603)-895-1329
Bedford Occupational / ExpressMED 159 North Broadway Salem NH 03079 Rockingham 603-898-0961 (603)898-0964
Center for Occupational Health- Exeter Hospital 6 Hampton Road Exeter NH 03833 Rockingham 603-580-6635 (603)-580-6579
Clear Choice MD – Urgent Care 750 Lafayette Road Portsmouth NH 03801 Rockingham 603-427-8539 (603)-294-0976
Convenient MD 1 Portsmouth Avenue Stratham NH 03885 Rockingham 603-772-3600 (603)-772-3601
Convenient MD 125 Indian Rock Road Windham NH 03087 Rockingham 603-890-6330 (603)-458-7626
Elliot Urgent Care- Londonderry Clinic 40 Buttrick Road Londonderry NH 03053 Rockingham 603-552-1550 (603)-552-1599
Occupational Health Services-Portsmouth Regional Hospital 25 New Hampshire Ave Portsmouth NH 03801 Rockingham 603-430-9675 (603)-334-6088
WorkPlace Wellness-PRH/PMC 44 Birch Street, Suite#306 Derry NH 03038 Rockingham 603-421-3680 (603)-421-3681
Convenient MD 14 Webb Place Dover NH 03820 Strafford 603-742-7900 (603)-343-4749
Seacoast Ortho/Sports Medicine 7 Marsh Brook Drive Somersworth NH 03878 Strafford 603-742-2007 (603)-749-4605
Seacoast Redicare 396 High Street Somersworth NH 03878 Strafford 603-692-6066 (603)-692-4815
Wentworth Douglas- Express Care 701 Central Avenue Dover NH 03820 Strafford 603-609-6700 (603)-609-6703
Monadnock Community Hospital- Occupational Medicine 452 Old Street Road Peterborough NH 03458 Sullivan 603-924-1795 (603)-924-4618
Souhegan Occupational Medicine 96 Old Dublin Road Peterborough NH 03458 Sullivan 603-924-0161 (603)924-0161
Valley Regional Healthcare- Occupational Medicine 243 Elm Street Claremont NH 03743 Sullivan 603-542-1825 (603)-542-3409

Please select the type of claim you wish to report.

Report a WC Claim – New Hampshire

REPORTING A WORKER’S COMPENSATION CLAIM – NEW HAMPSHIRE

  • If an employee is injured at work or claims he/she is injured at work you must report the injury to Cannon Cochran Management Services, Inc. (CCMSI), our claims administrator, immediately.
  • If an employee later loses time from work (even if paid salary continuation), you must contact CCMSI immediately.

How to Report?

  • Fax completed First Report of Occupational Injury CCMSI (603) 627-9057
  • Phone CCMSI M-F, 8:00am-4:30pm: (603) 627-9004 or (800) 985-2583
  • Email CCMSI: [email protected]
  • Claims also may be reported electronically. Contact Elizabeth Davis, Sr. Account Manager at CCMSI if you would like electronic access (sign in ID & password), [email protected],  (781) 683-1141
  • For after-hours claim reporting, electronic access is required
  • Contact your agent

 

MEDICAL TREATMENT

Call your preferred medical provider and advise them of the injured employee, provide details of the claim, contact information of CCMSI and schedule the appointment. Complete our Medical Referral Form NH – Click on link Medical Provider Form- NH, fax or have employee hand carry to appt.

For a listing of Providers, click on link  – Occupational Health providers in NH

Medical bills should be sent to CCMSI.

In case of an emergency or life threatening injury, call 911 for emergency services first, and then notify CCMSI.

                                      

WAGE STATEMENTS AND FRINGE BENEFIT FORMS

You may be asked to complete a wage statement or provide payroll information to the Adjuster. The Dept. of Labor will issue fines for forms that are filed late.  The employer may be responsible for any fine if information was not sent to CCMSI timely. CCMSI is responsible for filing all forms with the Dept. of Labor.

FRAUD & ABUSE

If you have knowledge or suspicion that there has been fraudulent claims activity, please report to

Marti Conti, Claims Manager, at GFIC or CCMSI immediately.

 

CONTACT INFORMATION

CCMSI, 1750 Elm Street, Manchester, NH, 03104, (800) 985-2583 or (603) 627-9004

Diane L. DuShane, Supervisor, (603) 314-4117 or (800) 985-2583, [email protected]

Marti Conti, Claims Service Manager, Great Falls Insurance Company, (207) 831-7606, [email protected]

GFIC, 86 Main Street, Suite 304, P.O. Box  590, Auburn, ME 04212, (877) 344-5408, (207) 333-3257 x 201

Report a WC Claim – Maine

REPORTING A WORKER’S COMPENSATION CLAIM – MAINE

  • If an employee is injured at work or claims he/she is injured at work you must report the injury to Cannon Cochran Management Services, Inc. (CCMSI), our claims administrator, immediately.
  • If an employee later loses time from work (even if paid salary continuation), you must contact CCMSI immediately.

HOW TO REPORT?

  • Fax completed First Report of Injury (WCB-1) OR (forms available at www.maine.gov/wcb/  online services-forms-WCB-1) to CCMSI (207) 347-7099
  • Phone CCMSI M-F, 8am-4:30pm: (207) 347-7050 or (800) 660-1880
  • Email CCMSI, [email protected]
  • Claims also may be reported electronically. Contact Bill Gourde at CCMSI if you would like electronic access (sign in ID & password), 207-347-7070, or [email protected]
  • For after-hours claim reporting, electronic access is required
  • Contact your agent

MEDICAL TREATMENT

In Maine, the employer can direct the injured employee’s medical care for the first 10 days of treatment. For your convenience, GFIC has compiled a recommended occupational provider list. You are not required to use a provider on this list. If you have a relationship with another medical provider, you may continue using this provider. Call the medical provider and advise them of the injured employee, provide details of the claim and contact information. Complete the Medical Referral Form located on our Useful Resources page, fax or have employee hand carry to appt.
Referral to the emergency room is the last resort. Medical bills should be sent to CCMSI.
In case of an emergency or life threatening injury, call 911 for emergency services first, then notify CCMSI.

WAGE STATEMENTS AND FRINGE BENEFIT FORMS

You may be asked to complete a wage statement or provide payroll information to the adjuster. The Workers’ Compensation Board will issue $100 fines for forms that are filed late. If an employee is late being paid indemnity benefits, the fine is up to $1,500. The employer may be responsible for any fine if information was not sent to CCMSI timely. CCMSI is responsible for filing all forms with the WCB.

FRAUD & ABUSE

If you have knowledge or suspicion that there has been fraudulent claims activity, please report to Marti Conti, Claims Manager, at GFIC or CCMSI immediately.

CONTACT INFORMATION

Sarah Barger Grant, Lost Time Adjuster, (207) 347-7055, [email protected]
Megan Wallace, Lost Time Adjuster, (207) 347-7056, [email protected]
Rebecca Elliott, Med Only Adjuster, (207) 347- 7087, [email protected]
Malissa Howe, Supervisor, (207) 347-7085 or (800) 660-1880 X 7085, [email protected]
Cannon Cochran Management Services, Inc., 324 Cummings Road, Suite 104, South Portland, ME 04106
Marti Conti, Claims Service Manager, Great Falls Insurance Company, (207) 831-7606, [email protected]
GFIC, 86 Main Street, Suite 304, P.O. Box 590, Auburn, ME 04212, (877) 344-5408, (207) 333-3257 x 201

Report an EPL Claim – Maine

REPORTING AN EMPLOYMENT PRACTICES LIABILITY CLAIM OR INCIDENT  (EPLI)

Step 1: Notice of claim, incident, or suit.

Step 2: Choose 1 of 4 ways to report a claim

  • Call GFIC
  • Fax notice of claim, incident or suit to GFIC (207) 333-3259
  • Email notice of claim, incident, or suit to GFIC [email protected]
  • Contact your agent

Step 3: GFIC will notify Hartford Steam Boiler (HSB) of the claim. You will receive an acknowledgement letter from HSB.

Step 4: HSB will review the claim and confirm coverage. Provide all correspondence to HSB. Cooperate fully with the HSB adjuster and assigned defense attorney.

Contact Info:
Adjuster – The Hartford Steam Boiler Inspection and Insurance Company
P.O. Box 6150, King of Prussia, PA 19406
(888) 472-5677 or fax (877) 472-4329
Claims Manager at GFIC – Marti Conti [email protected]
(207) 831-7606 (cell) or (207) 333-3257 x201