Claims Management Progress Report
Employer: ABC
Date of Report: 3/28/09Policy Renewal Date:02-Mar-2009 to 02-Mar-2010
Employee: Alejandro Sanchez-Medina Claim Number:002547-002921-WC-01
Date of Injury:7/24/08 Insurance Company:XYZ
|
Date File Referred to EAS
|
12/6/08 |
|
Last Doctor Visit: |
3/5/09 |
|
Next Doctor Visit: |
N/A, EE Return to Work Full Duty |
|
Employee Working?
|
Yes |
|
Date Returned to Trans Work: |
12/21/08 |
|
Date Returned to Perm. Mod/Alt Work: |
N/A; EE returned to Usual &
Customary Position
|
|
Date RTW to U&C: |
3/15/09 |
|
P&S Date: |
3/5/09 |
|
TTD Rate:
|
Weekly rate: $325.00 |
Abbreviation Key for Notes/History:
Ee = Employee Er = Employer Dr = Doctor P/c= Placed Call RTW = Return to Work
P & S = Permanent and Stationary
Notes/History: (3/01/09 – 3/28/09)
Adjuster will send the benefit notice and a 20 day closure. Reserves were reduced.Claim closed on 3/22/09.
Medical Status:
Permanent and Stationary and Return to Work Full Duty with no work restrictions.
Reserve Status: (7/24/08)
TOTAL
|
|
INDEMNITY |
MEDICAL |
REHABIL |
EXPENSE |
TOTAL |
|
Payments |
2,103.58 |
2,882.11 |
0.00 |
0.00 |
4,985.69 |
|
Recoveries |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
|
Net Paid to Date |
2,103.58 |
2,882.11 |
0.00 |
0.00 |
4,985.69 |
|
Remaining Reserve |
7,130.42 |
9,890.89 |
0.00 |
10.00 |
17,031.31 |
|
Total Experience |
9,234.00 |
12,773.00 |
0.00 |
10.00 |
22,017.00 |
Final Reserves: (3/22/09)
|
|
INDEMNITY |
MEDICAL |
REHABIL |
EXPENSE |
TOTAL |
|
Payments |
2,103.58 |
3,077.71 |
0.00 |
0.00 |
5,181.29 |
|
Recoveries |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
|
Net Paid to Date |
2,103.58 |
3,077.71 |
0.00 |
0.00 |
5,181.29 |
|
Remaining Reserve |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
|
Total Experience |
2,103.58 |
3,077.71 |
0.00 |
0.00 |
5,181.29 |
Recommendations / Comments
Claim Closed on 3/22/09