Attachment A

Attachment A

INTERSTATE CLAIM TRANSFER SUMMARY

Claimant Name:  ........................................................................................................................

Claim No:  .................../.......DOB:  ..../..../...........               DOI:  ..../..../..........

Date determined:  ...../...../........Designation:  .........................................

Brief description of condition:  ............................................................................................

Customer/Cost Centre: .............................................................................................

Nature of work when injured: ............................................................................................

..........................................................................................................................................

Date of last liability review:  ...../...../..........

Findings:  .............................................................................................................................

Is review of liability indicated? YES q NO q

If yes, what action is required and when?  ........................................................................................

..........................................................................................................................................

Are any of the following required: YES — NO — YES — NO

Rehabilitation q — q — Redeployment q — q

Work trial q — q — Medical review q — q

Household services q — q — Attendant care q — q

YES — NO

Has PRACSYS been noted? q — q

Has the claimant been notified of claim transfer? q — q

Has the Customer been notified of claim transfer? q — q

Is the claimant's NWE current? q — q

Is there an overpayment? q — q

Is Third Party recovery likely? q — q

Reason for Transfer  ..........................................................................................................

Referring Officer:  ............................................................................  Date:  ...../...../..........

Signature:  .......................................              Phone:  ..............................  State: ....................

Referring Officer:  ............................................................................  Date:  ...../...../..........

Signature:  .............................................              Designation:  ............................................................

Receiving Officer's comments (if any):  .........................................................................................