North American Risk Services, Inc. Workers’ Compensation CLAIMS FILE DOCUMENTATION EXPECTATIONS 14-DAYS WAGE BENEFITS Expectation: Due by the 14th day from the date reported. Copy and paste the template into the file and fill it in. Templates • For incident or medical only: No lost time or wages. TTD/TPD/PPD/Settlement If estimating the wage rate, document and justify the estimated rate with the calculation in the note AWW: $1,000.00 S-1 W/C Rate: $674.00 Jurisdiction: Iowa AWW calculated taking the 13 weeks before the DOI (04/14/2020), totaling $7,475. $7,474.00 / 13 = $575.00 AWW: $575 X 2/3 W/C Rate: $383.33 If losing time and being issued TPD: TPD for the week of 11/01/2020 – 11/07/2020: Injured worker worked a total of 14 hours. 14 hours x $15.00 = $210.00 AWW: $575.00 $575.00 - $210.00 = $365.00 $365.00 x 2/3 = $243.33 TPD issues for the week of 11/01/2020 – 11/07/2020 in the amount of $383.33. TPD is set for the next six weeks (11/01/2020 – 12/12/2020) for the weekly amount of $383.33. PPD is being issued for the impairment to the right shoulder because of the arthroscopic surgery. Impairment total 5%; 5% x 250 weeks = 12.5 weeks x $674.00 = $8,425.00. PPD is issued from 05/08/2020 to 08/03/2020 for 12.5 weeks of benefits at $674.00. *Were statutory defenses considered – for example, safety infractions. (Jurisdictionally specific) **Attach documentation! 18 19