CLAIM TRACKING CHECKLIST TEMPLATE

DEMOGRAPHIC INFORMATION

INJURED EMPLOYEE NAME	TITLE	EMPLOYEE ID
DEPARTMENT	DATE OF INCIDENT
TYPE OF INCIDENT	CLAIM NO.

WORK STATUS

SCHEDULED RETURN TO WORK DATE	ACTUAL RETURN TO WORK DATE
NOTES

TRACKING ITEMS

ITEM NAME	STATUS	ASSIGNED TO	DATE COMPLETED
Accident Reporting Forms:
Employee Incident/Accident Report
Back Injury Incident/Accident Report
Supervisor’s Investigation Report
Witness Statement Form
First Report of Injury Form
Managed Care Organization (MCO) Notified
Third Party Administrator (TPA) Notified
Claim Certification (Approved or Denied)
Supervisor Report of Return to Work
Return to Work Plan Development

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