North American Risk Services, Inc. Workers’ Compensation CLAIMS FILE DOCUMENTATION EXPECTATIONS 14-DAYS WITNESS Expectation: Due by the 14th day from the date reported. Copy and paste the template into the file and fill it in. Template • There were no witnesses to the injury Template • First Name: • Last Name: • Address: • Telephone: • Job title/duties: • Accident time/date/place: • What did you witness: SUBROGATION Expectation: Due by the 14th day from the date reported. Copy and paste the template into the file and fill it in. Template • Subrogation potential rationale: There is no subrogation potential as no third party was involved. Template • If subrogation potential, is there a third party involved that may share in the responsibility for this loss? • If so, please describe their involvement and possible negligence. Include the carrier’s name, type, coverage scope, and limits for the responsible 3rd party. • If subrogation potential, evidence preservation requirements. • State of Jurisdiction: • Does the Jurisdiction have SIF (Second Injury Fund): • Evaluation of Potential for SIF Recovery: 16 17