Excellence in Employment Practices Fund Reimbursement Form 2018

The Excellence in Employment Practices fund (the Fund) has been allocated to a proactive risk management initiative in 2018. The goal is to PREVENT ONE employment practices liability claim for California Healthcare Insurance company, Inc., RRG (CHI) owners who purchase the optional EPL coverage on their CHI policy. PREVENT ONE will provide expense reimbursement for approved risk mitigation efforts, up to $3000 per CHI owner (with EPL coverage). Reimbursement is for efforts/services incurred in 2018 and must be submitted by December 14, 2018. To obtain PREVENT ONE program reimbursement, complete this form and attach a copy of the facility's check and invoice supporting the EPL expense(s). Maximum reimbursement amount not to exceed $3000.
    If " other" is chosen, please consult your Optima risk management consultant for reimbursement approval.
  • Drop files here or
    Please upload a copy of the invoice for which reimbursement is being requested.
  • Drop files here or
    Please upload a copy of your facility's check or confirmation of financial transaction confirming payment of the above services.