North American Risk Services, Inc. Workers’ Compensation CLAIMS FILE DOCUMENTATION EXPECTATIONS 14-DAYS EMPLOYER INITIAL CONTACT Expectation: Due by the 14th day from the date reported. Copy and paste the template into the file and fill it in. Template • Contact name/title: • Employee supervisor: • Job description/duties: • How long on this job? • Prior claims? • AWW: • Wage statement requested: • Injured employee date of hire: • When accident reported/to whom: • Was the employee drug tested? • Date employee began losing time: • Paid wages on date of injury? • Wages continued by the employer? • Modified duty return/full duty return to work? • Modified duty available? • If there is no modified duty, consider transitional duty? • Injury description: • Treatment: • Med provider(s): • Directed/panel? • Subrogation potential: • Witnesses: • Any reason to doubt the validity of the claim? • Recorded on video surveillance? • Date of loss: • Time of loss: • Preferred Method of Contact: Email to send to the employer requesting the above information: Here is the list of questions for you to answer. Also, if you have any documentation about this injury, please fax those to the number listed below. Documentation includes your internal First report of injury, safety investigation, medical note(s), work slips, etc. Your help is greatly appreciated. 14 15