Self insured list - Colorado Department of Labor and Employment
Self insured list - Colorado Department of Labor and Employment
Self insured list - Colorado Department of Labor and Employment
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SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
939 06/15/86 ABF FREIGHT SYSTEM, INC. Mr. Allen King Mr. Stan McDaniel<br />
(ARKANSAS BEST CORPORATION AND Manager, Workers’ Compensation Director, Risk Management<br />
ITS WHOLY-OWNED SUBSIDIARY ABF ABF Freight System, Inc. ABF Freight System, Inc.<br />
FREIGHT SYSTEM, INC.) 3801 Old Greenwood Road 3801 Old Greenwood Road<br />
P. O. Box 10048 P. O. Box 10048<br />
Fort Smith, AR 72917-0048 Fort Smith, AR 72917-0048<br />
OFFICE: 479-785-6218 OFFICE: 479-785-6319<br />
FAX: 479-785-6396 FAX: 479-494-6624<br />
EMAIL: aking@arkbest.com<br />
EMAIL: aking@arkbest.com<br />
Mr. Stan McDaniel<br />
stanmcd@arkbest.com<br />
Director, Risk Management<br />
989 04/01/84 ADAMS COUNTY Ms. Sally Phillips Mr. Charles B. DuScha<br />
Risk Manager<br />
Risk Manager<br />
§8-42-124 Adams County Workers' Compensation Adams County<br />
C/O Jefferson County School District R-1<br />
Risk Management/HR <strong>Department</strong><br />
Risk Management <strong>Department</strong><br />
450 South 4th Avenue<br />
P. O. Box 4001 Brighton, CO 80601-3123<br />
Golden, CO 80401-0001<br />
OFFICE: 303-982-2439 OFFICE: 303-654-6076<br />
FAX: 303-982-2327 FAX: 303-654-6069<br />
EMAIL: sphillip@jeffco.k12.co.us<br />
EMAIL: cduscha@co.adams.co.us<br />
462 02/01/09 Adventist Health Systems Nancee R Smith ARM, CWCP Nancee R Smith ARM, CWCP<br />
Director Workers' Compensation Dept<br />
Director Workers' Compensation Dept<br />
Adventist Health systems<br />
Adventist Health systems<br />
602 Courtl<strong>and</strong> St #330 602 Courtl<strong>and</strong> St #330<br />
Orl<strong>and</strong>o FL 32789-3675 Orl<strong>and</strong>o FL 32789-3675<br />
Santa Clara, CA 95051-7201 Santa Clara, CA 95051-7201<br />
OFFICE: 407-200-4894 OFFICE: 407-200-4894<br />
FAX: 407-200-4762 FAX: 407-200-4762<br />
EMAIL: nancee.smith@ahss.org<br />
EMAIL: nancee.smith@ahss.org<br />
Page 1 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
484 11/01/99 AGILENT TECHNOLOGIES, INC. Debbie Baird Ms. Arlyne Gittens<br />
Supervisor<br />
Corporate Risk Management<br />
Sedgwick CMS<br />
Agilent Technologies, Inc.<br />
7400 East Orchard Road, Suite 4015 5301 Stevens Creek Boulevard<br />
P. O. Box 5107 (80155-5107) Mail Stop 1B-08<br />
Greenwood Village, CO 80111-2518 Santa Clara, CA 95051-7201<br />
TPA MAILING ADDRESS IS OFFICE: 303-713-6000 OFFICE: 408-345-8227<br />
P.O.Box 14493, Lexington KY 40512-4493 800-507-9656 FAX: 408-553-7516<br />
FAX: 303-713-6056<br />
EMAIL: arlyne_gittens@agilent.com<br />
EMAIL: deborah.baird@sedgwickcms.com<br />
Lori Hasty Examiner lori.hasty@sedgwickcms.com<br />
Barbara Sperry Med Examiner<br />
477 04/01/02 AMERICAN FURNITURE WAREHOUSE Karen Marie Lesko Ms. Becky Moul<br />
Director, Sales <strong>and</strong> Marketing<br />
Risk Manager<br />
Tri Star Risk Management<br />
American Furniture Warehouse<br />
P O Box 5007<br />
8820 American Way<br />
Denver CO 80217-5007 Englewood, CO 80112-7056<br />
OFFICE: 720-962-0222 OFFICE: 720-873-8612<br />
FAX: 720-962-0301 FAX: 720-873-8615<br />
EMAIL: karen.lesko@tristargroup.net<br />
bmoul@afwonline.com<br />
Laura Daniels, Branch Manager<br />
laura.daniels@tristargroup.net<br />
870 01/01/90 ARAPAHOE COUNTY Ms. Norma Stimmler Ms. Pat Skahill<br />
CTSI<br />
Arapahoe County<br />
§8-42-124 800 Grant Street, Suite 400 5334 South Prince Street<br />
Denver, CO 80203-2944 Littleton, CO 80166-0001<br />
OFFICE: 303-861-0507 OFFICE: 303-795-4573<br />
FAX: 303-861-1022 FAX: 303-738-7836<br />
EMAIL: nstimmler@ctsi.org<br />
EMAIL: pskahill@co.arapahoe.co.us<br />
Page 2 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
894 07/01/87 ARVADA, CITY OF Teree Carr Kori Riley<br />
Business Director<br />
Risk Management Division<br />
§8-42-124 PINNACOL ASSURANCE City <strong>of</strong> Arvada<br />
7501 E Lowery Blvd 8101 Ralston Road<br />
Denver, CO 80230-7006 P. O. Box 8101<br />
Arvada, CO 80001-8101<br />
Eric Wiant<br />
OFFICE: 303-361-4251 OFFICE: 720-898-7595<br />
FAX: 303-361-5251 FAX: 720-898-7591<br />
EMAIL: teree.carr@pinnacol.com<br />
EMAIL: ewiant@arvada.org<br />
kriley@arvada.org<br />
kriley@arvada.org<br />
975 10/06/81 ASPEN SKIING COMPANY Stacy Ross Ms. Kathy Broughton<br />
CCMSI<br />
Workers’ Compensation Manager<br />
§8-42-124 7600 East Orchard Road, Suite 360N Aspen Skiing Company<br />
Greenwood Village, CO 80111-2518 Box 1248<br />
P.O.Box 4998 Greenwood Village CO 80155-4998 Aspen, CO 81612-1248<br />
OFFICE: 303-804-2032 OFFICE: 970-920-0943<br />
FAX: 303-804-2005 FAX: 970-920-0955<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: kbroughton@aspensnowmass.com<br />
Cannon Cochran Management Services inc<br />
957 10/01/76 AURORA, CITY OF Ms. Nancy Kass Ms. Virginia S. Loughner<br />
Claims Supervisor<br />
Risk Manager<br />
§8-42-124 City <strong>of</strong> Aurora City <strong>of</strong> Aurora<br />
15151 East Alameda Parkway, Suite 3500 15151 East Alameda Parkway<br />
Aurora, CO 80012-1555<br />
Third Floor<br />
Aurora, Co 80012-1555<br />
OFFICE: 303-739-7011 OFFICE: 303-739-7003<br />
FAX: 303-739-7650 FAX: 303-739-7650<br />
EMAIL: nkass@ci.aurora.co.us<br />
EMAIL: vloughne@ci.aurora.co.us<br />
Page 3 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
463 11/07/08 BARRETT BUSINESS SERVICES INC CHRIS LYONS Mr. Steven McComb<br />
BBSI CORVEL CORPORATION WORKERS' COMPENSATION ADMINISTRATOR<br />
6455 S Yosemite St Suite 700 BARRETT BUSINESS SERVICES INC<br />
Greenwwod Village CO 80111 8100 NE PARKWAY DR SUITE 200<br />
VANCOUVER, WA 98662-<br />
866-449-5054<br />
OFFICE: 720-250-0735 OFFICE: 360-828-0685<br />
950 S CHERRY ST SUITE 1600 FAX: 866-449-5054 FAX: 360-828-0699<br />
EMAIL: chris_lyons@corvel.com<br />
EMAIL: STEVEN.MCCOMB@BBSIHQ.COM<br />
993 01/01/85 BALL CORPORATION Ms. Myra Jelinek Mr. Harold L. Lykins<br />
Specialty Risk Services<br />
Director, Corporate Risk<br />
§8-42-124 P.O.Box 221700 Ball Corporation<br />
Denver, CO 80222<br />
10 Longs Peak Drive<br />
Broomfield, CO 80021-2510<br />
OFFICE: 800-829-7985 X 58506 OFFICE: 303-460-2296<br />
FAX: 303-645-8654 FAX: 303-460-3716<br />
EMAIL: myra.jelinek@srsconnect.com<br />
EMAIL: dlykins@ball.com<br />
6053 South Fashion Square Drive<br />
Murray, UT 84107-5433<br />
489 01/01/98 BANNER HEALTH Ms. Kelly Kovatch Mr. Phil Holt<br />
Sentry Insurance<br />
Systems Director, Risk Financing<br />
P. O. Box 29466 Banner Health<br />
Phoenix, AZ 85038-9466<br />
1441 North 12th Street<br />
Phoenix, AZ 85006-2837<br />
OFFICE: 800-833-2244 OFFICE: 602-495-4799<br />
FAX: 480-860-7987 FAX: 602-495-4781<br />
EMAIL: kelly.kovatch@sentry.com<br />
EMAIL: tammy.willis@bannerhealth.com<br />
Page 4 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
829 01/01/93 BOULDER, CITY OF Ms. Stacy Ross Stewart Ellenberg ARM-P<br />
State Director<br />
Risk Manager<br />
CCMSI<br />
City <strong>of</strong> Boulder<br />
7600 East Orchard Road, #360N P. O. Box 791 or 1777 Broadway<br />
P. O. Box 4998 (80155-4998) Boulder, CO 80306-0791<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-804-2032 OFFICE: 303-441-3075<br />
FAX; 303-804-2005 FAX: 303-441-4381<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: eichemb@bouldercolorado.gov<br />
ellenbergs@bouldercolorado.gov<br />
Mr. Bob Eichem 303-441-1819<br />
Finance Director<br />
852 01/01/91 BOULDER COMMUNITY HOSPITAL Ms. Karen Marie Lesko Ms. Denise Granberg<br />
Director, Sales <strong>and</strong> Client Services<br />
Boulder Community Hospital<br />
TRI-Star Risk Management<br />
North Broadway & Balsam<br />
200 Union Boulevard, Suite 580 P. O. Box 9019<br />
P. O. Box 5007 (80217-5007) Boulder, CO 80301-9019<br />
Denver, CO 80228-1849<br />
OFFICE: 720-962-0274 OFFICE: 303-938-5344<br />
FAX: 720-962-0301 FAX: 720-565-0457<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: emphealth1@bch.org<br />
867 01/01/90 BOULDER COUNTY Ms. Pam Stonecipher, ARM, CIC Ms. Pam Stonecipher, ARM, CIC<br />
Boulder County<br />
Boulder County<br />
§8-42-124 Risk Manager Risk Manager<br />
P. O. Box 471 P. O. Box 471<br />
Boulder, CO 80306-0471 Boulder, CO 80306-0471<br />
2025 14th st 1st Floor<br />
OFFICE: 303-441-3872 OFFICE: 303-441-3872<br />
FAX: 303-441-3568 FAX: 303-441-3568<br />
EMAIL: pstonecipher@co.boulder.co.us<br />
EMAIL: pstonecipher@co.boulder.co.us<br />
pstonecipher@bouldercounty.org<br />
Page 5 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
873 06/01/89 CARGILL, INC. CLAIMS 11/01/05 & FORWARD<br />
Ms. Nhu Miller<br />
Mr. Brian Turnwall<br />
Team Leader<br />
Casualty Insurance Manager<br />
Cancelled effective 6/1/07 Specialty Risk Services Cargill, Inc.<br />
7670 South Chester Street, Suite 320 15407 McGinty Road West MS 12<br />
Englewood, CO 80112-3439 Wayzata, MN 55391-2365<br />
OFFICE: 800-829-7985 OFFICE: 952-742-5274<br />
303-645-8644 FAX: 952-742-7990<br />
FAX: 303-645-8654<br />
EMAIL: nancy_whitehead@cargill.com<br />
EMAIL: nhu.miller@srsconnect.com<br />
CLAIMS PRIOR TO 11/01/05 (Crawford will<br />
adjust through 11/01/06)<br />
Mr. Mark DiLoreto<br />
Manager<br />
Broadspire, A Crawford Company<br />
9200 East Panorama Circle, Suite 160<br />
P. O. Box 6502 (80155-6502)<br />
Englewood, CO 80112-3490<br />
OFFICE: 720-875-9021<br />
FAX: 720-875-9040<br />
EMAIL: mark.diloreto@choosebroadspire.com<br />
*Note: Crawford will service claims only to<br />
date above...at which time any<br />
claims will transfer to SRS.<br />
Page 6 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
956 12/01/75 CHEVRON U.S.A., INC. Ms Stacy Kimmell Ms. Kelly George<br />
Manager<br />
Insurance Division Claims Administrator<br />
Broadspire, A Crawford Company<br />
Chevron U.S.A., Inc.<br />
9200 East Panorama Circle, Suite 160 P. O. Box 6022<br />
P. O. Box 6502 (80155-6502) San Ramon, CA 94583-0722<br />
Englewood, CO 80112-3490<br />
OFFICE: 720-875-9231 OFFICE: 925-842-8164<br />
FAX: 720-875-9040 FAX: 925-842-8185<br />
EMAIL: stacy.kimmell@choosebroadspire.com EMAIL: kelly.george@chevron.com<br />
468 03/01/05 CHILDREN’S HOSPITAL ASSOCIATION, CLAIMS 06/01/06 & FORWARD<br />
THE<br />
Ms. Karen Marie Lesko<br />
Mr. Kevin Hamilton<br />
Director, Sales <strong>and</strong> Client Services<br />
Director <strong>of</strong> Benefits <strong>and</strong> Employee Health Services<br />
TRI-Star Risk Management<br />
The Children’s Hospital <strong>of</strong> Denver<br />
200 Union Boulevard, Suite 580 13611 E Colfax Ave. #200<br />
P. O. Box 5007 (80217-5007) Aurora, CO 80045<br />
Denver, CO 80228-1849<br />
OFFICE: 720-962-0274 OFFICE: 303-861-6402<br />
FAX: 720-962-0301 FAX: 303-764-8080<br />
EMAIL: karen.lesko@tristargroup.net<br />
Email: hamilton.kevin@tchden.org<br />
EMAIL: wukitsch.michael@tchden.org<br />
479 07/01/01 COACHMEN INDUSTRIES, INC. Ms. Annette Shafer LES THIMLAR<br />
AAH-CO., LLC<br />
Vice President<br />
3333 East Center Drive Coachmen Industries, Inc.<br />
Milliken, CO 80543-9322 P. O. Box 3300<br />
2831 Dexter Drive<br />
Elkhart, IN 46515-3300<br />
OFFICE: 970-587-0544 OFFICE: 574-266-2514<br />
FAX: 970-587-0545 FAX: 574-206-1700<br />
EMAIL: ashafer@allamericanhomes.com<br />
EMAIL: mmir<strong>and</strong>a@coachmen.com<br />
Page 7 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
487 05/17/99 COBE CARDIOVASCULAR, INC. Theresa Rabinek Ms. Diane Marie Lucero<br />
Corvel Corporation<br />
Treasury Manager<br />
Now known as SORIN Group USA 950 South Cherry Street, Suite 1600 Cobe Cardiovascular, Inc.<br />
effective 1/1/2007 Denver, CO 80246-2689 14401 West 65th Way<br />
Arvada, CO 80004-3539<br />
OFFICE: 303-692-9210<br />
FAX: 303-692-9103 OFFICE: 303-467-6280<br />
EMAIL: theresa_rabinek@corvel.com FAX: 303-467-6591<br />
EMAIL: diane.lucero@sorin-na.com<br />
Sub CONTRACT<br />
Mr. Jim Howey<br />
CCMSI<br />
7600 East Orchard Road, Suite 360N<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-337-6161<br />
FAX: 303-337-6165<br />
EMAIL: jhowey@ccmsi.com<br />
988 10/01/83 COLORADO HOSPITAL ASSOCIATION Kathy Gochnour Mr. Gary Swenson<br />
CorVell Corporation<br />
Director<br />
6455 S Yosemite St Suite 700 Support Services, Inc.<br />
Greenwood Village, CO 80111-2518 7335 East Orchard Road, Suite 200<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 800-929-6090 OFFICE: 720-489-9300<br />
FAX: 866-449-5059 FAX: 720-489-1166<br />
EMAIL:<br />
EMAIL: gary.swenson@cha.com<br />
839 01/01/92 COLORADO PERMANENTE MEDICAL Mr. John Walker Arne Haram, M.S.<br />
GROUP Operations Manager Human Resources <strong>Department</strong><br />
Original Sedgwick CMS Kaiser Foundation Health Plan <strong>of</strong> <strong>Colorado</strong><br />
7400 East Orchard Road, Suite 4015 10065 E Harvard Ave suite 400<br />
Anniversary P. O. Box 5107 (80155-5107) Denver, CO 80231<br />
Date: 04/01/92 Greenwood Village, CO 80111-2518<br />
OFFICE: 303-713-6030 OFFICE: 303-614-1546<br />
800-507-9656 FAX: 303-614-1495<br />
FAX: 303-713-6056<br />
arne.i.haram@kp.org<br />
EMAIL: jewalker@sedgwickcms.com<br />
Page 8 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
877 01/01/89 COLORADO SPRINGS, CITY OF Mr. Mark Anderson Mr. Mark Anderson<br />
Risk Manager<br />
Risk Manager<br />
§8-42-124 Risk Management Risk Management<br />
City <strong>of</strong> <strong>Colorado</strong> Springs<br />
City <strong>of</strong> <strong>Colorado</strong> Springs<br />
P. O. Box 1575 - Mail Code 630 P. O. Box 1575 - Mail Code 630<br />
<strong>Colorado</strong> Springs, CO 80901-1575 <strong>Colorado</strong> Springs, CO 80901-1575<br />
OFFICE: 719-385-5661 OFFICE: 719-385-5661<br />
FAX: 719-385-5677 FAX: 719-385-5677<br />
EMAIL: mk<strong>and</strong>erson@springsgov.com<br />
EMAIL: mk<strong>and</strong>erson@springsgov.com<br />
858 07/01/91 COLORADO SPRINGS SCHOOL DISTRICT Mr. Charles R. Murray, ARM SAME AS LOCAL<br />
NO. 11<br />
Risk Manager<br />
<strong>Colorado</strong> Springs School District 11<br />
1115 North El Paso Boulevard<br />
<strong>Colorado</strong> Springs, CO 80903-2599<br />
OFFICE: 719-520-2469<br />
FAX: 719-520-2383<br />
EMAIL: murracr@d11.org<br />
(Note: EMAIL: d11 are numbers)<br />
471 08/01/04 COLORADO STATE UNIVERSITY Ms. Karen Marie Lesko Sally Alex<strong>and</strong>er<br />
Director, Sales & Claims Services<br />
Director, Risk Management <strong>and</strong> Insurance<br />
(Claims from 08/01/04 <strong>and</strong> ongoing) TRI-Star Risk Management <strong>Colorado</strong> State University<br />
200 Union Boulevard, Suite 580 Office <strong>of</strong> Risk Management & Insurance Environmental<br />
Health Sevices<br />
P. O. Box 5007 (80217-5007) 141A General Services Builduing<br />
Denver, CO 80228-1849 Campus Delivery 6002<br />
Fort Collins, CO 80523-0001<br />
OFFICE: 720-962-0274 OFFICE: 970-491-6745<br />
FAX: 720-962-0301 FAX: 970-491-4804<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: sally.alex<strong>and</strong>er@colostate.edu<br />
earlie.thomas@colostate.edu<br />
Page 9 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
470 08/01/04 COLORADO STATE UNIVERSITY Ms. Karen Marie Lesko Sally Alex<strong>and</strong>er<br />
Director, Sales & Claims Services<br />
Director, Risk Management <strong>and</strong> Insurance<br />
(Tail claims from 07/01/96 - 06/30/04) TRI-Star Risk Management<br />
<strong>Colorado</strong> State University<br />
200 Union Boulevard, Suite 580 Office <strong>of</strong> Risk Management & Insurance Environmental<br />
Health Sevices<br />
P. O. Box 5007 (80217-5007) 141A General Services Builduing<br />
Denver, CO 80228-1849 Campus Delivery 6002<br />
Fort Collins, CO 80523-0001<br />
OFFICE: 720-962-0274 OFFICE: 970-491-6745<br />
FAX: 720-962-0301 FAX: 970-491-4804<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: sally.alex<strong>and</strong>er@colostate.edu<br />
sally.alex<strong>and</strong>er@colostate.edu<br />
469 01/01/05 COLUMBINE HEALTH SYSTEMS Ms. Karen Marie Lesko Kim Gabriel<br />
Director, Sales & Claims Services<br />
Senior Accountant<br />
Effective 7/1/09 change in TPA TRI-Star Risk Management Columbine Health Systems<br />
Mr. Gary Swenson 200 Union Boulevard, Suite 580 947 Worthington Circle<br />
Director P. O. Box 5007 (80217-5007) Fort Collins, CO 80526-1841<br />
Support Services, Inc. Denver, CO 80228-1849<br />
7335 East Orchard Road, Suite 200 OFFICE: 970-482-0198<br />
Greenwood Village, CO 80111-2518 OFFICE: 720-962-0274 FAX: 970-482-9148<br />
FAX: 720-762-0301<br />
EMAIL: dawn.filsinger@columbinehealth.com<br />
OFFICE: 720-489-9300 EMAIL: karen.lesko@tristargroup.net kim.gabriel@columbinehealth.com<br />
FAX: 720-489-1166<br />
Dawn Filsinger, Safety Officer, Columbine Health<br />
EMAIL: gary.swenson@cha.com<br />
TRI-Star will h<strong>and</strong>le all self-Insured period<br />
claims<br />
Systems,802 West Drake Suite 145,Fort Collins80526<br />
970-492-6233 970-492-6206 Fax<br />
888 11/01/87 CONAGRA FOODS, INC. Mr. Mike Stefan Mr. Jeff Regler<br />
Area Manager<br />
Associate Financial Analyst<br />
Sedgwick CMS<br />
ConAgra Foods, Inc.<br />
P. O. Box 540040 One ConAgra Drive, I-220<br />
Omaha, NE 68154-0040 Omaha, NE 68102-5001<br />
OFFICE: 402-963-2823 OFFICE: 402-595-4491<br />
FAX: 402-496-9830 FAX: 402-517-3168<br />
EMAIL: kcorcoran@sedgwickcms.com<br />
EMAIL: Rebecca_Sch<strong>of</strong>f@ars.aon.com<br />
Linda_J_Smith@ars.aon.com<br />
mstefan@sedgwickcms.com<br />
Page 10 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
482 01/01/00 COORSTEK, INC. Ms. Jan Olszewski Ondrea Matthews<br />
Sentry Insurance Company<br />
Risk Manager<br />
P. O. Box 29466 CoorsTek, Inc.<br />
Phoenix, AZ 85038-9466<br />
16000 Table Mountain Parkway<br />
Golden CO 80403-1693<br />
OFFICE: 480-860-7811 OFFICE: 303-271-7211<br />
FAX: 480-860-7702 FAX: 303-271-7003<br />
EMAIL: jan.olszewski@sentry.com<br />
EMAIL: omatthews@coorstek.com<br />
483 01/01/00 COSTCO WHOLESALE CORPORATION Ms. Elaine Nevens Ms. Ann Loonam<br />
Supervisor<br />
Workers Compensation Program Administrator<br />
Sedgwick CMS<br />
Costco Wholesale Corporation<br />
7400 East Orchard Road, Suite 4015 999 Lake Drive<br />
P. O. Box 5107 (80155-5107) Issaquah, WA 98027-8990<br />
Greenwood Village, CO 80111-2518<br />
P.O.Box14493 Lexington KY 40512-4493<br />
OFFICE: 303-713-6035 OFFICE: 425-313-8547<br />
800-507-9656 FAX: 425-313-8232<br />
FAX: 303-713-6056<br />
EMAIL: aloonam@costco.com<br />
EMAIL: enevens@sedgwickcms.com<br />
976 01/01/81 DENVER, CITY & COUNTY Mr. Raymond F. Sibley Robin Gray<br />
Director, Risk Management 201 W. Colfax Ave #1105<br />
§8-42-124 City <strong>and</strong> County <strong>of</strong> Denver City <strong>and</strong> County <strong>of</strong> Denver<br />
201 West Colfax Avenue, Dept. 1105 201 West Colfax Avenue, Dept. 1105<br />
Denver, CO 80202-5332 Denver, CO 80202-5332<br />
OFFICE: 720-913-3330 OFFICE: 720-913-3330<br />
FAX: 720-913-3184 FAX: 720-913-3184<br />
EMAIL: Robin.Gray@ci.denver.co.us<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
478 01/01/02 DENVER HEALTH & HOSPITAL Mr. Stacy Ross Mr. Richard R Reed, CRM<br />
AUTHORITY CCMSI Director, Risk Management<br />
7600 East Orchard Road, Suite 360N Denver Health & Hospital Authority<br />
Greenwood Village, CO 80111-2518 660 Bannock Street M/C 5015<br />
Denver, CO 80204-4507<br />
OFFICE: 303-804-2032 OFFICE: 303-436-6602<br />
FAX: 303-804-2005 FAX: 303-436-5073<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: rreed@dhha.org<br />
480 07/01/01 DENVER PUBLIC SCHOOLS Ms. Laura Daniels Mr. Stephen Finley<br />
Branch Manager<br />
Director, Risk Management<br />
§8-42-124 Tri-Star Denver Public Schools<br />
200 Union Blvd Ste 580 900 Grant Street<br />
Lakewood, CO 80228 Denver, CO 80203-2907<br />
OFFICE: 720-962-0222 OFFICE: 720-423-3515<br />
FAX: 720-962-0301 FAX: 720-423-3396<br />
EMAIL: laura.daniels@tristargroup.net<br />
EMAIL: stephen_finley@dpsk12.org<br />
Laura Daniels x 3212<br />
847 01/01/92 DOUGLAS COUNTY Ms. Stacy Ross Ms. Sheryl D. Monroe, ARM<br />
State Director<br />
Risk Manager<br />
§8-42-124 CCMSI Douglas County<br />
7600 East Orchard Road, #360N 100 3rd Street<br />
P. O. Box 4998 (80155-4998) Castle Rock, CO 80104-2425<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-804-2032 OFFICE: 303-660-7425<br />
FAX: 303-804-2005 FAX: 303-688-6596<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: smonroe@douglas.co.us<br />
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DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
851 08/01/91 DOUGLAS COUNTY SCHOOL DISTRICT Ms. Stacy Ross Mr. John Zimmerman<br />
RE-1 State Director Risk Manager<br />
CCMSI<br />
Douglas County School District RE-1<br />
7600 East Orchard Road, #360N 620 North Wilcox Street<br />
P. O. Box 4998 (80155-4998) Castle Rock, CO 80104-1739<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-804-2032 OFFICE: 303-387-0037<br />
FAX: 303-804-2005 FAX: 303-387-0110<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: john.zimmerman@dcsdk12.org<br />
943 10/01/72 EASTMAN KODAK COMPANY Ms. Cynthia Tucker Mr. Mark Johnson<br />
Branch Manager<br />
MS CPE<br />
§8-42-124 Gallagher Bassett Services, Inc. Eastman Kodak Company<br />
P. O. Box 4068 200 Ridge Road West<br />
Cancelled effective 5/1/07 Englewood, CO 80155-4068 Rochester, NY 14652-3403<br />
OFFICE: 303-796-9494, x201 OFFICE: 585-588-3868<br />
FAX: 303-796-9498 FAX: 585-722-9856<br />
EMAIL: cynthia_tucker@gbtpa.com<br />
EMAIL: mark.darence.johnson@kodak.com<br />
Brad Rutgers<br />
820 01/01/93 EDWARD C. LEVY COMPANY Director Mr. Kenneth Harrell<br />
ASU Group<br />
Controller<br />
Original Risk Management Edward C. Levy Company<br />
2120 University Park dr 2635 Delta Drive<br />
Anniversary OKEMOS, MI 48864 <strong>Colorado</strong> Springs, CO 80910-1007<br />
Date: 10/01/93 Till 3/31/08<br />
Mr. Joseph Tracey 517-381-7964 OFFICE: 719-392-4207<br />
Regional Claims Manager 517-349-9063 Fax FAX: 719-392-4245<br />
Cambridge Integrated Services Group<br />
EMAIL: dharrell@schmidtconstr.com<br />
P. O. Box 52106 ASU effective 4/1/08<br />
Phoenix, AZ 85004-4577<br />
*Send copy <strong>of</strong> Anniversary letter to:<br />
Ms. Ann Lowery<br />
OFFICE: 602-427-6044 Corporate Risk Manager<br />
FAX: 440-914-2551 Edward C. Levy<br />
EMAIL: joseph.tracey@cambridge-na.com 9300 Dix Street<br />
Detroit, MI 48209-1023<br />
OFFICE: 313-429-2200<br />
FAX: 313-849-9446<br />
EMAIL: alowery@edwclevy.net<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
813 02/01/95 E. I. duPONT DeNEMOURS & COMPANY Mr. Mark DiLoreto Ms. Carole A. Carr<br />
Manager<br />
Insurance Administrator, Finance<br />
Broadspire, A Crawford Company<br />
E. I. duPont deNemours & Company<br />
§8-42-124 P. O. Box 5347 1007 Market Street, #D8065<br />
Denver, CO 80217-5347 Wilmington, DE 19898-0001<br />
OFFICE: 303-752-5420 OFFICE: 302-773-6473<br />
800-321-9515 FAX: 302-773-3428<br />
FAX: 303-752-5425<br />
EMAIL: carole.a.carr@usa.dupont.com<br />
mark.diloreto@choosebroadspire.com<br />
845 01/01/92 EL PASO COUNTY Bev Richmond Ms. Andrea McGee<br />
TriStar risk management<br />
Risk & Workers' Compensation Division Manager<br />
P O Box 5007<br />
El Paso County Risk Management<br />
Bev Richmond Denver CO 80217-5007 27 East Vermijo Avenue, #560<br />
TriStar risk management <strong>Colorado</strong> Springs, CO 80903-2010<br />
P O Box 5007<br />
Denver CO 80217-5007 OFFICE: 720-962-0222 or 888-538-9847 OFFICE: 719-520-7431<br />
FAX: 720-962-0301 FAX: 719-520-7413<br />
EMAIL: beverly.richmond@tristargroup.net EMAIL: <strong>and</strong>reamcgee@elpasoco.com<br />
OFFICE: 720-962-0222<br />
FAX: 720-962-0301<br />
na<br />
EMAIL: beverly.richmond@tristargroup.net<br />
nanenemerenda@elpasoco.com<br />
869 11/01/89 EMERSON ELECTRIC CO. Mr. John Walker Ms. Linda Donahue<br />
Operations Manager<br />
Sr. Insurance Analyst<br />
Sedgwick CMS<br />
Emerson Electric Co.<br />
7400 East Orchard Road, Suite 4015 8000 West Florissant Avenue<br />
P. O. Box 5107 (80155-5107) Building AA, Station 1918<br />
Greenwood Village, CO 80111-2518 St. Louis, MO 63136-8506<br />
OFFICE: 303-713-6030 OFFICE: 314-553-1918<br />
800-507-9656 FAX: 314- 553-2463<br />
FAX: 303-713-6036<br />
EMAIL: linda.donahue@emrsn.com<br />
EMAIL: jewalker@sedgwickcms.com<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
880 01/01/88 EXEMPLA, INC. Mr. John Walker Ms. Michelle Horning<br />
Operations Manager<br />
Occupational Health Services<br />
Original Sedgwick CMS Exempla, Inc.<br />
Anniversary 7400 East Orchard Road, Suite 4015 3655 Lutheran Parkway, Suite 407<br />
P. O. Box 5107 (80155-5107) Wheat Ridge, CO 80022-6009<br />
Date: 08/01/88 Greenwood Village, CO 80111-2518<br />
OFFICE: 303-713-6030 OFFICE: 303-425-2603<br />
800-507-9656 FAX: 303-467-8789<br />
FAX: 303-713-6056<br />
EMAIL: horningm@exempla.org<br />
EMAIL: jewalker@sedgwickcms.com<br />
883 05/01/88 FEDERAL EXPRESS CORPORATION Ms. Debbie Baird Ms. Julia Stegall<br />
Claims Supervisor<br />
Federal Express Risk Management<br />
Sedgwick CMS<br />
Federal Express Corporation<br />
7400 East Orchard Road, Suite 4015 3620 Hacks Cross Road<br />
P. O. Box 5107 (80155-5107) Building B, 3rd Floor<br />
Greenwood Village, CO 80111-2518 Memphis, TN 38125-8800<br />
OFFICE: 303-713-6010 OFFICE: 901-434-4557<br />
800-507-9656 FAX: 901-434-4585<br />
FAX: 303-713-6056<br />
EMAIL: jgstegall@fedex.com<br />
EMAIL: dbaird@sedgwickcms.com<br />
464 02/01/06 FEDERATED DEPARTMENT STORES, INC. Mr. Tom Conrad Mr. Ron Godfrey<br />
Workers' Compensation Manager<br />
Director, Risk Management<br />
Macy's (Federated <strong>Department</strong> Stores), Inc.<br />
Macy's (Federated <strong>Department</strong> Stores), Inc.<br />
Name Change to Macy's, inc. effective 6/1/07 7 West Seventh Street<br />
7 West Seventh Street<br />
Cincinnati, OH 45202-2424 Cincinnati, OH 45202-2424<br />
OFFICE: 513-579-7996 OFFICE: 513-579-7628<br />
FAX: 513-579-7115 FAX: 513-579-7174<br />
EMAIL: tom.conrad@fds.com<br />
EMAIL: ron.godfrey@fds.com<br />
ron.godfrey@macys.com<br />
tom.conrad@macys.com<br />
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DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
849 10/01/91 FEDEX FREIGHT WEST, INC. Mr. Joseph Tracey Ms. Deborah Newby<br />
Manager<br />
Risk Manager<br />
Cambridge Integrated Services Group<br />
FedEx Freight West, Inc.<br />
P. O. Box 52106 6411 Guadalupe Mines Road<br />
Phoenix, AZ 85072-2106 Suite 3180<br />
San Jose, CA 95120-5000<br />
OFFICE: 602-427-6044 OFFICE: 408-323-4147<br />
FAX: 847-953-0997 FAX: 870-365-4814<br />
EMAIL: joseph.tracey@cambridge-na.com<br />
MAIL: deborah.newby@freight.fedex.com<br />
865 01/01/90 FEDEX GROUND PACKAGE SYSTEMS, INC. Mr. Mark DiLoreto Mr. Larry Parks<br />
Manager<br />
Senior Manager, Workers’ Compensation<br />
Broadspire, A Crawford Company<br />
FedEx Ground Package Systems, Inc.<br />
9200 East Panorama Circle, Suite 160 3875 Embassy Parkway, 3rd Floor, Suite 320<br />
P. O. Box 6502 (80155-6502) P. O. Box 5459<br />
Englewood, CO 80112-3490 Akron, OH 44334-0459<br />
OFFICE: 720-875-9021 OFFICE: 330-665-8512<br />
FAX: 720-875-9040 FAX: 330-665-8522<br />
EMAIL: mark.diloreto@choosebroadspire.com EMAIL: larry.parks@fedex.com<br />
893 09/15/87 FORD MOTOR COMPANY Ms. Debbie Hopkins Mr. Richard Wood<br />
WC Claims Supervisor<br />
Ford Motor Company<br />
ESIS<br />
19540 Allen Road<br />
P. O. Box 31082 Melvindale, MI 48122-1622<br />
Tampa, FL 33631-3082<br />
OFFICE: 800-992-7578 OFFICE: 313-248-9917<br />
FAX: 800-208-8281 FAX: 313-206-4660<br />
EMAIL: debbie.hopkins@esis.com<br />
EMAIL: rwood4@ford.com<br />
lmcdon16@ford.com<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
876 01/01/89 FORT COLLINS, CITY OF Ms. Stacy Ross Mr. Lance Murray<br />
State Director<br />
Risk Manager<br />
§ 8-42-124 CCMSI City <strong>of</strong> Fort Collins<br />
7600 East Orchard Road, #360N Risk Management Division<br />
P. O. Box 4998 (80155-4998) P. O. Box 580<br />
Greenwood Village, CO 80111-2518 Ft. Collins, CO 80522-0580<br />
OFFICE: 303-804-2032 OFFICE: 970-221-6807<br />
FAX: 303-804-2005 FAX: 970-221-6296<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: lmurray@fcgov.com<br />
815 01/01/94 FREEDOM COMMUNICATIONS, INC. Mr. John Walker Lynda L. Bemis<br />
Operations Manager<br />
Risk & Enterprise Services<br />
Original Sedgwick CMS Freedom Communications, Inc.<br />
Anniversary 7400 East Orchard Road, Suite 4015 17666 Fitch<br />
P. O. Box 5107 (80111-5107) Irvine, CA 92614-6022<br />
Date: 04/15/94 Greenwood Village, CO 80111-2518<br />
OFFICE: 303-713-6030 OFFICE: 949-253-2334<br />
800-507-9656 FAX: 949-798-3566<br />
FAX: 303-713-6056<br />
EMAIL: lbemis@freedom.com<br />
EMAIL: jewalker@sedgwickcms.com<br />
elaine.nevens@sedgwickcms.com<br />
909 01/01/66 GATES CORPORATION CLAIMS 06/01/03 & FORWARD<br />
Ms. Suzanne Limppo<br />
Ms. Jeanette McAl<strong>list</strong>er<br />
Gallagher Basset Services, Inc.<br />
HSE/Manager, Workers’ Compensation<br />
The Quorum West, Suite 305<br />
Gates Corporation<br />
Revoked 6/1/08 7935 East Prentice Avenue P. O. Box 5887<br />
Englewood, CO 80111-2717<br />
1551Wewatta Street<br />
Denver, CO 80217-5887<br />
OFFICE: 303-796-9494, x218 OFFICE: 303-744-5072<br />
FAX: 303-796-9498 FAX: 303-744-4895<br />
EMAIL: suzanne_ limppo@gbtpa.com<br />
EMAIL: jmcal<strong>list</strong>er@gates.com<br />
CLAIMS PRIOR TO 06/01/03<br />
Ms. Tamara Corbin<br />
Senior Account Manager<br />
GAB Robins North America<br />
3350 Shelby Street, Suite 300<br />
Ontario, CA 91764-4882<br />
OFFICE: 909-941-3247<br />
FAX: 909-484-2597<br />
EMAIL: corbint@gabrobins.com<br />
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DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
834 01/01/93 GOODRICH CORPORATION Ms. Nhu Miller Judy Salas<br />
Specialty Risk Services<br />
Human Resources Manager<br />
§ 8-42-124 P. O. Box 221700 Goodrich Corporation<br />
Denver, CO 80222-8700<br />
50 William White Boulevard<br />
Pueblo, CO 81001-4856<br />
judy.salas@goodrich.com<br />
OFFICE: 800-829-7985 OFFICE: 719-948-0403<br />
303-645-8644 FAX: 719-948-3112<br />
FAX: 303-645-8654<br />
EMAIL: barrie.green@goodrich.com<br />
EMAIL: nhu.miller@srsconnect.com<br />
887 01/01/88 GRAND JUNCTION, CITY OF CLAIMS 02/01/06 & FORWARD Mr. David L. Roper<br />
City <strong>of</strong> Gr<strong>and</strong> Junction<br />
Ms. Karen Marie Lesko<br />
250 North 5th Street<br />
Director, Sales & Claims Services Gr<strong>and</strong> Junction, CO 81501-2668<br />
TRI-Star Risk Management<br />
200 Union Boulevard, Suite 580<br />
P. O. Box 5007 (80217-5007)<br />
Denver, CO 80228-1849<br />
OFFICE: 720-962-0274 OFFICE: 970-244-1592<br />
FAX: 720-762-0301 FAX: 970-256-4007<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: daver@ci.gr<strong>and</strong>jct.co.us<br />
889 09/30/87 HEWLETT-PACKARD COMPANY Mr. John Walker Ms. Cristina Tate<br />
Operations Manager<br />
Hewlett-Packard Company<br />
Sedgwick CMS<br />
3000 Hanover Street<br />
7400 East Orchard Road, Suite 4015 Mail Stop 1041<br />
P. O. Box 5107 (80155-5107) Palo Alto, CA 94304-1181<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-713-6030 OFFICE: 650-236-2563<br />
800-507-9656 650-857-6940<br />
FAX: 303-713-6047 FAX: 650-852-8116<br />
EMAIL: jewalker@sedgwickcms.com<br />
EMAIL: cristina.tate@hp.com<br />
janice.styles@hp.com<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
811 08/01/95 HYATT CORPORATION Ms. Cynthia Tucker Ms. Kelly Wasilewski<br />
Branch Manager<br />
Director, Risk Management<br />
Gallagher Bassett Services, Inc.<br />
Administration<br />
P. O. Box 4068 Hyatt Corporation<br />
Englewood, CO 80155-4068<br />
71 South Wacker Drive, 14th Floor<br />
Chicago, IL 60606-4637<br />
OFFICE: 303-796-9494, x201 OFFICE: 312-780-5509<br />
FAX: 303-796-9498 FAX: 312-780-5284<br />
EMAIL: cynthia_tucker@gbtpa.com<br />
EMAIL: kelly.wasilewski@corphq.hyatt.com<br />
853 07/01/91 INTERNATIONAL PAPER COMPANY Ms. Courtney Thomas Ms. Penny Humphrey<br />
Examiner<br />
WC Insurance Administrator<br />
Sedgwick CMS<br />
International Paper Company<br />
500 North Akard Street, Suite 2200 6400 Poplar Avenue, Tower 3<br />
Dallas, TX 75201-3302 Memphis, TN 38197<br />
OFFICE: 214-849-5018 OFFICE: 901-419-3938<br />
FAX: 214-849-5201 FAX: 901-419-3940<br />
EMAIL: cathomas@sedgwickcms.com<br />
EMAIL: penny.humphrey@ipaper.com<br />
875 01/01/89 JEFFERSON COUNTY Linda Mitchell Linda Mitchell<br />
Workers' Compensation Analyst<br />
Benefits & Workers' Compensation Manager<br />
§8-42-124 Jefferson County Human Resources<br />
3500 Illinois Street, Suite 2500 Jefferson County<br />
Golden, CO 80401-6023 3500 Illinois Street, Suite 2500<br />
Golden, CO 80401-6023<br />
OFFICE: 303-271-8430 OFFICE: 303-271-8405<br />
FAX: 303-271-8442 FAX: 303-271-8442<br />
EMAIL: twise@jeffco.us<br />
EMAIL: lmitchl@jeffco.us<br />
lmitchl@jeffco.us<br />
303-271-8430<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
973 07/01/80 JEFFERSON COUNTY SCHOOL Ms. Sally Phillips Joel Hirschback<br />
DISTRICT R-1 Insurance Manager Insurance Manager<br />
Risk Management <strong>Department</strong><br />
Risk Management <strong>Department</strong><br />
Jefferson County School District R-1 Jefferson County School District R-1<br />
§8-42-124 P. O. Box 4001 P. O. Box 4001<br />
Golden, CO 80401-0001 Golden, CO 80401-0001<br />
OFFICE: 303-982-2439 OFFICE: 303-982-2439<br />
FAX: 303-982-2447 FAX: 303-982-2447<br />
EMAIL: sphillip@jeffco.k12.co.us<br />
Ms. Sally Phillips<br />
jhirschb@jeffco.k12.co.us<br />
840 01/01/92 KAISER FOUNDATION HEALTH PLAN Mr. John Walker Arne Haram, M.S.<br />
OF COLORADO Operations Manager Human Resources <strong>Department</strong><br />
Sedgwick CMS<br />
Kaiser Foundation Health Plan <strong>of</strong> <strong>Colorado</strong><br />
7400 East Orchard Road, Suite 4015 10065 E Harvard Ave suite 400<br />
Original P. O. Box 5107 (80155-5107) Denver, CO 80231<br />
Anniversary Greenwood Village, CO 80111-2518<br />
Date: 04/01/92<br />
OFFICE: 303-713-6030 OFFICE: 303-614-1546<br />
800-507-9656 FAX: 303-614-1495<br />
FAX: 303-713-6056<br />
arne.i.haram@kp.org<br />
EMAIL: jewalker@sedgwickcms.com<br />
475 08/01/03 KNIGHT TRANSPORTATION, INC. Avizent/Frank Gates Company Mr. Brett Sant<br />
5353 N 16th st Suite 250 Vice President, Safety<br />
Phoenix, AZ 85016-3225<br />
Knight Transportation, Inc.<br />
5601 West Buckeye Road<br />
Effective 11/1/08 Phoenix, AZ 85043-4603<br />
Till 12/31/08 Leo Mccann OFFICE: 602-606-6218 OR 800-489-2000, x218<br />
Ms. Michelle Murray Vice-President Avizent/Frank Gates Company FAX: 602-606-6118<br />
Baldwin & Lyons, Inc. 5000 Bradenton Ave EMAIL: bsant@knighttrans.com<br />
1099 North Meridian, Suite 700 Dublin OH 43017<br />
Indianapolis, IN 46204-1036 614-791-7642<br />
OFFICE: 317-636-9800, x320<br />
614-932-8663 Fax<br />
FAX: 317-632-9444<br />
"lmccann@avizentrisk.com<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
Lisa Olson Assistant Operations Manager<br />
962 02/01/78 KROGER COMPANY, THE Mr. Tim Nockels Mr. Mark Gully<br />
Operations Manager<br />
Corporate Claims Manager<br />
Sedgwick CMS<br />
The Kroger Company<br />
215 South State Street, Suite 420 1014 Vine st<br />
Salt Lake City, UT 84111-2326 Cincinnati, OH 45202-1100<br />
Lisa 801-258-9751<br />
OFFICE: 801-258-9712 OFFICE: 513-762-1507<br />
FAX: 801-258-9730 FAX: 513-762-<br />
EMAIL: tim.nockels@sedgwickcms.com<br />
EMAIL: mark.gully@kroger.com<br />
lisa.olson@sedgwickcms.com<br />
481 09/01/00 LABOR READY, INC. Janet Johnson Stephanie Vezina<br />
State Reporting Associate<br />
Risk Finance<br />
ESIS, Inc<br />
<strong>Labor</strong> Ready, Inc.<br />
120 North 9th st P. O. Box 2910<br />
Richmond, IN 47374 Tacoma, WA 98401-2910<br />
OFFICE: 253-680-8484 OR 800-610-8920<br />
Office: 765-983-6244 FAX: 253-502-5865 OR 800-850-9809<br />
Fax: 765-983-6303<br />
EMAIL: svezina@laborready.com<br />
janet.johnson@esis.com<br />
896 01/01/87 LAKEWOOD, CITY OF Adusting claims in house effective 1/1/08 Mr. Ken Milano<br />
<strong>Department</strong> <strong>of</strong> Employee Relations<br />
§8-42-124 Risk Management Division<br />
Ms. Stacy Ross sross@ccmsi.com Dee Ann Pfifer City <strong>of</strong> Lakewood<br />
State Director City <strong>of</strong> Lakewood 480 South Allison Parkway<br />
CCMSI Risk Management Coordinator Lakewood, CO 80226-3123<br />
7600 East Orchard Road, #360N Employee Relations<br />
P. O. Box 4998 (80155-4998) 303-987-7660 OFFICE: 303-987-7701<br />
Greenwood Village, CO 80111-2518 FAX: 303-987-7712 FAX: 303-987-7712<br />
deepfi@lakewood.org<br />
EMAIL: kenmil@lakewood.org<br />
CCMSI will adjust claims on or before 123107 deepfi@lakewood.org<br />
OFFICE: 303-804-2032<br />
FAX: 303-804-2005<br />
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
01/01/88 LARIMER COUNTY Ms. Karen Marie Lesko Jeff Green<br />
Director, Sales & Claims Services<br />
Risk Manager<br />
§8-42-124 TRI-Star Risk Management Larimer County<br />
200 Union Boulevard, Suite 580 2555 Midpoint Drive, Suite B<br />
P. O. Box 5007 (80217-5007) Fort Collins, CO 80525-4425<br />
Denver, CO 80228-1849<br />
jlgreen@larimer.org<br />
OFFICE: 720-962-0274 OFFICE: 970-498-5962<br />
FAX: 720-962-0301 FAX: 970-498-5965<br />
EMAIL: karen.lesko@TRI-Stargroup.net<br />
EMAIL: salex<strong>and</strong>er@larimer.org<br />
465 01/01/06 LITTLETON, CITY OF Ms. Stacy Ross Mr. Joseph M. Gryniewicz, Jr.<br />
State Director<br />
SPHR, <strong>Employment</strong> <strong>and</strong> Risk Manager<br />
CCMSI<br />
City Of Littleton<br />
7600 East Orchard Road, #360N 2255 West Berry Avenue<br />
P. O. Box 4998 (80155-4998) Littleton, CO 80120-1151<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-804-2032 OFFICE: 303-795-3857<br />
FAX: 303-804-2005 FAX: 303-795-3794<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: jgryniewicz@littletongov.org<br />
890 10/01/87 LONGMONT, CITY OF Ms. Kim Brunson Ms. Kim Brunson<br />
Claims Adjuster<br />
Claims Adjuster<br />
§8-42-124 City <strong>of</strong> Longmont City <strong>of</strong> Longmont<br />
Civic Center Complex<br />
Civic Center Complex<br />
350 Kimbark 350 Kimbark<br />
Longmont, CO 80501-5500 Longmont, CO 80501-5500<br />
OFFICE: 303-651-8724 OFFICE: 303-651-8724<br />
FAX: 303-774-4314 FAX: 303-774-4314<br />
EMAIL: kim.brunson@ci.longmont.co.us<br />
EMAIL: kim.brunson@ci.longmont.co.us<br />
Page 22 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
466 09/01/05 LOWE’S HIW, INC. Ms. Nhu Miller Ms. Tia Schweikert<br />
Specialty Risk Services<br />
Manager, Workers’ Compensation<br />
P. O. Box 221700 Lowe’s HIW, Inc.<br />
Denver, CO 80222-8700 P. O. Box 1000<br />
Mooresville, NC 28115-1000<br />
OFFICE: 303-645-8644 OFFICE: 704-758-3055<br />
800-829-7985 FAX: 704-757-0530<br />
FAX: 303-645-8654<br />
EMAIL: tia.l.schweikert@lowes.com<br />
EMAIL: nhu.miller@srsconnect.com<br />
485 01/01/99 LSI LOGIC CORPORATION Suzanne L Wilson Ms. Karen Miller, ARM<br />
Vice President<br />
Risk Manager<br />
Original Matrix Absence Management LSI Logic Corporation<br />
Anniversary 5225 Hellyer Ave # 210 1621 Barber Lane, MS: AD-106<br />
Date: 09/01/99 San Jose CA 95138-1001 Milipitas, CA 95035-7455<br />
Off: 408-361-7321 OFFICE: 408-433-7022<br />
FAX: 408-361-9110 FAX: 408-954-3634<br />
EMAIL: suzanne.wilson@matrixcos.com<br />
EMAIL: karen.miller@lsi.com<br />
4700 Lincoln Avenue, Suite 104<br />
Albuquerque, NM 87109-2303<br />
464 02/01/06 Macy's inc Please see Federated <strong>Department</strong> Stores<br />
824 04/01/93 MC LANE COMPANY, INC. Mr. Larry Stadler Ms. Melanie Bennett<br />
Claims Manager - Phoenix<br />
Corporate Senior Supervisor Accountant<br />
AIG Claims Service, Inc.<br />
McLane Company, Inc.<br />
2929 North Central Avenue, 9th Floor 4747 McLane Parkway<br />
Phoenix, AZ 85102-2727 Temple, TX 76503-6115<br />
OFFICE: 602-468-8708 OFFICE: 254-771-7428<br />
800-456-1547 FAX: 254-770-5387<br />
FAX: 1+866-743-1908<br />
EMAIL: melanie.bennett@mclaneco.com<br />
EMAIL: larry.stadler@aig.com<br />
karen.nitsch@aig.com<br />
Page 23 6/22/2009
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PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
814 08/01/94 MEMORIAL HOSPITAL Will Mercado Will Mercado<br />
Memorial Health System<br />
Memorial Health System<br />
§8-42-124 (2) 2502 Pikes Peak Ave #108 2502 Pikes Peak Ave #108<br />
<strong>Colorado</strong> Springs, CO 80909-5533 <strong>Colorado</strong> Springs, CO 80909-5533<br />
guillermo.mercado@memorialhealthsystem.com<br />
G<br />
OFFICE: 719-365-1192 OFFICE: 719-365-1192<br />
FAX: 719-365-6812 FAX: 719-365-6812<br />
guillermo.mercado@memorialhealthsystem.com<br />
473 01/01/04 MESA COUNTY Ms. Karen Marie Lesko Mr. Mark Reitz, C.P.M.<br />
Director, Sales & Claims Services<br />
Mesa County Purchasing &<br />
§8-42-124 (2) TRI-Star Risk Management Risk Management Division<br />
200 Union Boulevard, Suite 580 Mesa County<br />
P. O. Box 5007 (80217-5007) 544 Rood Avenue, 2nd Floor<br />
Lakewood, CO 80228-1849 P. O. Box 20000<br />
Gr<strong>and</strong> Junction, CO 81501-5063<br />
Norie Mayne 720-962-0286 720-962-0301 Fax Jean Boothe Risk Specia<strong>list</strong> 970-244-1868<br />
OFFICE: 720-962-0274 OFFICE: 970-255-7150<br />
FAX: 720-762-0301 FAX: 970-244-1868<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: mark.reitz@mesacounty.us<br />
Norie.mayn@tristargroup.com jean.boothe@mesacounty.us<br />
476 07/01/03 MESA COUNTY VALLEY SCHOOL Ms. Karen Marie Lesko Ms. Sheila Naski<br />
DISTRICT 51 Director, Sales & Claims Services Workers’ Compensation<br />
TRI-Star Risk Management Mesa County Valley School District 51<br />
§8-42-124(2) 200 Union Boulevard, Suite 580 2115 Gr<strong>and</strong> Avenue<br />
P. O. Box 5007 (80217-5007) Gr<strong>and</strong> Junction, CO 81501-8007<br />
Lakewood, CO 80228-1849<br />
OFFICE: 720-962-0274 OFFICE: 970-254-5176<br />
FAX: 720-762-0301 FAX: 970-254-5284<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: shenaski@mesa.k12.co.us<br />
Page 24 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
817 01/01/94 NATIONAL JEWISH MEDICAL AND Ms. Karen Marie Lesko Ms. Tamara Barhite<br />
RESEARCH CENTER Director, Sales & Claims Services Benefits <strong>and</strong> Compensation Manager<br />
TRI-Star Risk Management<br />
National Jewish Medical <strong>and</strong><br />
200 Union Boulevard, Suite 580 Research Center<br />
P. O. Box 5007 (80217-5007) 1400 Jackson Street, G-115<br />
Denver, CO 80228-1849 Denver, CO 80206-2761<br />
OFFICE: 720-962-0274 OFFICE: 303-398-1037<br />
FAX: 720-762-0301 FAX: 303-398-1775<br />
EMAIL: karen.lesko@tristargroup.net<br />
EMAIL: BarhiteT@njc.org<br />
barhitet@njhealth.org or kjeldenl@njhealth.org<br />
497 07/01/96 NORDSTROM, INC. CLAIMS 07/01/06 & FORWARD<br />
Steve Tolan<br />
Ms. Debbie Bordeaux<br />
Workers' Compensation Manager<br />
Network Administrator<br />
Nordstrom, Inc.<br />
Nordstrom, Inc.<br />
P. O. Box 25799 P. O. Box 21865<br />
Santa Ana, CA 92799-5799 Seattle, WA 98111-3865<br />
OFFICE: 714-513-4766 OFFICE: 206-303-2506<br />
FAX: 714-513-4778 FAX: 206-303-2689<br />
EMAIL: steve.tolan@nordstrom.com<br />
EMAIL: debbie.bordeaux@nordstrom.com<br />
CLAIMS PRIOR TO 07/01/06<br />
Mr. Bob Haugen<br />
Workers’ Compensation Manager<br />
Nordstrom, Inc.<br />
P. O. Box 21865<br />
Seattle, WA 98111-3865<br />
OFFICE: 206-303-2500<br />
877-275-7475, x6549<br />
FAX: 206-303-2689<br />
EMAIL: bob.haugen@nordstrom.com<br />
Page 25 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
826 03/01/93 OREGON STEEL MILLS, INC. (d.b.a. Rocky Mr. John Walker Ms. Carolyn Bjur<br />
Mountain Steel Mills) Operations Manager Corporation Manager<br />
Sedgwick CMS, Inc.<br />
Workers’ Compensation<br />
7400 East Orchard Road, Suite 4015 Rocky Mountain Steel Mills<br />
P. O. Box 5107 (80155-5107) P. O. Box 5368<br />
Greenwood Village, CO 80111-2518 Portl<strong>and</strong>, OR 97228-5368<br />
OFFICE: 303-713-6030 OFFICE: 503-240-5239<br />
800-507-9656 FAX: 503-240-5798<br />
FAX: 303-713-6056<br />
EMAIL: bjurc@osm.com<br />
EMAIL: jewalker@sedgwickcms.com<br />
472 04/15/04 PEABODY ENERGY CORPORATION Ms. Stacy Ross Shannon Orl<strong>and</strong>o<br />
State Director<br />
Manager--Insurance Claims<br />
CCMSI<br />
Peabody Energy Corporation<br />
7600 East Orchard Road, #360N 701 Market Street, Suite 600<br />
P.O. Box 4998 (80155-4998) St. Louis, MO 63101-1826<br />
Greenwood Village, CO 80111-2517<br />
OFFICE: 314-342-3469<br />
OFFICE: 303-804-2032 FAX: 314-342-7740<br />
FAX: 303-804-2005<br />
EMAIL: sorl<strong>and</strong>o@peabodyenergy.com<br />
EMAIL: sross@ccmsi.com<br />
Lynnette M. Rasch LEFT Peabody Feb 2009<br />
Wendy Garcia, Acct Supervisor<br />
828 01/01/93 PITKIN COUNTY Ms. Stacy Ross Laura Laubhan<br />
State Director<br />
Human Resources manager<br />
§8-42-124 CCMSI Pitkin County<br />
7600 East Orchard Road, #360N 530 East Main Street, Suite 202<br />
P. O. Box 4998 (80155-4998) Aspen, CO 81611-1948<br />
Greenwood Village, CO 80111-2518<br />
krisj@co.pitkin.co.us Kris Jewkes Risk Mgmt Coordina<br />
OFFICE: 303-804-2032 OFFICE: 970-429-2792<br />
FAX: 303-804-2005 FAX: 970-920-5049<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: laural@co.pitkin.co.us<br />
Vicky Roden Account Mgr CCMSI vroden@ccmsi.com<br />
Page 26 6/22/2009
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PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
885 01/01/88 PORTERCARE ADVENTIST HEALTH Ms. Stacy Ross Mr. Richard Osborn<br />
SYSTEM State Director Director, Risk Management<br />
CCMSI<br />
PorterCare Adventist Health System<br />
7600 East Orchard Road, #360N 2525 South Downing Street<br />
P. O. Box 4998 (80155-4998) Denver, CO 80210-5876<br />
Canceled effective midnight 1/31/09 Greenwood Village, CO 80111-2518<br />
In Adventist Health Systems effective 2/1/09 OFFICE: 303-804-2032 OFFICE: 303-778-2538<br />
FAX: 303-804-2005 FAX: 303-778-5295<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: richardosborn@centura.org<br />
897 01/01/87 POUDRE SCHOOL DISTRICT R-1 Ms. Stacy Ross Ms. Kristin Bennett<br />
State Director<br />
Benefits Manager<br />
§8-42-124 CCMSI Poudre School District R-1<br />
7600 East Orchard Road, #360N 2407 LaPorte Avenue<br />
P. O. Box 4998 (80155-4998) Ft. Collins, CO 80521-2297<br />
Greenwood Village, CO 80111-2518<br />
A1 OFFICE: 303-804-2032 OFFICE: 970-490-3627<br />
FAX: 303-804-2005 FAX: 970-490-3529<br />
EMAIL: sross@ccmsi.com<br />
EMAIL: kbennett@psdschools.org<br />
Kathy Lindgren<br />
871 04/01/89 POUDRE VALLEY HEALTH CARE, INC. Vicky Roden Diane M Gross<br />
CCMSI<br />
Associate General Counsel<br />
Original 7600 East Orchard Road, #360N Poudre Valley Health System<br />
Anniversary P. O. Box 4998 (80155-4998) 2315 Harmony Rd Suite 200<br />
Date: 01/01/89 Mr. Gary Swenson till 12/31/08 Greenwood Village CO 80111-2518 Ft. Collins, CO 80528-3929<br />
Director 303-804-2031<br />
Support Services, Inc. 217-477-3007 Fax OFFICE: 970-237-7030<br />
7335 East Orchard Road, Suite 200 FAX: 970-237-7094<br />
Greenwood Village, CO 80111-2518 vroden@ccmsi.com EMAIL: dmg5@pvhs.org<br />
OFFICE: 720-489-9300<br />
FAX: 720-489-1166<br />
EMAIL: gary.swenson@cha.com<br />
All SI period claims adjusted by CCMSI<br />
Page 27 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
843 01/01/92 PRECISION CASTPARTS CORPORATION - CLAIMS 01/01/06 & FORWARD<br />
ADVANCED FORMING TECHNOLOGIES<br />
Ms. Debbie Baird<br />
Ms. Mim Duffy<br />
Sedgwick CMS<br />
Human Resources Manager<br />
7400 East Orchard Road, Suite 4015 Precision Castparts Corporation -<br />
P. O. Box 5107 (80155-5107) Advanced Forming Technologies<br />
Greenwood Village, CO 80111-2518 7040 Weld County Road 20<br />
Longmont, CO 80504-9423<br />
OFFICE: 303-713-6010 OFFICE: 303-833-6012<br />
800-507-9656 FAX: 303-833-6440<br />
FAX: 303-713-6056<br />
EMAIL: mduffy@pcc-aft.com<br />
EMAIL: dbaird@sedgwickcms.com<br />
CLAIMS PRIOR TO 01/01/06<br />
Mr. Wes Johnson<br />
ESIS<br />
P. O. Box 911<br />
Portl<strong>and</strong>, OR 97207-0911<br />
OFFICE: 503-598-1477<br />
FAX: 503-431-6811<br />
EMAIL: Wesley.Johnson@esis.com<br />
494 01/01/97 PRINCIPAL FINANCIAL GROUP, INC. Mr. Steve C. Jones Ms. Lori Diercks<br />
Claim Analyst<br />
Assistant Claim Manager<br />
Principal Financial Group, Inc.<br />
Principal Financial Group, Inc.<br />
711 High Street 711 High Street<br />
Des Moines, IA 50392-2040 Des Moines, IA 50392-2040<br />
OFFICE: 515-248-2274 OFFICE: 515-247-6761<br />
FAX: 866-496-6524 FAX: 866-496-6524<br />
EMAIL: Jones.Steve.C@principal.com<br />
EMAIL: diercks.lori@principal.com<br />
Page 28 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
857 01/01/91 PUEBLO, CITY OF Bill Rush Ms. Beth Vega<br />
Director Risk Management<br />
Director, Personnel<br />
§8-42-124 Summit Point Consulting City <strong>of</strong> Pueblo<br />
P O Box 5130 P. O. Box 1427<br />
Denver CO 80217-5130 Pueblo, CO 81002-1427<br />
OFFICE: 303-721-3265 OFFICE: 719-553-2633<br />
All <strong>Self</strong>-Insurance period claims transferred FAX: 719-553-2696<br />
from SCA to Summit effective 1/1/08 FAX: 303-721- EMAIL: bvega@pueblo.us<br />
EMAIL: RWilber@SCA-Ins.com d<strong>and</strong>erson@pueblo.us<br />
Mr. Ray Wilber, ARM<br />
836 07/01/92 PUEBLO SCHOOL DISTRICT NO. 60 Bill Rush Ms. Patricia L. Gonzalez<br />
Director Risk Management<br />
Executive Director <strong>of</strong> Staff Relations<br />
§8-42-124 Summit Point Consulting Human Resources Office<br />
P O Box 5130<br />
315 W 11th st<br />
Denver CO 80217-5130 Pueblo, CO 81003-2804<br />
OFFICE: 303-721-3265<br />
All <strong>Self</strong>-Insurance period claims transferred OFFICE: 719-549-7132<br />
from SCA to Summit effective 1/1/08 FAX: 303-721- FAX: 719-253-6042<br />
EMAIL: RWilber@SCA-Ins.com<br />
EMAIL: pgonzale@pueblo60.k12.co.us<br />
Mr. Ray Wilber, ARM<br />
891 10/01/87 R. R. DONNELLEY & SONS Ms. Cynthia Tucker Mr. Timothy Gagen<br />
Branch Manager<br />
Senior Risk Analyst<br />
Gallagher Bassett Services, Inc.<br />
R. R. Donnelley & Sons<br />
Canceled effective 7/1/07 P. O. Box 4068 111 South Wacker Drive, 37th Floor<br />
Englewood, CO 80155-4068 Chicago, IL 60606-4301<br />
OFFICE: 303-796-9494, x201 OFFICE: 312-326-8925<br />
FAX: 303-796-9498 FAX: 312-326-8557<br />
EMAIL: cynthia_tucker@gbtpa.com<br />
EMAIL: timothy.gagen@rrd.com<br />
Page 29 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
972 03/01/80 REGIONAL TRANSPORTATION DISTRICT Mr. Robert L. Medina Mr. Robert L. Medina<br />
Risk Manager<br />
Risk Manager<br />
Regional Transportation District<br />
Regional Transportation District<br />
1600 Blake Street 1600 Blake Street<br />
Denver, CO 80202-1324 Denver, CO 80202-1324<br />
OFFICE: 303-299-2715 OFFICE: 303-299-2715<br />
FAX: 303-299-2029 FAX: 303-299-2029<br />
EMAIL: robert.medina@rtd-denver.com<br />
EMAIL: robert.medina@rtd-denver.com<br />
960 02/18/77 SAFEWAY, INC. Ms. Debbie Dunst Ms Chi Nguyen<br />
Workers’ Compensation Manager<br />
Loss Control Analyst<br />
Safeway, Inc.<br />
Corporate Workers' Compensation<br />
6900 South Yosemite Street Risk Management<br />
P. O. Box 5927 T.A. Safeway, Inc.<br />
Englewood, CO 80112-1418<br />
4410 Rosewood Drive<br />
Pleasanton, CA 94588-3050<br />
OFFICE: 303-843-7870 OFFICE: 925-226-5074<br />
FAX: 303-843-7948 FAX: 925-226-5990<br />
EMAIL: debbie.dunst@safeway.com<br />
EMAIL: chi.nguyen2@safeway.com<br />
jim.walmann@safeway.com<br />
827 01/01/93 SALVATION ARMY, THE Ms. Nhu Miller Mr. John McCarthy<br />
Team Leader<br />
Director, Risk Management<br />
Specialty Risk Services<br />
The Salvation Army<br />
7670 South Chester Street, Suite 320 180 East Ocean Boulevard<br />
Englewood, CO 80112-3439 Long Beach, CA 90802-4709<br />
OFFICE: 800-829-7985 OFFICE: 562-491-8380<br />
303-645-8644 FAX: 562-491-8793<br />
FAX: 303-645-8654<br />
EMAIL: evelyn.garcia@usw.salvationarmy.org<br />
EMAIL: nhu.miller@srsconnect.com<br />
john.mccarthy@usw.salvationarmy.org<br />
Page 30 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
492 03/01/97 SISTERS OF CHARITY OF LEAVENWORTH Ms. Karin Carstensen Ms. Kathleen Miner Tulipana<br />
SYSTEM, INC. Claims Examiner System Director, Risk Management<br />
Sedgwick CMS<br />
Sisters <strong>of</strong> Charity <strong>of</strong> Leavenworth Health System, Inc.<br />
10909 Mill Valley Road 9801 Renner Boulevard, Suite 100<br />
Omaha, NE 68154-3950 Lenexa, KS 66219-9745<br />
OFFICE: 402-496-2000 OFFICE: 913-895-2843<br />
FAX: 402-496-6511 FAX: 913-895-2910<br />
EMAIL: k.carstensen@sedgwickcms.com<br />
EMAIL: kathleen.tulipana@sclhs.net<br />
848 11/01/91 SMURFIT-STONE CONTAINER Mr. Mark DiLoreto Monica Lavy<br />
ENTERPRISES, INC. Service Center Manager Casualty & <strong>Self</strong> Insurance Specia<strong>list</strong><br />
Broadspire, A Crawford Company<br />
Smurfit-Stone Container Enterprises, Inc.<br />
9200 East Panorama Circle, Suite 160 Six CityPlace Drive<br />
P. O. Box 6502 (80155-6502) Creve Coeur, MO 63141-7167<br />
Englewood, CO 80112-3490<br />
OFFICE: 720-875-9204 OFFICE: 314-656-5433<br />
FAX: 720-875-9040 FAX: 314-787-6182<br />
EMAIL: mark.diloreto@choosebroadspire.com EMAIL: cmalawy@smurfit.com<br />
mlavy@smurfit.com<br />
487 05/17/99 SORIN Group USA Please see Cobe Cardiovascular<br />
499 07/01/96 STATE OF COLORADO Teree Carr Joel Hirschboeck<br />
Business Director<br />
Risk Manager<br />
§8-42-124 PINNACOL ASSURANCE <strong>Department</strong> <strong>of</strong> Personnel <strong>and</strong> Administration<br />
7501 E Lowery Blvd State <strong>of</strong> <strong>Colorado</strong><br />
Denver, CO 80230-7006<br />
1313 Sherman Street, First Floor<br />
Denver, CO 80203-2236<br />
OFFICE: 303-361-4251 OFFICE: 303-866-3846<br />
FAX: 303-361-5251 FAX: 303-894-2409<br />
EMAIL: teree.carr@pinnacol.com<br />
EMAIL: joel.hirschboeck@state.co.us<br />
Brenda.hardwick@state.co.us<br />
Page 31 6/22/2009
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ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
855 02/01/91 TARGET STORES CLAIMS 02/01/05 & FORWARD<br />
Ms. Susan Holt<br />
Ms. Judy Essen<br />
Sedgwick CMS<br />
Target Stores<br />
Custer Court 1<br />
C/O Aon Risk Consultants, Inc.<br />
501 West President George Bush Highway 8300 Norman Center Drive, Suite 400<br />
Richardson, TX 75080-1132 Minneapolis, MN 55437-3844<br />
OFFICE: 469-624-1000 OFFICE: 952-656-8290<br />
FAX: 214-624-1010 FAX: 847-953-2851<br />
EMAIL: sholt@sedgwickcms.com<br />
EMAIL: judy_essen@ars.aon.com<br />
CLAIMS PRIOR TO 02/01/05<br />
Unit Manager (Ms. Elaine Nevens)<br />
Constitution States Service Company<br />
P. O. Box 173762<br />
Denver, CO 80217-3762<br />
OFFICE: 800-227-1538<br />
FAX: 877-801-9674<br />
EMAIL:<br />
844 01/01/92 THORNTON, CITY OF Mr. Bill Rush, CPCU, ARM, AIC, AIS Ms. Chris Schneider<br />
FCC Services, Inc.<br />
Risk Management Administrator<br />
§8-42-124 7951 East Maplewood Avenue, Suite 225 City <strong>of</strong> Thornton<br />
Greenwood Village, CO 80111-4723<br />
Civic Center<br />
9500 Civic Center Drive<br />
Thornton, CO 80229-1220<br />
OFFICE: 303-721-3265 OFFICE: 303-538-7303<br />
FAX: 303-721-9202 FAX: 303-538-7522<br />
EMAIL: bill.rush@fccservices.com<br />
EMAIL: chris.schneider@city<strong>of</strong>thornton.net<br />
838 04/01/92 TRI-STATE GENERATION & Ms. Elda M. de la Pena Ms. Elda M. de la Pena<br />
TRANSMISSION ASSOCIATION, INC. Tri-State Generation & Transmission Association, Inc. Tri-State Generation & Transmission Association, Inc.<br />
1100 West 116th Street 1100 West 116th Street<br />
Westminster, CO 80234-2814 Westminster, CO 80234-2814<br />
OFFICE: 303-254-3198 OFFICE: 303-254-3198<br />
FAX: 303-254-6018 FAX: 303-254-6018<br />
EMAIL: edelapena@tristategt.org<br />
EMAIL: edelapena@tristategt.org<br />
P.O.Box 33695 Denver CO 80233 P.O.Box 33695 Denver CO 80233<br />
Page 32 6/22/2009
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PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
942 01/01/72 UNITED AIRLINES, INC. Ms. Cynthia Tucker Mr. John Smolk<br />
Branch Manager<br />
Manager<br />
§8-42-124 Gallagher Bassett Services, Inc. Workers' Compensation Program<br />
P. O. Box 4068 WHQHR<br />
Englewood, CO 80155-4068<br />
United Airlines, Inc.<br />
P. O. Box 66100<br />
Chicago, IL 60666-0100<br />
OFFICE: 303-796-9494, x201 OFFICE: 847-700-7504<br />
FAX: 720-493-3845 FAX: 847-700-5833<br />
EMAIL: cynthia_tucker@gbtpa.com<br />
EMAIL: john.smolk@united.com<br />
496 10/01/96 UNIVERSITY OF COLORADO Mr. Gary Longfellow Teena Shepperson<br />
University Risk Management<br />
Financial Analyst<br />
§8-42-124 University <strong>of</strong> <strong>Colorado</strong> University Risk Management<br />
1800 Grant Street, Suite 700 University <strong>of</strong> <strong>Colorado</strong><br />
Denver, CO 80203-1185 1800 Grant Street, Suite 700<br />
Denver, CO 80203-1185<br />
OFFICE: 303-860-5677 303-860-5712<br />
FAX: 303-860-5680 FAX: 303-860-5680<br />
EMAIL: gary.longfellow@cusys.edu<br />
teena.shepperson-turner@cu.edu<br />
970 01/01/80 VAIL ASSOCIATES, INC. CLAIMS 08/01/05 & FORWARD<br />
Original Mr. Bruce Borner Mr. Craig George<br />
Anniversary Liberty Mutual Group Risk Management<br />
Date: 01/10/80 Helmsman Management Services, Inc. Vail Associates, Inc.<br />
2100 Walnut Hill Lane P. O. Box 7<br />
P. O. Box 168208 Vail, CO 81658-7000<br />
Irving, TX 75016-8208<br />
OFFICE: 800-300-0110, x2225 OFFICE: 303-404-1894<br />
FAX: 603-334-8098 FAX: 303-404-6422<br />
EMAIL: bruce.borner@libertymutual.com<br />
EMAIL: Ccathcart@vailresorts.com<br />
CLAIMS PRIOR TO 08/01/05<br />
Ms. Wendy Garcia<br />
Account Manager<br />
CCMSI<br />
7600 East Orchard Road, Suite 360N<br />
Greenwood Village, CO 80111-2518<br />
OFFICE: 303-804-2020<br />
FAX: 303-804-2005<br />
EMAIL: wgarcia@ccmsi.com<br />
Page 33 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
822 04/30/93 VALERO ENERGY CORPORATION Ms. Alison Collier Mr. Theodore Guidry II<br />
CCMSI<br />
Executive Director<br />
7600 East Orchard Road, Suite 360N Business Risk Management<br />
Greenwood Village, CO 80111-2518<br />
Valero Energy Corporation<br />
6000 North Loop 1604 W<br />
San Antonio, TX 78249-1100<br />
OFFICE: 303-337-6161, x105 OFFICE: 210-345-2048<br />
FAX: 303-337-6165 FAX: 210-345-2964<br />
EMAIL: acollier@ccmsi.com<br />
EMAIL: eric.honeyman@valero.com<br />
846 01/01/92 WELD COUNTY Ms. Norma Stimmler Ms Michelle Raimer<br />
County Technical Service, Inc.<br />
Human Resources Analyst<br />
800 Grant Street, Suite 400 Weld County<br />
Denver, CO 80203-2944 P. O. Box 758<br />
Greeley, CO 80632-0758<br />
OFFICE: 303-861-0507 OFFICE: 970-336-7220<br />
FAX: 303-861-1022 FAX: 970-352-9019<br />
EMAIL: nstimmler@ctsi.org<br />
EMAIL: mraimer@co.weld.co.us<br />
467 06/01/05 WENDY’S INTERNATIONAL, INC. CLAIMS 07/04/05 & FORWARD Tracy Ridenour<br />
Risk Programs Analyst<br />
Jennifer Napier<br />
Wendy's/Arby's Group, Inc.<br />
Gallagher Bassett Service, Inc.<br />
1155 Perimeter Center West<br />
P. O. Box 4068 Atlanta GA 30338<br />
Englewood, CO 80155-4068<br />
Allen Zearing Supervisor 800-933-8143 X234<br />
allen_zearing@gbtpa.com<br />
tracy.ridenour@wendysarbys.com<br />
OFFICE: 800-933-8143, x229 OFFICE: 678-514-6751<br />
FAX: 303-796-9498 FAX: 678-514-<br />
EMAIL: jennifera_napier@gbtpa.com<br />
EMAIL: kim_mead@wendys.com<br />
jennifer 800-938-8143 X212<br />
CLAIMS PRIOR TO 07/03/05<br />
Ms. Anita Fresquez-Montoya<br />
ESIS<br />
P. O. Box 911<br />
Portl<strong>and</strong>, OR 97207-0911<br />
OFFICE: 303-683-6591<br />
FAX: 303-683-6608<br />
800-992-7578 Ms. Kimberly Mead<br />
EMAIL: anita.fresquez-montoya@esis.com<br />
Page 34 6/22/2009
SELF INSURED LIST<br />
PERMIT<br />
ANNIVERSARY<br />
DATE NAME OF PERMIT TPA OR LOCAL PERMIT HOLDER<br />
ALL CLAIMS<br />
997 01/01/86 WESTMINSTER, CITY OF<br />
Ms. Sally Phillips<br />
Ms. Martee Erichson<br />
§8-42-124 Risk Manager Risk Manager<br />
C/O Jefferson County School District R-1<br />
City <strong>of</strong> Westminster<br />
Risk Management <strong>Department</strong><br />
4800 West 92nd Avenue<br />
P. O. Box 4001 Westminster, CO 80031-6387<br />
Golden, CO 80401-0001<br />
OFFICE: 303-982-2439<br />
OFFICE: 303-430-2400, x2156<br />
FAX: 303-982-2327 FAX: 303-706-3924<br />
EMAIL: sphillip@jeffco.k12.co.us<br />
EMAIL: merichson@ci.westminster.co.us<br />
Effective 7/1/09 change from in house to TPA<br />
886 01/01/88 WEYERHAEUSER COMPANY Laurie Iverson Ms. Betsie Doust<br />
Specialty Risk Services<br />
Manager, Administration<br />
Ms. Jessie Garbarino P.O.Box 221700 Weyerhaeuser Company<br />
Senior Claims Representative Denver, CO 80222 P. O. Box 9777, NB2-2B4<br />
Weyerhaeuser Company Federal Way, WA 98063-9777<br />
PO Box 9777, NB2-2E4<br />
Federal Way, WA 98063-9777 OFFICE: 800-829-7985 X 58506 OFFICE: 253-924-7591<br />
FAX: 303-645-8654 FAX: 253-924-4440<br />
OFFICE: 253-924-7685<br />
EMAIL: betsie.doust@weyerhaeuser.com<br />
FAX: 253-924-4440 laurie.iverson@srsconnect.com<br />
EMAIL:<br />
jessie.garbarino@weyerhaeuser.com<br />
All past, Present, Future claims are h<strong>and</strong>led by SRS<br />
863 01/01/90 YELLOW TRANSPORTATION, INC. Ms. Kelly Castanon Ms. Jill A. Rueter<br />
Gallagher Bassett Services, Inc.<br />
Insurance Specia<strong>list</strong><br />
Revoked 10/1/08 P. O. Box 4200 Yellow Transportation, Inc.<br />
Rancho Cucamonga, CA 91729-4200 P. O. Box 7270<br />
Overl<strong>and</strong> Park, KS 66207-0270<br />
OFFICE: 909-581-1919, x252 OFFICE: 913-696-6107<br />
FAX: 909-581-1996 FAX: 913-234-9173<br />
EMAIL: kelly_castanon@gbtpa.com<br />
EMAIL: jilla.rueter@yrcw.com<br />
866-517-6782 X252<br />
10990 Roe Avenue Overl<strong>and</strong>park KS 66211<br />
Page 35 6/22/2009
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