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): .........................................................................................