1. PSA with Adminsure Inc. — Costa Mesa City Council, April 4, 2023 (part 2 of 2)

Third Party Workers’ Compensation Claims Administration Request for Proposal Response
City of Costa Mesa
March 1, 2023


WORK STATUS TAB

SCREEN SHOT

Paid
this Period Paid Outstanding Incurred Recovery
Workers' Compensation Active Claims Listed by Allocation Employee's Name
Cause of Injury
Description of Injury
Case No.

Status
Claim Type
Department
Injury Date
Days Lost
Closing Date
Org1 Desc: Administrative Services
14-120112 04/30/2014 0.00
Open 0.00

0.00 0.00

0.00 0.00
2,339.88

0.00 0.00

0.00 2,160.12

0.00 0.00

0.00 4,500.00

0.00 0.00

0.00 ADMSRVDeveloped discomfort in the
base of her left
Left hand/fingers and Right
hand
Total 0.00 2,535.66 2,549.34 5,085.00 0.00
Medical
TD
Other Indemnity
Rehab
PD
Legal Expense
Other Expense 0.00 195.78 389.22 585.00 0.00
160

0.00 Future Med-Lim
Org1 Desc 1 0.00

0.00 0.00

0.00 2,339.88

0.00 0.00

0.00 2,160.12

0.00 0.00

0.00 4,500.00

0.00 0.00

0.00 Org1 Desc 0.00 2,535.66 2,549.34 5,085.00 0.00

0.00 195.78 389.22 585.00 0.00
Medical
TD
PD
Rehab
Other Indemnity
Legal Expense
Other Expense

Page 1 of 54 ends

Paid
this Period Paid Outstanding Incurred Recovery
Workers' Compensation Active Claims Listed by Allocation Employee's Name
Cause of Injury
Description of Injury
Case No.

Status
Claim Type
Department
Injury Date
Days Lost
Closing Date
13-115343 02/10/2013 0.00
Open 0.00

0.00 0.00

0.00 0.00
1,438.01
905.31
1,381.85

0.00 0.00

0.00 11,892.10

0.00 0.00

0.00 13,330.11
905.31
1,381.85

0.00 0.00

0.00 PUBSAFDeveloped severe pain in
his right foot when walking
Right Foot Pain
Total 0.00 4,139.80 12,992.10 17,131.90 0.00
Medical
TD
Other Indemnity
Rehab
PD
Legal Expense
Other Expense 0.00 414.63 1,100.00 1,514.63 0.00
471

3.00 Future Medical
2008001048 09/25/2006 0.00
Open 0.00

0.00 0.00

0.00 0.00
45,273.61
32,336.97
21,342.62

0.00 0.00

0.00 35,051.76

0.00 0.00

0.00 80,325.37
32,336.97
21,342.62

0.00 0.00

0.00 PUBSAFCONTINOUS TRAUMA TO
NECK

STRAIN DISC NECK
Total 0.00 99,074.79 42,180.17 141,254.96 0.00
Medical
TD
Other Indemnity
Rehab
PD
Legal Expense
Other Expense 0.00 121.59 7,128.41 7,250.00 0.00
471
117.00
Future Medical
Org1 Desc 196 54,662.69
52,037.44
6,289.54

0.00 10,351.21
2,039.10
5,355,484.38
3,817,187.62
2,559,240.47
144,601.00
436,632.69
435,963.74
6,028,742.58
358,027.23
1,508,352.59
61,752.20
499,336.95
48,775.32
11,384,226.96
4,175,214.85
4,067,593.06
206,353.20
935,969.64
484,739.06
-12,500.00
-12,500.00

0.00 0.00
-1,024,875.44

0.00 Org1 Desc 132,791.86 13,041,503.94 9,303,196.21 22,344,700.15 -1,064,875.44 7,411.88 292,394.04 798,209.34 1,090,603.38 -15,000.00
Medical
TD
PD
Rehab
Other Indemnity
Legal Expense
Other Expense
Grand Total: 244 66,469.92
74,718.64
935.86

0.00 10,351.21
2,811.15
6,510,797.23
4,381,846.79
3,008,507.24
172,745.31
485,862.51
679,960.35
7,656,584.54
535,402.19
1,847,677.43
81,752.20
518,936.20
119,307.77
14,167,381.77
4,917,248.98
4,856,184.67
254,497.51
1,004,798.71
799,268.12
-20,000.00
-12,500.00

0.00 0.00
-1,137,644.57

0.00 Grand Total: 171,486.38 15,738,346.35 11,783,856.47 27,522,202.82 -1,185,144.57 16,199.60 498,626.92 1,024,196.14 1,522,823.06 -15,000.00 Medical
TD
PD
Rehab
Other Indemnity
Legal Expense
Other Expense

Page 54 of 54 ends

Reserve Total
Processed Claim Number Claimant Incident Transaction Type Reason Examiner Amount Claim Number: 02IRV00684
03/17/2015 02/09/2002 Other Expense Barrile, Ronece 5,767.8802IRV00684 03/25/2015 02/09/2002 Permanent Disability Barrile, Ronece 9,749.0002IRV00684 03/25/2015 02/09/2002 Permanent Disability Barrile, Ronece -9,749.0102IRV00684 Claim Number Total 3 5,767.87
Claim Number: 04IRV00895
03/09/2015 04/03/2004 Other Indemnity Barrile, Ronece 750.0004IRV00895 Claim Number Total 1 750.00
Claim Number: 05IRV01027
03/26/2015 03/01/2005 Medical Auto Cuevas, Diana -58,000.0005IRV01027 03/26/2015 03/01/2005 Other Expense Auto Cuevas, Diana -5,959.2905IRV01027 03/26/2015 03/01/2005 Rehab Auto Cuevas, Diana -1,000.0005IRV01027 Claim Number Total 3 -64,959.29
Claim Number: 06IRV01238
03/12/2015 11/16/2006 Medical Auto Barrile, Ronece -6,163.6806IRV01238 03/12/2015 11/16/2006 Other Expense Auto Barrile, Ronece -1,246.4006IRV01238 Claim Number Total 2 -7,410.08
Claim Number: 11-110195
03/11/2015 01/19/2011 Other Expense Barrile, Ronece -7,057.8011-110195 03/11/2015 01/19/2011 Permanent Disability Barrile, Ronece -27,100.9711-110195 03/11/2015 01/19/2011 Permanent Disability Barrile, Ronece 457.1711-110195 03/11/2015 01/19/2011 Rehab Barrile, Ronece -4,000.0011-110195 03/11/2015 01/19/2011 Temporary Disability Barrile, Ronece -457.1711-110195 Claim Number Total 5 -38,158.77
Claim Number: 11-110691
03/30/2015 03/25/2011 Medical Auto Cuevas, Diana -9,304.8411-110691 03/30/2015 03/25/2011 Other Expense Auto Cuevas, Diana -1,860.0011-110691 Claim Number Total 2 -11,164.84

Page 1 of 9 ends

Processed Claim Number Claimant Incident Transaction Type Reason Examiner Amount Claim Number: 9603140027
03/31/2015 10/24/1995 Medical Barrile, Ronece -104,417.369603140027 03/31/2015 10/24/1995 Other Expense Barrile, Ronece -11,996.159603140027 03/31/2015 10/24/1995 Other Indemnity Barrile, Ronece -129.949603140027 03/31/2015 10/24/1995 Permanent Disability Barrile, Ronece -88,550.009603140027 Claim Number Total 4 -205,093.45
Grand Total 142 -60,285.97

Page 9 of 9 ends

DateNumber Claim NumberClaimantDescriptionPayeeAmount Code Workers' Compensation Claims Voucher/Check Register
For Month Ending
Payment Method Desc: Check
03/04/201574814 11-112189Chiropractic TreatmentHiguera, Ron J. D.C., M.S.330.08 PUBSAF 03/04/201574815 13-117025Medical ApplianceTeam Makena, LLC168.00 PUBSAF 03/04/201574816 14-121165Medical TreatmentNational Ambulatory Hernia Ins119.12 PUBSAF 03/04/201574817 15-121376Physical TherapyOrtho Med Group & ARC102.08 PUBWRK 03/04/201574818 15-121376Physical TherapyOrtho Med Group & ARC102.08 PUBWRK 03/04/201574819 15-121376Physical TherapyOrtho Med Group & ARC102.08 PUBWRK 03/04/201574820 14-117523Medical TreatmentNicholas E Rose M.D81.97 PUBSAF 03/04/201574821 13-117103Medical TreatmentNational Ambulatory Hernia Ins92.05 PUBSAF 03/04/201574822 06IRV01207Medical TreatmentPacific Cardiovascular Association123.37 PUBSAF 03/04/201574823 9503140060Medical PrescriptionStone River Pharmacy Solutions **751.98 PUBSAF 03/04/201574824 15-121330Physical TherapyCalifornia Rehabilitation & Sports104.21 COMDEV 03/04/201574825 06IRV01178Medical TreatmentMichael P. Weinstein M.D.163.31 PUBSAF 03/04/201574826 13-117422Medical TreatmentSand Canyon Medical Group49.98 PUBSAF 03/04/201574827 15-121612Medical TreatmentSand Canyon Urgent Care73.91 COMSRV 03/04/201574828 15-121557Medical TreatmentSand Canyon Urgent Care82.36 COMSRV 03/04/201574829 07IRV01299Medical TreatmentCindy I Chen Md Apc283.67 PUBSAF 03/04/201574830 14-120290Physical TherapyCalifornia Rehabilitation & Sports93.77 PUBSAF 03/04/201574831 12-114633Physical TherapyAlign Networks, Inc.105.69 PUBSAF 03/04/201574832 9303140078Medical TreatmentElite Orthopedics125.26 PUBWRK 03/04/201574833 14-120344Medical TreatmentSaddleback Memorial Medical Center *8,642.87 PUBSAF 03/04/201574834 12-113561Medical TreatmentProCare Work Injury Center Irvine90.12 PUBSAF 03/04/201574835 14-120750Medical TreatmentSand Canyon Medical Group69.02 PUBSAF 03/04/201574836 8403140001Medical TreatmentNewport Harbor Anesthesia Cons881.90 PUBSAF

Page 1 of 33 ends

DateNumber Claim NumberClaimantDescriptionPayeeAmount Code Workers' Compensation Claims Voucher/Check Register
For Month Ending
Payment 36 -30,135.11
Payment Method Desc: Void
03/18/201575033 13-116114Medical PrescriptionStone River Pharmacy Solutions **-42.04 PUBSAF Payment 1 -42.04
Grand Total: 766 60,599.94

Page 33 of 33 ends

Claimant Name 12-114974
Status: Open
Incident Date: 12/03/2012
Denied Date:

Insured:

Public Safety
Claimant:

Claimant Address
Hire Date: 12/30/2002
Incident: During a simulation training, a tourniquet was applied to the left arm Type:

Cause: Miscellaneous Strain
Body Part: Multiple Body Parts
Nature of Injury: Multi Physical Injuries
Type: Indemnity
Closed Date: Opened Date: 12/28/2012
Insured Reported Date: 12/21/2012 Deductible: 0.00
SSN: XXX-XX-7262
Sex: Female
Rancho Santa Margarita, CA 92688
Birth Date: 02/07/1978 Examiner: 
Weekly Wage: 1,658.00
Total Incurred Payments Outstanding Recovery
Medical 81,095.47 20,915.15 60,180.32 0.00
TD 90,784.14 90,784.14 0.00 0.00
PD 42,000.00 11,922.29 30,077.71 0.00
Rehab 8,000.00 0.00 8,000.00 0.00
Other Indemnity 2,156.25 656.25 1,500.00 0.00
Legal 15,000.00 10,339.45 4,660.55 0.00
Other Expense 35,225.33 26,599.33 8,626.00 0.00
Total: 274,261.19 161,216.61 0.00113,044.58

Page 1 of 1 ends

Claims by Nature of Injury
Nature of Injury Frequency Total Incurred Average/Claim% % % Total Paid % All Other Cumulative Trauma 12,763 12,7631 1 2 156 337 100 Cancer 28,285 14,1422 2 4 173 0 0
Contusion 3,110 6225 6 0 8 1,375 80
Dermatitis 145 1451 1 0 2 145 8
Foreign Body 1,317 6582 2 0 8 281 13
Fracture 19,000 9,5002 2 3 116 12,878 86
Hearing Loss (Cumulative) 9,550 9,5501 1 1 117 0 0
Hernia 71,900 23,9673 4 11 293 9,854 40
Inflammation 174 1741 1 0 2 174 1
Laceration 2,017 4035 6 0 5 2,017 7
Miscellaneous 1,032 2065 6 0 3 1,032 4
Multi Physical Injuries 4,200 4,2001 1 1 51 311 1
Puncture 858 2154 5 0 3 858 3
Respiratory Disorders 12,735 12,7351 1 2 156 0 0
Sprain 89,889 11,2368 10 14 137 8,609 23
Strain 397,836 10,46938 48 61 128 120,550 76
Grand Total: 654,811 8,18580
158,420
Claims by Claim Cause
Claim Cause Frequency Total Incurred Average/Claim% % % Cut/Scraped by Broken Glass 37,469 37,4691 1 3 198
Cut/Scraped by Other Object 143 1431 1 0 1
Fall on Same Level 16,750 16,7501 1 1 89
Fall on Stairs 1,959 9792 3 0 5
Foreign Matter/Object in Eye 377 3771 1 0 2
Hit by Falling/Flying Object 0 01 1 0 0
Hit/Injured by Animal/Insect 23,606 7,8693 4 2 42
Holding or Carrying 9,000 9,0001 1 1 48
Lifting 57,063 57,0631 1 5 302
Miscellaneous Cause 848,061 30,28828 42 67 160
Miscellaneous Exposure/Contact 430 4301 1 0 2
Miscellaneous Fall or Slip 54,542 18,1813 4 4 96
Miscellaneous Strain 61,517 10,2536 9 5 54
Miscellaneous Vehicle Accident 2,944 2,9441 1 0 16
Other Cumulative Trauma 110,382 15,7697 10 9 83
Pushing or Pulling 1,772 1,7721 1 0 9
Reaching 14,950 7,4752 3 1 40
Repetitive Motion 15,286 3,0575 7 1 16
Vehicle Upset 9,859 9,8591 1 1 52

Page 1 of 2 ends

Grand Total: 1,266,110 18,89767

Claims by Body Part
Body Part Frequency Total Incurred Average/Claim% % %
72,427 18,1074Abdomen/Groin 5 11 221
915 9151Ankle 1 0 11
198 1981Buttock(s) 1 0 2
280 2801Chest (Ribs/Sternum/Other) 1 0 3
9,550 9,5501Ear(s) 1 1 117
7,208 1,8024Elbow 5 1 22
1,317 6582Eye(s) 2 0 8
41,556 8,3115Facial Soft Tissue 6 6 102
921 3073Finger(s) 4 0 4
22,054 3,6766Foot 8 3 45
462 1543Hand 4 0 2
1,345 6732Head Injury 2 0 8
98,508 12,3138Knee 10 15 150
4,436 2,2182Lower Arm 2 1 27
145 1451Lower Leg 1 0 2
197,357 28,1947Lumbar/Sacral Vertebrae 9 30 344
12,735 12,7351Lung(s) 1 2 156
761 3812Miscellaneous 2 0 5
0 01Mouth 1 0 0
53,555 8,9266Multiple Body Parts 8 8 109
11,215 11,2151Multiple Trunk 1 2 137
2,589 1,2942Neck 2 0 16
28,002 4,0007Shoulder(s) 9 4 49
1,101 5512Thoracic and Lumbar 2 0 7
95 951Thumb 1 0 1
81,435 81,4351Upper Arm/Clavicle/Scapula 1 12 995
476 2382Upper Leg 2 0 3
4,167 1,3893Wrist 4 1 17

Page 1 of 2 ends

Grand Total: 654,811 8,18580

Paid
this Period Paid Outstanding Incurred Recovery
For Month Ending
Workers' Compensation Claims Closed this Month
Employee's Name
Cause of Injury
Description of Injury
Case No.

Status
Department
Claim Type
Closing Date
Injury Date
Days Lost
14-119454 05/25/2014 0.00
Closed 03/23/2015 0.00

0.00 0.00

0.00 0.00
2,307.97
9,023.68

0.00 0.00

0.00 0.00
2,307.97
9,023.68

0.00 0.00

0.00 0.00
PUBSAF
He rolled his ankle on uneven
ground when jumping over a
fence
Right ankle fracture
Total 0.00 11,490.62 0.00 11,490.62 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 158.97 0.00 158.97 0.00
411
Indemnity 44.00
14-120530 06/09/2014 0.00
Closed 03/12/2015 0.00

0.00 0.00

0.00 0.00
1,619.67

0.00 0.00

0.00 1,619.67

0.00 0.00

0.00 PUBSAF
Stepped on curb and right
ankle rolled off curb while
walking back to police
Right ankle / Right foot strain
Total 0.00 1,763.56 0.00 1,763.56 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 143.89 0.00 143.89 0.00
471
Medical Only 0.00
06IRV01238 11/16/2006 0.00
Closed 03/12/2015 0.00

0.00 0.00

0.00 0.00
452.59

0.00 0.00

0.00 452.59

0.00 0.00

0.00 PUBSAF
Continuous trauma; routine
police duties contact with
numerous people on course of
TB Exposure
Total 0.00 461.59 0.00 461.59 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 9.00 0.00 9.00 0.00
Future Medical 0.00
11-110691 03/25/2011 0.00
Closed 03/30/2015 0.00

0.00 0.00

0.00 0.00
695.16
563.84

0.00 0.00

0.00 0.00
695.16
563.84

0.00 0.00

0.00 0.00
PUBSAF
Exposure to sun when
responding to outdoor calls for
service.

Skin Cancer
Total 0.00 1,603.65 0.00 1,603.65 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 344.65 0.00 344.65 0.00
481
Future Medical 4.00
2009105552 06/05/2009 0.00
Closed 03/12/2015 0.00

0.00 0.00

0.00 0.00
18,524.09
10,022.42
1,380.00

0.00 0.00

0.00 18,524.09
10,022.42
1,380.00

0.00 0.00

0.00 PUBSAF
(CONTINUOUS TRAUMA)
Routine police duties, i.e.,
getting in and out of patrol car,
Bilateral Shoulder Strain /
Right Knee Strain
Total 0.00 30,122.05 0.00 30,122.05 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 195.54 0.00 195.54 0.00
420
Future Medical 42.00

Page 1 of 4 ends

Paid
this Period Paid Outstanding Incurred Recovery
For Month Ending
Workers' Compensation Claims Closed this Month
Employee's Name
Cause of Injury
Description of Injury
Case No.

Status
Department
Claim Type
Closing Date
Injury Date
Days Lost
05IRV01027 03/01/2005 0.00
Closed 03/26/2015 0.00

0.00 0.00

0.00 0.00
54,248.25
39,137.42
19,806.29
420.00

0.00 0.00

0.00 0.00
54,248.25
39,137.42
19,806.29
420.00

0.00 0.00

0.00 0.00
PUBSAF
Strained low back, CT.
wearing gunbelt, sitting in car,
twisting in car to use
Lower Back
Total 0.00 113,647.96 0.00 113,647.96 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 36.00 0.00 36.00 0.00
Future Medical 0.00
14-121095 10/07/2014 0.00
Closed 03/18/2015 0.00

0.00 0.00

0.00 0.00
952.51

0.00 0.00

0.00 952.51

0.00 0.00

0.00 PUBSAF
Developed pain in his right foot
after participating in block
training / baton use
Right foot pain/plantar fascitis
Total 0.00 1,143.98 0.00 1,143.98 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

0.00 191.47 0.00 191.47 0.00
471
Indemnity 0.00
14-121165 11/20/2014 119.12
Closed 03/18/2015 0.00

0.00 0.00

0.00 0.00
491.16

0.00 0.00

0.00 491.16

0.00 0.00

0.00 PUBSAF
Strained his lower abdominal
area while participating in
physical training at the police
Lower abdomen / groin strain
Total 129.37 527.24 0.00 527.24 0.00
Medical
TD
PD
Rehab
Other Indemnity
Other Expenses
Legal Expenses

10.25 36.08 0.00 36.08 0.00
411
Medical Only 0.00
Grand Total: 18 1,552.81

0.00 0.00

0.00 89,732.90
66,841.79
21,186.29
420.00

0.00 0.00

0.00 0.00
89,732.90
66,841.79
21,186.29
420.00

0.00 0.00

0.00 0.00
Grand Total: 1,700.90 181,585.16 0.00 181,585.16 0.00
148.09 3,404.18 0.00 3,404.18 0.00
Medical
PD
Other Indemnity
TD
Rehab
Other Expenses
Legal Expenses

Page 4 of 4 ends

Measures the total number of claims that are closed in a month period. Ideally, we want to close more claims than are opened in a month. Closing the claims is an important factor in mitigating the overall cost of claims. The higher the number, the better. 0 1
2 3
4 5
6 7 Number of Claims Closed
Claims Closed by Month
FY XX
FY XX
FY XX
Prepared by AdminSure
Closing the claims is an important factor in mitigating the overall cost of claims. The higher the number the better.

Measures the total number of claims that are closed in a month period. Ideally, we want to close more claims than are opened in a month. 0 0
7 DECEMBER

CLAIMS CLOSED BY
MONTH DECEMBER 20XX

FY XX FY XX FY XX
4 6
19 0
2 4
6 8
10 12
14 16
18 20
FY 20XX FY 20XX FY 20XX
Claims Closed YTD
Comparison
Employee's Name Case No. Claim Type Injury Date Paid
this Period Paid Outstanding Incurred RecoveryCause of Injury Status Department Workers' Compensation Claims Opened this Month
Description of Injury
Days Lost
15-122031 03/12/2015 0.00
Open 0.00

0.00 0.00

0.00 0.00
10,000.00
11,006.40

0.00 0.00

0.00 0.00
10,000.00
11,006.40

0.00 0.00

0.00 0.00
PUBSAFDeveloped a hernia after his
motorcycle struck a curb and
Left Abdominal hernia
Total 0.00 0.00 22,156.40 22,156.40 0.00
471
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 0.00 0.00 1,150.00 1,150.00 0.00
Indemnity

0.00 15-122032 03/19/2015 0.00
Open 0.00

0.00 0.00

0.00 0.00
2,100.00

0.00 0.00

0.00 2,100.00

0.00 0.00

0.00 PUBSAFWhile struggling with a
combative mental health
Left shoulder strain
Total 0.00 0.00 2,290.00 2,290.00 0.00
411
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 0.00 0.00 190.00 190.00 0.00
Medical Only

0.00 15-122008 03/20/2015 0.00
Open 0.00

0.00 0.00

0.00 0.00
2,500.00

0.00 0.00

0.00 2,500.00

0.00 0.00

0.00 PUBWRKSustained injury to his right
wrist while digging post holes
Right wrist sprain
Total 0.00 0.00 2,725.00 2,725.00 0.00
551
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 0.00 0.00 225.00 225.00 0.00
Medical Only

0.00 15-121893 03/09/2015 0.00
Open 0.00

0.00 0.00

0.00 0.00
10,000.00
9,500.00

0.00 0.00

0.00 0.00
10,000.00
9,500.00

0.00 0.00

0.00 0.00
PUBSAFExposure to sun during the
course of work caused her to
Left ear skin cancer
Total 0.00 0.00 20,850.00 20,850.00 0.00
411
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 0.00 0.00 1,350.00 1,350.00 0.00
Indemnity

0.00 15-121829 02/15/2015 83.26
Closed 0.00

0.00 0.00

83.26 0.00

0.00 0.00

83.26 0.00

0.00 0.00

0.00 0.00
PUBSAFEE was reaching for keys
when his left thumb hit a
Left Thumb Puncture Wound
Total 95.20 95.20 0.00 95.20 0.00
411
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 11.94 11.94 0.00 11.94 0.00
Medical Only

0.00

Page 1 of 2 ends

Employee's Name Case No. Claim Type Injury Date Paid
this Period Paid Outstanding Incurred RecoveryCause of Injury Status Department Workers' Compensation Claims Opened this Month
Description of Injury
Days Lost
15-121948 03/12/2015 0.00
Open 0.00

0.00 0.00

0.00 0.00
950.00

0.00 0.00

0.00 950.00

0.00 0.00

0.00 PUBSAFWhile cleaning the range area
/ walking in the parking lot on a
Left eye irritation
Total 0.00 0.00 1,036.00 1,036.00 0.00
411
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 0.00 0.00 86.00 86.00 0.00
Medical Only

0.00 15-121993 12/12/2014 0.00
Open 0.00

0.00 0.00

0.00 0.00
1,500.00

0.00 0.00

0.00 1,500.00

0.00 0.00

0.00 PUBSAFEE injured her left knee while
walking and then colliding with
Left knee contusion
Total 0.00 0.00 1,735.00 1,735.00 0.00
423
TD
PD
Other Indemnity
Medical
Rehab
Legal Expenses
Other Expenses 0.00 0.00 235.00 235.00 0.00
Indemnity

0.00 Grand Total: 7 83.26

0.00 0.00

0.00 83.26

0.00 0.00

0.00 27,050.00
20,506.40

0.00 0.00

0.00 0.00
27,133.26
20,506.40

0.00 0.00

0.00 0.00
Grand Total: 95.20 95.20 50,792.40 50,887.60 0.00
Medical
TD
PD
Rehab
Other Indemnity
Legal Expenses
Other Expenses 11.94 11.94 3,236.00 3,247.94

Page 2 of 2 ends

Measures the total number of new claims filed in a month. This number includes claims that have been or may be denied. This number may reflect unsafe work practices or morale problems.

Typically the cost associated with these claims become most prevalent two years later. The lower the number the better.
0 1
2 3
4 5
6 Number of Claims Opened
Claims Opened by Month
FY XX
FY XX
FY XX
Prepared by AdminSure
reflect unsafe work practices or morale problems. Typically the cost associated with these claims become most prevalent two years later.

Measures the total number of new claims filed in a month. This number includes claims that have been or may be denied. This number may The lower the number the better.
4 2
3 DECEMBER

CLAIMS OPENED BY
MONTH DECEMBER 20XX

FY XX FY XX FY XX
15 14
22 0
5 10
15 20
25 FY 20XX FY 20XX FY 20XX
Claims Opened YTD
Comparison
Claim Lag Time
Claimant Incident DateClaim Number Insured Reported
Days between
Adjusting Loc. Received Reported/Received Incident/ReceivedIncident/Reported Days between Days between
15-121829 02/15/2015 02/20/2015 03/03/20155 11 16
15-121893 03/09/2015 03/09/2015 03/09/20150 0 0
15-121948 03/12/2015 03/12/2015 03/16/20150 4 4
15-121993 12/12/2014 03/19/2015 03/23/201597 4 101
15-122008 03/20/2015 03/20/2015 03/24/20150 4 4
15-122031 03/12/2015 03/27/2015 03/27/201515 0 15
15-122032 03/19/2015 03/26/2015 03/27/20157 1 8
Grand Total: 7
Average Lag Time: 17.71 3.43 21.14

5.00 4.00Median Lag Time: 8.00

Page 1 of 1 ends

Litigated Claims by Claimant Type
Claimant Type Frequency Total Incurred Average/Claim% % %Open Count Closed Count 5,585,257 174,53932Future Medical 46 34 7432 0
5,117,056 196,81026Indemnity 37 31 8326 0
5,883,500 490,29212Indemnity/Future Medical 17 35 20712 0 Grand Total: 16,585,813 236,94070

Work Status
Claim Number Claimant Injury Date Exam Date Work StatusNext Appointment Date Work Status/Restrictions Accepted
Delayed
Denied
11-110678 03/12/2011 12/29/2014 Temporary Total Disability TTD03/22/2015 Y N
N
14-119529 06/03/2014 01/27/2015 Full Time / Modified Duty No squatting/kneeling; No climbing ladders greater than 6 feet03/10/2015 N N
N
14-119538 03/31/2014 01/19/2015 Part Time / Modified Duty continue working 4 hours per day03/12/2015 N N
N
14-120344 08/07/2014 03/03/2015 Full Time / Modified Duty 40 hours per week; limited pushing, pulling reaching and overhead use
03/31/2015 Y
N
N
14-120784 10/15/2014 02/13/2015 Full Time / Modified Duty No heavy lifting greater than 25 lbs.; No repetitive lifting greater than 15 lbs.
03/09/2015 N
N
N
14-120940 10/30/2014 01/22/2015 Full Time / Modified Duty No repetitive reaching, pushing, and pulling. Restricted to desk-type work and/or detective-type work; she should not be out in the field interacting with suspects where she may have to do takedowns, etc. 03/19/2015 N
N
N
14-121112 11/30/2014 01/05/2015 Full Time / Modified Duty NO FORCEFUL OR REP PUSH/PULLING WITH RIGHT HAND; NO LIFTING/PULLING/PUSHING OVER 10 LBS
03/04/2015 Y
N
N
15-121893 03/09/2015 03/10/2015 Full Time / Modified Duty03/23/2015 N N
N
15-121993 12/12/2014 02/27/2015 Full Time / Modified Duty Limited kneeling03/27/2015 N Y
N
15-122008 03/20/2015 03/20/2015 Part Time / Modified Duty Must use splint or brace, no use of right hand.03/27/2015 Y N
N
11 Grand Total:

Page 1 of 1 ends

Claimant Claim Number Injury - Date Claim Type Litigated Examiner Settle - Date Settlement Type Settlement Amount Claims Settled Last Month
12-113827 06/28/2012 Future Medical N RBARRILE 03/06/2015 Stipulated Award 0.00

Page 1 of 1 ends

0.0001965-1966 0.000.001 0.00 0.00 0.00 0.000.00
2,090.7501975-1976 0.002,090.751 0.00 0.00 0.00 2,090.750.00 14,876.3501976-1977 0.0014,876.351 0.00 0.00 0.00 14,876.350.00 38,799.0001977-1978 0.0038,799.004 0.00 0.00 0.00 38,799.000.00 76,978.3401978-1979 0.0076,978.3411 0.00 0.00 0.00 76,978.340.00 49,930.2301979-1980 0.0049,930.2371 0.00 0.00 0.00 49,930.230.00 59,062.5601980-1981 0.0059,062.5683 0.00 0.00 0.00 59,062.560.00 267,454.5701981-1982 0.00267,454.5786 0.00 0.00 129,444.76 138,009.810.00 470,412.1101982-1983 0.00470,412.1185 0.00 0.00 54,895.72 415,516.390.00 432,260.9911983-1984 24,733.32407,527.6776 0.00 0.00 0.00 432,260.990.00 85,430.7801984-1985 0.0085,430.7881 0.00 0.00 0.00 85,430.780.00 316,736.6601985-1986 0.00316,736.6699 0.00 0.00 0.00 316,736.660.00 479,259.7401986-1987 0.00479,259.74117 0.00 0.00 0.00 479,259.740.00 274,088.1401987-1988 0.00274,088.1490 0.00 0.00 0.00 274,088.140.00 394,446.7701988-1989 0.00394,446.77135 0.00 0.00 0.00 394,446.770.00 801,891.5511989-1990 103,577.75698,313.80115 102.01 0.00 210.00 801,681.550.00 1,421,579.7521990-1991 123,252.721,298,327.03120 0.00 0.00 0.00 1,421,579.750.00 752,565.0811991-1992 12,122.18740,442.90108 230.82 0.00 0.00 752,565.080.00 1,109,156.7521992-1993 98,804.441,010,352.31159 378.54 0.00 0.00 1,109,156.750.00 1,173,868.7511993-1994 91,424.431,082,444.32141 0.00 0.00 37,132.79 1,136,735.960.00 1,243,668.8931994-1995 170,078.061,073,590.83124 2,074.48 0.00 97,654.52 1,146,014.370.00 2,028,844.1231995-1996 182,414.931,846,429.19105 2,462.06 -205,093.45 170,769.13 1,858,074.991498.00 582,548.6801996-1997 0.00582,548.68118 0.00 0.00 14,370.10 568,178.580.00 1,342,706.9241997-1998 289,142.081,053,564.84112 18.00 0.00 3,000.00 1,339,706.920.00

Page 1 of 2 ends

Total Claims
IncurredPaid
This Period Paid Outstanding Incurred Recovery
Policy Period
Open This Period Net Incurred
Workers' Compensation Claims Summary by Year
For Month Ending
Days Lostby Date of Injury
1,254,733.7321998-1999 72,249.671,182,484.06123 0.00 0.00 16,500.00 1,238,233.730.00 2,019,465.6231999-2000 75,846.551,943,619.07106 0.00 0.00 84,632.72 1,934,832.900.00 3,362,447.6682000-2001 821,560.282,540,887.38110 2,216.45 0.00 195,693.10 3,166,754.56419.00 2,937,156.6692001-2002 666,566.482,270,590.18121 1,930.14 5,767.87 15,000.00 2,922,156.6610.00 2,094,804.0792002-2003 557,801.031,537,003.04117 848.01 0.00 23,643.00 2,071,161.072882.00 1,567,806.8552003-2004 244,294.661,323,512.19132 3,975.29 750.00 18,146.75 1,549,660.10412.00 3,856,844.3472004-2005 1,254,260.332,602,584.01128 4,039.84 -64,959.29 584,164.00 3,272,680.34620.00 2,544,633.74112005-2006 641,943.251,902,690.49130 3,015.26 0.00 39,545.22 2,505,088.521093.00 1,499,732.9882006-2007 238,993.831,260,739.15121 1,210.54 -7,410.08 6,716.04 1,493,016.942009.00 1,020,650.0652007-2008 143,009.65877,640.41118 34.25 -100.00 1,194.34 1,019,455.721867.00 3,579,071.27102008-2009 1,188,804.222,390,267.05135 5,519.15 -18,387.14 187,328.09 3,391,743.184125.00 2,295,431.78142009-2010 789,623.481,505,808.30108 5,320.26 0.00 1,844.10 2,293,587.682558.00 2,019,939.65172010/2011 573,167.481,446,772.17113 17,747.45 -49,323.61 50,717.86 1,969,221.793190.00 2,268,314.68222011/2012 1,019,303.821,249,010.86115 23,030.56 6,000.13 1,858.23 2,266,456.451866.00 2,073,750.92262012/2013 1,043,377.251,030,373.67111 13,295.06 5,174.53 2,190.65 2,071,560.272455.00 1,848,212.98352013/2014 860,877.02987,335.96142 37,601.33 15,198.37 0.00 1,848,212.982153.00 654,811.07352014/2015 496,390.80158,420.2780 49,237.36 252,096.70 0.00 654,811.07248.00 Grand Total: 38,532,845.83 11,783,619.71 50,316,465.54174,286.86244 4053 -60,285.97 1,736,651.12 48,579,814.42

Page 2 of 2 ends

DateNumber Claim NumberClaimantPayeeAmount Code
Workers' Compensation Claims Transaction Report
For Month Ending
From Thru
Payment Transaction Desc: Chiropractic Treatment
03/04/201574840 03IRV00765Ideal Chiropractic165.66 PUBSAF01/29/2015 02/12/2015 03/04/201574814 11-112189Higuera, Ron J. D.C., M.S.330.08 PUBSAF01/28/2015 02/06/2015 03/11/201574866 11-112189Higuera, Ron J. D.C., M.S.172.30 PUBSAF02/11/2015 02/11/2015 03/18/201575020 11-112189Higuera, Ron J. D.C., M.S.150.80 PUBSAF02/18/2015 02/20/2015 03/25/201575073 11-112189Higuera, Ron J. D.C., M.S.138.63 PUBSAF02/20/2015 02/25/2015 Payment 5 957.47
Payment Transaction Desc: Court Reporter Expense
03/25/201575132 01IRV00531Peranich Reporting508.90 COMSRV11/21/2014 11/21/2014 03/25/201575130 04IRV00895BARRETT REPORTING INC958.75 PUBSAF02/13/2015 02/13/2015 Payment 2 1,467.65
Payment Transaction Desc: Medical Appliance
03/04/201574815 13-117025Team Makena, LLC168.00 PUBSAF01/09/2015 01/09/2015 03/18/201574978 14-117491Recovery Medical Services, LLC83.95 PUBSAF02/20/2015 02/20/2015 03/25/201575086 14-119045Team Makena, LLC131.16 PUBWRK02/23/2015 02/23/2015 03/25/201575084 9303140150South Coast Medical145.86 COMSRV02/27/2015 02/27/2015 03/25/201575087 14-117468A+ Medical Supplies150.00 PUBSAF02/23/2015 02/23/2015 03/25/201575062 9603140097Advanced Hearing Services400.00 PUBSAF03/10/2015 03/10/2015 Payment 6 1,078.97
Payment Transaction Desc: Medical Case Management
03/04/201574852 14-119538Comp Nurse Solutions1,881.00 PUBSAF01/12/2015 02/20/2015 03/18/201575047 13-116144CNS LLC671.00 PUBWRK02/07/2015 03/04/2015 03/25/201575138 14-119045CNS LLC836.00 PUBWRK01/10/2015 03/13/2015 Payment 3 3,388.00

Page 1 of 12 ends

DateNumber Claim NumberClaimantPayeeAmount Code
Workers' Compensation Claims Transaction Report
For Month Ending
From Thru
03/25/201575121 2009105542Prosport Physical Therapy RSM104.21 PUBSAF02/27/2015 02/27/2015 03/25/201575114 14-120344The Kinetic Chain Physical Therapy107.25 PUBSAF02/24/2015 02/24/2015 03/25/201575112 14-120865Gateway Rehab and Wellness184.20 PUBSAF02/25/2015 02/27/2015 03/25/201575113 14-120344The Kinetic Chain Physical Therapy219.27 PUBSAF02/26/2015 03/03/2015 03/25/201575115 14-120865Gateway Rehab and Wellness303.68 PUBSAF02/13/2015 02/19/2015 03/25/201575116 14-117491ACIC Physical Therapy624.83 PUBSAF01/07/2015 01/29/2015 03/25/201575068 14-120940Prosport Physical Therapy RSM104.21 PUBSAF02/20/2015 02/20/2015 03/25/201575069 14-120940Prosport Physical Therapy RSM104.21 PUBSAF02/18/2015 02/18/2015 03/25/201575070 14-120940Prosport Physical Therapy RSM104.21 PUBSAF02/11/2015 02/11/2015 03/25/201575071 14-121237Prosport Physical Therapy RSM104.21 PUBSAF02/26/2015 02/26/2015 03/25/201575072 8403140001Fairbanks Power Physical Therapy105.69 PUBSAF02/23/2015 02/23/2015 03/25/201575067 15-121330California Rehabilitation & Sports110.29 COMDEV03/02/2015 03/02/2015 03/25/201575083 2009105542MSC Group, Inc242.68 PUBSAF01/05/2015 01/05/2015 Payment 60 8,219.82
Grand Total: 257 68,369.03

Page 12 of 12 ends

Prepared by AdminSure
Bank Statement Balance: $180,273.84
Less: Outstanding Checks: ($21,373.82)
Reconciled Bank Balance: $158,900.02
Less: Bank Adjustments & Errors $0.00
Adjusted Checkbook Balance: $158,900.02
Difference $0.00
Bank Adjustment & Error Detail: $0.00
Minimum Trust Amount: $0.00
Reconciled Bank Balance: $0.00
Funding Amount Needed: $0.00
Prior Month Funds Request Balance: $0.00
Disbursements Made This Period: $0.00
Less: Voids $0.00
Less: Interest Paid $0.00
Less: Credits Received This Period: $0.00
Funding Amount Due: $0.00
Bank Name
Client Name

CHECK RECONCILIATION REPORT
PREPARED BY ADMINSURE CHECKS CLEARED as of PAGE 1 OF 9
Check Date Check Number Payee
Check
Amount
Cleared
Amount
Outstanding
Check Amount
12/19/14 19497 Hooman Rastegar, M.D. $146.91 $0.00 $146.91 01/05/15 19585 Peranich Reporting $620.50 $0.00 $620.50 02/10/15 19807 MedReview Inc. $41.02 $41.02 $0.00
02/11/15 19813 MedReview Inc. $1,020.16 $1,020.16 $0.00 02/11/15 19814 MedReview Inc. $146.34 $146.34 $0.00
02/12/15 19826 MedReview Inc. $187.25 $187.25 $0.00
02/12/15 19827 MedReview Inc. $60.00 $60.00 $0.00
02/12/15 19828 MedReview Inc. $1,466.65 $1,466.65 $0.00 02/13/15 19838 Apex Healthcare Medical Center, Inc. $219.59 $219.59 $0.00 02/13/15 19840 MedReview Inc. $1,231.34 $1,231.34 $0.00 02/13/15 19841 MedReview Inc. $69.06 $69.06 $0.00
02/13/15 19845 New Age Translations, Inc. $177.00 $177.00 $0.00 02/17/15 19851 MedReview Inc. $88.09 $88.09 $0.00
02/18/15 19869 Apex Healthcare Medical Center, Inc. $162.44 $162.44 $0.00 02/18/15 19870 Apex Healthcare Medical Center, Inc. $211.05 $211.05 $0.00 02/18/15 19871 Apex Healthcare Medical Center, Inc. $116.49 $116.49 $0.00 02/18/15 19875 B. Richard Burke DPM * $141.91 $141.91 $0.00 02/18/15 19877 MedReview Inc. $2,745.34 $2,745.34 $0.00 02/18/15 19878 MedReview Inc. $29.59 $29.59 $0.00
02/19/15 19885 Foundation Medical Group, Inc $130.19 $130.19 $0.00 02/19/15 19886 Alliance Urgent Care $72.24 $72.24 $0.00 02/19/15 19896 MedReview Inc. $215.85 $215.85 $0.00
02/19/15 19897 MedReview Inc. $110.81 $110.81 $0.00
02/19/15 19898 MedReview Inc. $11.30 $11.30 $0.00
02/20/15 19901 University Spine and Orthopedics $178.66 $178.66 $0.00 02/20/15 19903 San Bernardino Medical Orthopedic Group $235.22 $235.22 $0.00 02/20/15 19904 MedReview Inc. $636.44 $636.44 $0.00
02/23/15 19907 San Bernardino Medical Orthopedic Group $211.42 $211.42 $0.00 02/23/15 19908 SOUTH COAST DME $182.51 $182.51 $0.00
02/23/15 19909 Mh Express Pharmacy $119.34 $119.34 $0.00 02/23/15 19911 MedReview Inc. $288.62 $288.62 $0.00
02/23/15 19913 ISYS $384.00 $384.00 $0.00
02/24/15 19914 EA Integrated Health Services $96.90 $96.90 $0.00 02/24/15 19915 San Bernardino Medical Orthopedic Group $11.91 $11.91 $0.00 02/24/15 19916 MedReview Inc. $9.69 $9.69 $0.00
02/25/15 19917 John G. Ellis, M.D. Inc. $162.44 $162.44 $0.00

CHECK RECONCILIATION REPORT
PREPARED BY ADMINSURE CHECKS CLEARED as of PAGE 9 OF 9
Check Date Check Number Payee
Check
Amount
Cleared
Amount
Outstanding
Check Amount
03/26/15 20169 Walgreens $16.57 $0.00 $16.57
03/26/15 20170 University Spine and Orthopedics $546.88 $546.88 $0.00 03/26/15 20171 Physical Medicine Institute $2,250.00 $0.00 $2,250.00 03/26/15 20172 Walgreens $13.63 $0.00 $13.63
03/26/15 20173 MedReview Inc. $1,031.55 $0.00 $1,031.55 03/26/15 20174 MedReview Inc. $86.47 $0.00 $86.47
03/27/15 20177 Arrowhead Evaluation Services, Inc. $5,000.00 $0.00 $5,000.00 03/27/15 20178 CompToday $9.14 $0.00 $9.14
03/27/15 20179 CompToday $8.74 $0.00 $8.74
03/27/15 20180 CompToday $28.38 $0.00 $28.38
03/27/15 20181 Healthpointe Med Grp dba SCOSMC $15.21 $0.00 $15.21 03/27/15 20182 Southern Calif Permanente Med Grp** $144.94 $0.00 $144.94 03/27/15 20183 CA Emerg Phys Med Grp $202.50 $0.00 $202.50 03/27/15 20184 Align Networks, Inc. $129.41 $0.00 $129.41 03/27/15 20185 Align Networks, Inc. $76.30 $0.00 $76.30 03/27/15 20186 Align Networks, Inc. $674.20 $0.00 $674.20 03/27/15 20187 Fairbanks Power Physical Therapy $112.11 $0.00 $112.11 03/27/15 20188 Fairbanks Power Physical Therapy $112.11 $0.00 $112.11 03/27/15 20189 Align Networks, Inc. $56.41 $0.00 $56.41 03/27/15 20190 Align Networks, Inc. $399.25 $0.00 $399.25 03/27/15 20191 Southland Spine & Rehab Med Ctr $39.18 $0.00 $39.18 03/27/15 20192 Fairbanks Power Physical Therapy $296.67 $0.00 $296.67 03/27/15 20193 Align Networks, Inc. $98.02 $0.00 $98.02 03/27/15 20194 MedReview Inc. $755.88 $0.00 $755.88
03/27/15 20195 MedReview Inc. $2,408.26 $0.00 $2,408.26 03/30/15 20196 CompToday $19.70 $0.00 $19.70
03/30/15 20197 MedReview Inc. $129.48 $0.00 $129.48
03/31/15 20199 Economy Transport LLC $648.00 $0.00 $648.00 03/31/15 20200 KAISER FOUNDATION HOSPITAL $487.53 $0.00 $487.53 03/31/15 20201 Southland Spine & Rehab Med Ctr $152.13 $0.00 $152.13 03/31/15 20202 Healthpointe Med Grp dba SCOSMC $1,898.43 $0.00 $1,898.43 03/31/15 20203 MedReview Inc. $329.34 $0.00 $329.34
03/31/15 20204 MedReview Inc. $998.44 $0.00 $998.44
GRAND TOTALS: $127,757.43 $87,875.21 $39,882.22
OSHA's Form 300
Log of Work-Related Injuries and Illnesses
Year
Attention:This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent possible while the information is being used for
occupational safety and health purposes.

U.S. Department of Labor
Occupational Safety and Health Administration
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA office for help.

Establishment name
City State
Identify the person Describe the case
Form approved OMB no. 1218-0176
Classify the case
(A)
Case
no.
(B)
Employee's name
(C)
Job title
(D) (E) (F) CHECK ONLY ONE box for each case
based on the most serious outcome for
that case:Date of injury
or onset
of illness
Where the event occurred
(e.g. Welder) (e.g. Loading dock north end)
Remained at Work
Death
(G)
Describe injury or illness, parts of body affected,
and object/substance that directly injured
Days away
from work
(H) (I) (J)
Job Transfer
or restriction
Other record-
able cases
Enter the number of
days the injured or
ill worker was:

Check the "Injury" column or
choose one type of illness:

Away
from
work
On job
transfer or
restriction
(K) (L)
(M)
(1) (2) (3) (4) (5) (6)
See The Legend Below
(e.g. Second degree burns onor made person ill
right forearm from acetylene torch)
days daysx 0.000.00 xPolice Department 03/12/2015 Other/unknown Hernia Abdomen/GroinXXXXX XXXXX days daysx 0.000.00 xPolice Department 03/19/2015 Other/unknown Strain Shoulder(s)XXXXX XXXXX days daysx 11.000.00 xPublic Works 03/20/2015 Other/unknown Sprain WristXXXXX XXXXX days daysx 13.000.00 xPolice Department 03/09/2015 Other/unknown Cancer Facial Soft TissueXXXXX XXXXX days daysx 0.000.00 xPolice Department 02/15/2015 Other/unknown Puncture ThumbXXXXX XXXXX days daysx 0.000.00 xPolice Department 03/12/2015 FBI Range Foreign Body Eye(s)XXXXX XXXXX days daysx 28.000.00 xPolice Department 12/12/2014 Office Contusion KneeXXXXX XXXXX Grand Total 0 0 3 4 0.00 52.00 6 1 0 0 0 0
(1) (2) (3) (4) (5) (6)
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instructions, search and gather the data needed, complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office Legend: 1- injury 2- Skin disorder 3- Respiratory condition 4- Poisoning 5- Hearing loss 6- All other illness Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

Page 1 of 1 ends

OSHA's Form 300A
Summary of Work-Related Injuries and Illnesses
Year
U.S. Department of Labor
Occupational Safety and Health Administration
From approved OMB no.1218-0176
0 0 3 4

0.00 52.00
6 1
0 0
0 0
(1)
(2)
(3)
(4)
(5)
(6)
All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log to verify that the entries are complete and accurate before completing this summary.

Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the Log. If you had no cases, write "0".

Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR Part 1094.35, in OSHA's recordkeeping rule, for further details on the access provisions for these forms Number of Cases
Total number of
deaths
Total number of Total number of Total number of
cases with days
away from work
cases with job
transfer or restriction
other recordable
cases
Establishment information
Number of Days
Total number of days away Total number of days of job
from work transfer or restriction
Injury and Illness Types
Total number of ...
(G) (H) (I) (J)
(K) (L)
(M)
Your establishment name
Street
City State CA ZIP
Industry description (e.g., Manufacture of motor truck trailers) Standard Industrial Classification (SIC), if known (e.g.,3715) OR
North American Industrial Classification (NAICS), if known (e.g.,336212) Injuries
Skin disorders
Respiratory conditions
Poisonings
Hearing loss
All other illnesses
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.

Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

Employment information
Sign here
Knowingly falsifying this document may result in a fine. (if you don't have these figures, see the
Worksheet on the back of this page to estimate.)
Annual average number of employees
Total hours worked by all employees last year
Company executive Title
DatePhone
( ) - / /
9229SC

Page 1 of 1 ends

OSHA's Form 301
Injury and Illnesses Incident Report
Attention:This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent possible while the information is being used for
occupational safety and health purposes
U.S. Department of Labor
Occupational Safety and Health Administration
This Injury and illness Incident Report is one of the
first forms you must fill out when a recordable work-
related injury or illness has occurred. Together with
the Log of Work-Related Injuries and Illnesses and the
accompanying Summary, these forms help the
employer and OSHA develop a picture of the extent
and severity of work-related incidents.

Within 7 calendar days after you receive
information that a recordable work-related injury or
illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation,
insurance, or other reports may be acceptable
substitutes. To be considered an equivalent form,
any substitute must contain all the information
asked for on this form.

According to Public Law 91-596 and 29 CFR
1904, OSHA's recordkeeping rule, you must keep
this form on file for 5 years following the year to
which it pertains.

If you need additional copies of this form, you
may photocopy and use as many as you need.

Information about the employee
1) Full name
2) Street
City State ZIP
3) Date of birth
4) Date hired
Information about the physician or other health care
5)
CA 92860
Male
Female
x
6) Name of Physicans or other health care professional
7) If treatment was given away from the worksite, where was it given? Facility
Street
City State ZIP
8) Was employee treated in an emergency room?
9) Was employee hospitalized overnight as an in-patient? Completed by ________________________________________________ Title ________________________________________________________ Phone (______)________-________________________ Date __ /__ /__ Form approved OMB no. 1218-0176
professional
Information about the case
10) Case number from the Log (Transfer the case number from the Log after you record the case.) 11) Date of injury or illness
12) Time employee began work
13) Time of event
What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry." What happened? Tell us how the injury occurred.
fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."
What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or score." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.

If the employee died, when did death occur? Date of death 06/21/1960
02/22/1996
Sand Canyon Urgent Care
Yes
No
02/15/2015
6:00 AM
Reaching for keys when thumb hit wooden storage box.

EE was reaching for keys when his left thumb hit a wooden storage box located in his patrol car and he received puncture wound from a splinter
N/A
Left Thumb Puncture Wound
6:00 PM
Yes
No
x
x
check if time cannot be determined
Examples: "When ladder slipped on wet floor, worker
14)
15)
16)
17)
18)

XXXXX XXXXX
XXXXX
XXXXX
Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

Page 1 of 7 ends

According to Public Law 91-596 and 29 CFR
1904, OSHA's recordkeeping rule, you must keep
this form on file for 5 years following the year to
which it pertains.

If you need additional copies of this form, you
may photocopy and use as many as you need.

Information about the employee
1) Full name
2) Street
City State ZIP
3) Date of birth
4) Date hired
Information about the physician or other health care
5)
CA 92705
Male
Female
x
6) Name of Physicans or other health care professional
7) If treatment was given away from the worksite, where was it given? Facility
Street
City State ZIP
8) Was employee treated in an emergency room?
9) Was employee hospitalized overnight as an in-patient? Completed by ________________________________________________ Title ________________________________________________________ Phone (______)________-________________________ Date __ /__ /__ Form approved OMB no. 1218-0176
professional
Information about the case
10) Case number from the Log (Transfer the case number from the Log after you record the case.) 11) Date of injury or illness
12) Time employee began work
13) Time of event
What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry." What happened? Tell us how the injury occurred.
fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."
What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or score." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.

If the employee died, when did death occur? Date of death 04/27/1979
12/27/1999
Sand Canyon Urgent Care
Yes
No
03/19/2015
6:00 AM
Struggling with combative mental health patient
While struggling with a combative mental health patient, he injured his left shoulder N/A
Left shoulder strain
1:13 PM
Yes
No
x
x
check if time cannot be determined
Examples: "When ladder slipped on wet floor, worker
14)
15)
16)
17)
18)

Page 7 of 7 ends

# of Total Paid Outstanding Outstanding Reserves Total Incurred in Q1 2015 #of # of Open Client Employees This Quarter Reserves Per Total # of Employees Total Pd Q1 + Outstanding Open Claims Litigated Claims Client X 2,986 $920,366.80 $10,026,752.09 $3,357.92 $10,947,118.89 191 59 Client Y 4,623 $988,715.96 $13,758,746.45 $2,976.15 $14,747,462.41 231 80 AVERAGES 3,805 $954,541.38 $11,892,749.27 $3,167.04 $12,847,290.65 211 70 WORKERS’ COMPENSATION CLAIMS

CLIENT COMPARISON REPORT AS
OF
Prepared by AdminSure Page 1 of 1
# of Total Average Per # of Total Average Per
Nature of Injury Claims Incurred Claim Nature of Injury Claims Incurred Claim Strain 88 $9,244,148.00 $114,620.00 Strain 94 $14,197,761.00 $151,040.00 Miscellaneous 24 $731,037.00 $30,460.00 Miscellaneous 36 $1,902,197.00 $52,839.00 Sprain 20 $2,079,150.00 $103,957.00 All Other Cumulative Trauma 25 $4,789,022.00 $191,561.00 All Other Cumulative Trauma 13 $1,464,653.00 $112,666.00 Sprain 20 $1,504,961.00 $75,248.00 Contusion 12 $3,023,302.00 $251,942.00 Contusion 19 $2,104,025.00 $110,738.00 Fracture 8 $531,734.00 $66,467.00 Carpal Tunnel Syndrome 10 $571,972.00 $57,197.00 Multi Physical Injuries 6 $481,307.00 $80,218.00 Fracture 7 $597,706.00 $85,387.00 Mental Stress 6 $123,189.00 $20,531.00 Multi Physical/Mental injuries 5 $470,084.00 $94,017.00 All Other Specific Injury 4 $62,769.00 $15,692.00 Mental Stress 4 $1,171,495.00 $292,874.00 Puncture 2 $200,934.00 $100,467.00 Contagious Disease 3 $264,424.00 $88,141.00 TOTAL 183 $17,942,223.00 $897,020.00 TOTAL 223 $27,573,647.00 $1,199,042.00 Client YClient X

WORKERS' COMPENSATION CLAIMS

FREQUENCY & SEVERITY BY NATURE OF INJURY

TOP TEN LISTED BY FREQUENCY
as of

CLAIMS HANDLING ANALYSIS
2010 2011 2012 2013 2014 2015
Future Medical 13 15 13 9 1 0
Indemnity 49 59 45 60 65 9
Medical Only 70 66 60 60 60 15
TOTAL 132 140 118 129 126 24
2010 2011 2012 2013 2014 2015
TOTAL 2 20 8 18 7 0
2010 2011 2012 2013 2014 2015
Average Lag Time 9.38 94.23 18.77 23.39 58.61 12.17
2010 2011 2012 2013 2014 2015
Average Lag Time 6.75 58.82 15.98 8.14 11.18 9.67
2010 2011 2012 2013 2014 2015
Future Medical 1279 1203 967 614 434 37
Indemnity 432 460 481 338 205 39
Medical Only 78 97 54 71 78 38
Litigated 1663 1012 1064 619 351 0
2010 2011 2012 2013 2014 2015
Future Medical 99 274 65 15 0 0
Indemnity 67 49 74 55 33 9
Medical Only 0 0 0 0 0 0
Litigated 122 299 304 136 43 0
AVERAGE # OF DAYS LOST PER CLAM
# OF CLAIMS REPORTED PER YEAR
# OF LITIGATED CLAIMS

DAYS FROM EMPLOYEE'S INJURY TO DATE EMPLOYER NOTIFIED

DAYS FROM EMPLOYERS DATE OF KNOWLEDGE TO DATE REPORTED TO TPA

AVERAGE DAYS OPEN PER CLAM
Prepared by AdminSure
Data Valued as of

Page 1 of 1 ends

CLAIM RATIOS
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical Only 70 66 -6% 60 -9% 60 0% 60 0% 15 -75%
Indemnity 49 59 20% 45 -24% 60 33% 65 8% 9 -86%
TOTAL 119 125 105 120 125 24
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Litigated 2 20 900% 8 -60% 18 125% 7 -61% 0 -100%
Non-Litigated 130 120 -8% 110 -8% 111 1% 119 7% 24 -80% TOTAL 132 140 118 129 126 24
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Future Medical 13 15 15% 13 -13% 9 -31% 1 -89% 0 -100%
Non-Future Medical 119 125 5% 105 -16% 120 14% 125 4% 24 -81% TOTAL 132 140 118 129 126 24
2010 2011 % 2012 % 2013 % 2014 % 2015 %
OPEN 7 13 86% 27 108% 30 11% 39 30% 18 -54%
CLOSED 125 127 2% 91 -28% 99 9% 87 -12% 6 -93%
TOTAL 132 140 118 129 126 24

RATIO OF OPEN TO CLOSED CLAIMS

RATIO OF FUTURE MEDICAL TO NON-FUTURE MEDICAL CLAIMS

RATIO OF LITIGATED TO NON-LITIGATED CLAIMS

RATIO OF MEDICAL ONLY CLAIMS TO INDEMNITY CLAIMS
Prepared by AdminSure Data Valued as of Page 1 of 1

CLIENT X

AVERAGE CLAIM COSTS
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $820.75 $834.81 2% $662.51 -21% $924.85 40% $1,154.63 25% $1,266.40 10% Temporary Disability $0.00 $0.00 0% $0.00 0% $0.00 0% $0.00 0% $17.15 0% Permanent Disability $0.00 $0.00 0% $0.00 0% $0.00 0% $23.00 0% $0.00 0% Voc Rehab $0.00 $0.00 0% $0.00 0% $0.00 0% $0.00 0% $0.00 0% Other Indem $0.00 $0.00 0% $0.00 0% $0.00 0% $0.00 0% $0.00 0% Legal $0.00 $0.00 0% $0.00 0% $0.00 0% $0.00 0% $0.00 0% Other $10.39 $23.01 0% $2.43 0% $48.84 1910% $317.21 0% $134.58 -58% TOTAL $831.14 $857.82 3% $664.94 -22% $973.69 46% $1,494.84 54% $1,418.13 -5% 2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $6,030.82 $14,747.98 145% $24,543.37 66% $17,994.69 -27% $13,153.71 -27% $4,988.17 -62% Temporary Disability $3,668.03 $4,638.96 26% $6,747.29 45% $8,063.74 20% $4,622.25 -43% $1,187.92 -74% Permanent Disability $2,450.32 $2,932.67 20% $4,926.23 68% $5,437.97 10% $2,272.97 -58% $0.00 -100% Voc Rehab $275.76 $376.84 37% $761.14 102% $532.08 -30% $223.08 -58% $0.00 -100% Other Indem $372.41 $561.43 51% $265.00 -53% $1,014.48 283% $384.82 -62% $0.00 -100% Legal $608.21 $2,569.56 322% $2,378.80 -7% $3,271.26 38% $1,380.52 -58% $0.00 -100% Other $1,473.05 $2,344.97 59% $3,314.84 41% $4,270.26 29% $2,747.17 -36% $900.85 -67% TOTAL $14,878.60 $28,172.41 89% $42,936.67 52% $40,584.48 -5% $24,784.52 -39% $7,076.94 -71% 2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $31,927.33 $20,616.91 -35% $29,596.32 44% $21,682.14 -27% $18,000.00 -17% $0.00 0% Temporary Disability $10,049.74 $3,707.97 -63% $6,302.72 70% $1,091.19 -83% $0.00 -100% $0.00 0% Permanent Disability $10,934.61 $6,480.68 -41% $5,824.81 -10% $542.35 -91% $0.00 -100% $0.00 0% Voc Rehab $810.35 $0.00 -100% $1,017.63 -5% $0.00 0% $0.00 0% $0.00 0% Other Indem $514.27 $975.30 90% $964.14 -1% $0.00 0% $0.00 0% $0.00 0% Legal $1,884.64 $3,922.62 108% $2,562.18 -35% $0.00 0% $0.00 0% $0.00 0% Other $4,113.53 $4,077.15 -1% $4,552.03 12% $2,719.67 -40% $3,600.00 32% $0.00 0% TOTAL $60,234.47 $39,780.63 -34% $50,819.83 28% $26,035.35 -49% $21,600.00 -17% $0.00 -100%

AVERAGE COST PER CLAIM PER YEAR - MEDICAL ONLY

AVERAGE COST PER CLAIM PER YEAR - INDEMNITY

AVERAGE COST PER CLAIM PER YEAR - FUTURE MEDICAL
Prepared by AdminSure Data Valued as of Page 1 of 2

AVERAGE CLAIM COSTS
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $50,634.41 $42,421.63 -16% $101,044.34 138% $39,654.15 -61% $25,818.39 -35% $0.00 -100% Temporary Disability $12,725.85 $10,973.56 -14% $28,670.94 161% $20,160.95 -30% $7,953.51 -61% $0.00 -100% Permanent Disability $11,962.68 $11,558.06 -3% $23,627.14 104% $15,303.58 -35% $10,416.74 -32% $0.00 -100% Voc Rehab $2,279.05 $1,105.63 -51% $5,828.87 427% $1,713.85 -71% $1,714.29 0% $0.00 -100% Other Indem $3,157.66 $2,332.68 -26% $2,567.22 10% $3,338.43 30% $1,744.57 -48% $0.00 -100% Legal $14,750.14 $9,402.56 -36% $14,620.26 55% $10,618.56 -27% $9,247.69 -13% $0.00 -100% Other $12,074.76 $6,794.71 -44% $12,836.64 89% $10,919.29 -15% $8,583.62 -21% $0.00 -100% TOTAL $107,584.55 $84,588.83 -21% $189,195.41 124% $101,708.81 -46% $65,478.81 -36% $0.00 -100% 2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $2,272.59 $2,100.43 -8% $1,130.23 -46% $1,740.15 54% $872.71 -50% $548.25 -37% Temporary Disability $1,428.07 $567.07 -60% $336.43 -41% $743.19 121% $487.90 -34% $4.91 -99% Permanent Disability $728.58 $341.90 -53% $130.17 -62% $62.72 -52% $205.71 228% $0.00 -100% Voc Rehab $50.09 $0.95 0% $0.00 -100% $10.87 #DIV/0! $0.00 0% $0.00 0% Other Indem $92.50 $53.92 -42% $0.00 -100% $27.39 #DIV/0! $34.48 0% $0.00 0% Legal $170.42 $493.32 189% $99.82 -80% $151.48 52% $94.13 0% $0.00 0% Other $397.99 $377.22 -5% $177.06 -53% $411.23 132% $400.00 -3% $116.70 -71% TOTAL $5,140.24 $3,934.81 -23% $1,873.71 -52% $3,147.03 68% $2,094.93 -33% $669.86 -68%

AVERAGE COST PER CLAIM PER YEAR - LITIGATED

AVERAGE COST PER CLAIM PER YEAR - CLOSED
Prepared by AdminSure Data Valued as of Page 2 of 2
Measures the total liability of claims. This number indicates how well Client is at controlling costs through reduced claims, return to work, and claim closure. This number will directly correlate to increases in annual deposits that must be paid. The lower the number the better. $844,949
$764,843
$414,200
$0
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
Cost of All Claims
FY XX FY XX FY XX
Prepared by AdminSure Valued as of
$7,045
$60,738
$725
$0
$1,748
$48,932
$10,013
$346
$2,507
$63,735
$2,471
$941

FUTURE MEDICAL INDEMNITY INDEMNITY/FUTURE

MEDICAL

MEDICAL ONLY

COST OF ALL CLAIMS
DECEMBER 2 0XX

FY XXXX FY XXXX FY XXXX
$56,000
$58,000
$60,000
$62,000
$64,000
$66,000
$68,000
$70,000
$72,000

FY XXXX FY XXXX FY XXXX
YTD Comparison
Check Number
Check Date
81468
04/09/20XX
Employer
1470 South Valley Vista Drive, Suite 230
Diamond Bar, California 91765
Telephone (909) 861-0816
Fax (909) 860-3995
Payee Address
Payee Name MedReview Inc.

Post Office Box 5108
Diamond Bar CA 91765
From ThroughIncident Date DescriptionClaim NumberClaimant Name AmountDocument # 15-12205403/25/2015 03/25/2015 03/25/2015 3.90 Medical Review 413197P 15-12205403/25/2015 03/25/2015 03/25/2015 21.67Medical Review 413197O 14-12117712/05/2014 03/16/2015 03/16/2015 4.33Medical Review 413198F 14-12117712/05/2014 03/16/2015 03/16/2015 0.95Medical Review 413198P 14-12117712/05/2014 03/16/2015 03/16/2015 6.50Medical Review 413198O Check Total: 5 37.352Number of Claims:

PAY
TO
THE
ORDER
OF
CHECK

AMOUNTDATE
Thirty Seven Dollars And 35/100
81468
**********37.35
MedReview Inc.

Post Office Box 5108
Diamond Bar, CA 91765
16-66
1220

BANK OF AMERICA
222 North Catalina Avenue
Redondo Beach, CA 90277 NUMBER
C
Workers' Compensation
Administered by AdminSure (909) 861-0816
90 THIS CHECK EXPIRES AND IS VOID

DAYS FROM CHECK DATE
DateNumber Claim NumberClaimantDescriptionPayeeAmount Code Workers' Compensation Claims Check Register
For Month Ending XXXXXX
04/09/201581468 Medical Review ServicesMedReview Inc.0.95 L0054XXXXX XXXXX 04/09/201581468 Medical Review ServicesMedReview Inc.3.90 L0060XXXXX XXXXX 04/09/201581468 Medical Review ServicesMedReview Inc.4.33 L0054XXXXX XXXXX 04/09/201581468 Medical Review ServicesMedReview Inc.6.50 L0054XXXXX XXXXX 04/09/201581468 Medical Review ServicesMedReview Inc.21.67 L0060XXXXX XXXXX Grand Total: 5 37.35

Page 1 of 1 ends

Test Savings and Fee Summary
From 07/01/2022 thru 07/31/2022

Page 1 of 1 ends

Client: Total:Total
PercentageAmountMetric
$26,635.81PPO Red
$0.00
$9,279.00
$502.20

80.44%
$1,095,443.59 74.00%
$1,582,857.99
$296.92
$275.35
IPFS Fee
BR Fee
OCR Fee
Red Less Dups
Total Red
All Other Red
OSR Red
$487,414.40
BR Reg Red
$1,967,720.48Total Charges
0Work Units
1,073Bill Count
Dup Red
$1,068,235.51
eBill Fee $141.60
Additional Charge $0.00
109:1

73.02%$1,080,860.48
$0.00
$14,583.11
$0.00
$4,610.75
$0.00
$0.00
$0.00
ROI
Net Savings
Total Fee
UR Advisor Fee
SR Fee
PPO Fee
All Other Fee
Nurse Fee
Neg Fee
AP Fee $0.00
OSR Fee $49.56
From 07/01/2022 Thru 07/31/2022
Savings by Service Class

Page 1 of 1 ends

Client: Total:Total
Service Class Bill Count Total Charges
Additional
Charge Dup Red BR Reg Red PPO Red OSR Red All Other Red Total Red Total Red % Total Allowance

ANESTHESIOLOGY
DRUGS

DURABLE MEDICAL EQUIPMENT

EVALUATION AND MANAGEMENT

FACILITY-ASC

FACILITY-INPATIENT HOSPITAL

FACILITY-OUTPATIENT HOSPITAL

HEARING SERVICES

HOME HEALTH

MEDICAL AND SURGICAL SUPPLIES

MEDICAL-LEGAL

MEDICINE

NON MEDICAL

ORTHODIC PROCEDURES AND DEVICES

PATHOLOGY

PHYSICAL MEDICINE AND REHAB

RADIOLOGY

SURGERY

TRANSPORTATION
Unknown
Total
4 $12,912.00 $0.00 $0.00 $10,751.28 $314.14 $0.00 $0.00 $11,065.42 85.70% $1,846.58 196 $107,274.56 $0.00 $10,786.91 $46,654.57 $463.15 $163.74 $8.98 $58,077.35 54.14% $49,197.21 17 $13,085.72 $0.00 $1,082.92 $3,630.41 $607.80 $0.00 $117.41 $5,438.54 41.56% $7,647.18 380 $145,977.91 $0.00 $13,988.33 $61,942.08 $8,057.66 $0.00 $0.00 $83,988.07 57.53% $61,989.84 12 $115,315.92 $0.00 $0.00 $100,233.47 $705.45 $0.00 $0.00 $100,938.92 87.53% $14,377.00 5 $1,114,694.73 $0.00 $429,717.45 $599,103.32 $1,375.34 $0.00 $0.00 $1,030,196.11 92.42% $84,498.62 11 $106,550.34 $0.00 $1,538.34 $80,311.86 $42.31 $0.00 $0.00 $81,892.51 76.86% $24,657.83 1 $6,175.00 $0.00 $0.00 $6,175.00 $0.00 $0.00 $0.00 $6,175.00 100.00% $0.00 18 $19,967.64 $0.00 $0.00 $1,027.80 $0.00 $0.00 $0.00 $1,027.80 5.15% $18,939.84 11 $5,397.40 $0.00 $84.92 $3,162.52 $249.65 $0.00 $4.97 $3,502.06 64.88% $1,895.34 18 $37,318.86 $0.00 $9,444.93 ($251.62) $0.00 $0.00 $0.00 $9,193.31 24.63% $28,125.55 24 $19,032.99 $0.00 $0.00 $11,878.52 $531.65 $0.00 $0.00 $12,410.17 65.20% $6,622.82 9 $1,548.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.00% $1,548.85 6 $9,541.27 $0.00 $0.00 $2,169.92 $1,012.74 $0.00 $165.56 $3,348.22 35.09% $6,193.05 24 $64,007.92 $0.00 $1,087.44 $58,162.20 $371.60 $42.81 $0.00 $59,664.05 93.21% $4,343.87 259 $85,310.17 $0.00 $4,161.78 $31,932.24 $4,731.49 $0.00 $0.00 $40,825.51 47.86% $44,484.66 35 $25,400.24 $0.00 $1,554.00 $18,083.28 $777.45 $68.80 $0.00 $20,483.53 80.64% $4,916.71 26 $48,838.32 $0.00 $2,591.13 $29,382.15 $1,990.00 $0.00 $0.00 $33,963.28 69.54% $14,875.04 5 $5,657.26 $0.00 $3,876.25 $640.28 $0.00 $0.00 $0.00 $4,516.53 79.84% $1,140.73 12 $23,713.38 $0.00 $7,500.00 $3,246.23 $5,405.38 $0.00 $0.00 $16,151.61 68.11% $7,561.77 1,073 $1,967,720.48 $0.00 $487,414.40 $1,068,235.51 $26,635.81 $275.35 $296.92 $1,582,857.99 80.44% $384,862.49 From 07/01/2022 thru 07/31/2022
PPO/OSR Penetration

Page 1 of 1 ends

Bill.Jurisdiction State PPO/OSR Bill Count Total Charges BR Allowance* Billed To PPO/OSR PPO/OSR Red PPO/OSR Fee PPO/OSR Savings PPO/OSR Penetration PPO/OSR Efficiency AZ
CA
ID
MS
TX
Total
PrimeHealth Pend And Transmit
Total
Anthem Blue Cross Pend and Transmit
Coventry Pend And Transmit
HealthSmart Pend And Transmit
IQ Analysis FS
No PPO
PrimeHealth Pend And Transmit
Total
Coventry Pend And Transmit
Total
No PPO
Total
PrimeHealth Pend And Transmit
Total
1 $60.75 $46.90 $46.90 $9.38 $1.69 20.00% 100.00% 200.00 1 $60.75 $46.90 $46.90 $9.38 $1.69 20.00% 100.00% 200.00 236 $4,574,189.43 $1,334,886.56 $1,334,886.56 $353,573.92 $84,628.67 26.49% 24.50% 64.90 8 $766,650.02 $114,752.08 $114,752.08 $406.09 $101.54 0.35% 2.11% 0.07 471 $697,440.32 $497,226.39 $497,226.39 $4,755.56 $1,283.46 0.96% 9.13% 0.88 253 $659,480.04 $221,512.40 $221,512.40 $6,862.63 $1,503.66 3.10% 4.07% 1.26 2,661 $2,844,808.26 $1,061,182.86 $0.00 $0.00 $0.00
7,130 $4,740,985.70 $2,218,774.65 $2,218,774.65 $193,643.08 $44,438.25 8.73% 40.72% 35.55 10,759 $14,283,553.77 $5,448,334.94 $4,387,152.08 $559,241.28 $131,955.58 12.75% 80.52% 102.67 1 $2,162.00 $825.13 $825.13 $8.25 $2.06 1.00% 100.00% 10.00 1 $2,162.00 $825.13 $825.13 $8.25 $2.06 1.00% 100.00% 10.00 1 $3,748.00 $1,629.11 $0.00 $0.00 $0.00
1 $3,748.00 $1,629.11 $0.00 $0.00 $0.00
1 $1,798.00 $1,427.12 $1,427.12 $168.52 $30.33 11.81% 100.00% 118.10 1 $1,798.00 $1,427.12 $1,427.12 $168.52 $30.33 11.81% 100.00% 118.10 10,763 $14,291,322.52 $5,452,263.20 $4,389,451.23 $559,427.43 $131,989.66 12.74% 80.51% 102.57 DASHBOARD SAMPLE 1 of 2

DASHBOARD SAMPLE 2 of 2

Kaliope Layton, SIA, WCCP, WCCA
Senior Workers' Compensation Claims Supervisor/Manager
Professional
Experience
2016–Present AdminSure Inc.

Senior Workers’ Compensation Claims Supervisor/Manager
 Performs an extensive range of claims services which includes supervising accounts and claims staff ; communication with employers, injured workers, medical provid ers (medical management and return-to-work program management), and
attorneys (litigation and subrogation management);
coordinates accurate and timely deliver y of monetary (i. e.

Ed Code, LC4850 benefits, CalPERS, SJDB/vocational
rehabilitation, and settlements) and medical benefits (benefit administration as well as excess reporting; utilization review and bill review management); investigates questio nable claims, and when required, attends v arious depositions, WCAB conferences, trials, et cetera.
 Assists with conducting claims reviews, training sessions, and educational seminars; and coordinates various outside expert service providers reference ADA accommodation meetings, MSA reviews, ergonomic assessments, et cetera.
2003–2015 Various TPAs
Senior Workers' C
ompensation Claims Adjuster
 Perf
ormed an extensive range of claims services including
communication with employers, injured workers, medical
providers, and attorneys; coordinated accurate and timely delivery of benefits; investigated questionable claims, and when required, attended various WCAB conferences.

Education  State Certified Self -Insurance Workers’ Compensation Administrator.
 Workers’ Compensation Claims Professional Designation (WCCP).
 Workers’ Compensation Claims Administration Certification (WCCA).

References Please refer to our Client List.

Denise Perez, SIA, WCCA
Senior Workers' Compensation Claims Adjuster
Professional
Experience
2022–Present AdminSure Inc.

Senior Workers’ Compensation Claims Adjuster
 Performs an extensive range of claims services which includes communication with employers, injured wo rkers, medical providers (medical management and return-to-work
program management), and attorneys (litigation and
subrogation management); coordinates accurate and
timely delivery of monetary (i.e. Ed Code, LC4850
benefits, CalPERS, SJDB/vocational rehabilitation, and
settlements) and medical benefits (benefit administration as well as excess reporting; utilization review and bill review management); investigates qu estionable claims, and when required, attends var ious depositions, WCAB conferences, trials, et cetera.
 Assists with conducting claims reviews, training sessions, and educational seminars; and coordinates various outside expert service providers reference ADA accommodation meetings, MSA reviews, ergonomic assessments, et cetera.
1996–2021 Various TPAs
Senior Workers' C
ompensation Claims Adjuster
Education
 Performed an extensive range of claims services including communication with employers, injured workers, medical
providers, and attorneys; coordinated accurate and timely d
elivery of benefits; investigated questionable claims, and when required, attended various W
CAB conferences.
 State Certified Self-I nsurance Workers’ Compensation Administrator.
 Workers’ C
ompensation Claims Administration Certification
(WCCA).

References Please refer to our Client List.

Page 36 of 46 ends

VENDOR APPLICATION FORM
FOR
RFP No. 23-10 for Third Party Compensation Claims Administration TYPE OF APPLICANT:  NEW  CURRENT VENDOR
Legal Contractual Name of Corporation: ______________________________________ Contact Person for Agreement: _________ ____________________________________ Title: ______________________________ E-Mail Address: ______________________ Business Telephone: _________________________ Business Fax: ________________ Corporate Mailing Address: ________________________________________________ City, State and Zip Code: __________________________________________________ Contact Person for Proposals: _________ _____________________________________ Title: ______________________________ E-Mail Address: ______________________ Business Telephone: _________________________ Business Fax: ________________ Is your business: (check one)
 NON PROFIT CORPORATION  FOR PROFIT CORPORATION
Is your business: (check one)
 CORPORATION  LIMITED LIABILITY PARTNERSHIP
 INDIVIDUAL  SOLE PROPRIETORSHIP
 PARTNERSHIP  UNINCORPORATED ASSOCIATION
X
AdminSure Inc.

Alithia Vargas-Flores
President [email protected]
909.396.5814 909.978.1131
3380 Shelby Street
Ontario, CA 91764
President
Alithia Vargas-Flores
[email protected]
909.396.5814 909.978.1131
X
X

Page 37 of 46 ends

Names & Titles of Corporate Board Members
(Also list Names & Titles of persons with written authorization/resolution to sign contracts) Names Title Phone
___________________________________ ________________ ___________________ ___________________________________ ________________ ___________________ ___________________________________ ________________ ___________________ ___________________________________ ________________ ___________________ ___________________________________ ________________ ___________________ ___________________________________ ________________ ___________________ Federal Tax Identification Number: __________________________________________ City of Costa Mesa Business License Number:
________________________________________
(If none, you must obtain a Costa Mesa Business License upon award of contract.) City of Costa Mesa Business License Expiration Date: ________________________________ Alithia Vargas-Flores President 909.396.5814
Ashley Sells Corporate Secretary 909.718.1200
95-3773318
0000021568
2023

Page 38 of 46 ends

EX PARTE COMMUNICATIONS CERTIFICATION
Please indicate by signing below one of the following two statements. Only sign one statement.

I certify that Proposer and Proposer’s represen tatives have not had any communication with a City Councilmember concerning informal RFP No. 23-10 for Third Party Compensation Claims Administration at any time after February 16, 2023.
________________________________ Date: _______________________ Signature
________________________________
Print
OR
I certify that Proposer or Proposer’s representatives have communicated after February 16, 2023 with a City Councilmember concerning informal RFP No. 23-10 for Third Party Compensation Claims Administration. A copy of all such communications is attached to this form for public distribution.
________________________________ Date: _______________________ Signature
________________________________
Print
March 1, 2023
Alithia Vargas-Flores

Page 39 of 46 ends

DISQUALIFICATION QUESTIONNAIRE
The Contractor shall complete the following questionnaire:

Has the Contractor, any officer of the Contractor, or any employee of the Contractor who has proprietary interest in the Contractor, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a federal, state, or local government project because of a violation of law or safety regulation?
Yes _____ No _____
If the answer is yes, explain the circumstances in the following space.

Page 40 of 46 ends

DISCLOSURE OF GOVERNMENT POSITIONS
Each Proposer shall disclose below whether any owner or employee of Contractor currently hold positions as elected or appointed officials, directors, officers, or employees of a governmental entity or held such positions in the past twelve months. List below or state "None." None.

Page 41 of 46 ends

COMPANY PROFILE & REFERENCES
Company Legal Name:

Company Legal Status (corporation, partnership, sole proprietor etc.):

Active licenses issued by the California State Contractor’s License Board:

Business Address:

Website Address:

Telephone Number: Facsimile Number:

Email Address:

Length of time the firm has been in business:

Length of time at current location:

Is your firm a sole proprietorship doing business under a different name: ___Yes ___No
If yes, please indicate sole proprietor’s name and the name you are doing business under:

Federal Taxpayer ID Number:

Regular Business Hours:

Regular holidays and hours when business is closed:

Contact person in reference to this solicitation:

Telephone Number: Facsimile Number:

Email Address:

Contact person for accounts payable:

Telephone Number: Facsimile Number:

AdminSure Inc.

Corporation
N/A
3380 Shelby Street, Ontario, CA 91764
www.adminsure.com
909.396.5814 909.978.1131
[email protected]
Over 40 Years; Since 1982
Over 5 Years; Since 2017
X
95-3773318
7:30 a.m. - 4:30 p.m.

Only State and/or Federal Holidays
909.396.5814 909.978.1131
[email protected]
909.718.1200 909.978.1131
Alithia Vargas-Flores
Ashley Sells
Email Address:

Name of Project Manager:

Telephone Number: Facsimile Number:

Email Address:

COMPANY PROFILE & REFERENCES (Continued)
Submit the company names, addresses, telephone numbers, email, contact names, and brief contract descriptions of at least three clients, preferably other municipalities for whom comparable projects have been completed or submit letters from your references which include the requested information.

Company Name:

Contact Name:

Contract Amount:

Email:

Address:

Brief Contract Description:

Company Name:

Telephone Number:

Contact Name:

Contract Amount:

Email:

Address:

Brief Contract Description:
[email protected]
Kaliope Layton
909.861.9571 909.860.3995
[email protected]
City of Newport Beach, Client Since 1/1/15
Barbara Salvini, Human Resources Director, 949.644.3259 $360k
[email protected]
100 Civic Center Drive, Newport Beach, CA 92658
Third Party Workers' Compensation Claims Administration, and Utilization Review Services, and Partial Bill Review Services.

City of Irvine, Client Since 10/1/08
949.724.6079
Lori Thompson, Human Resources Manager
$336k
[email protected]
1 Civic Center Plaza, Irvine, CA 92606
Third Party Workers' Compensation Claims Administration, and Utilization Review Services, and Full Bill Review Services.

Company Name:

Telephone Number:

Contact Name:

Contract Amount:

Email:

Address:

Brief Contract Description:

City of Santa Ana, Client Since 10/1/18
714.647.5472
$600k
Debbie Scott-Leistra, Risk Manager
[email protected]
20 Civic Center Plaza, Santa Ana, CA 92701
Third Party Workers' Compensation Claims Administration, and Utilization Review Services, and Full Bill Review Services.

Page 45 of 46 ends

BIDDER/APPLICANT/CONTRACTOR CAMPAIGN CONTRIBUTION

DISCLOSURE FORM
Proposer/Consultant/Applicant is required to identify any campaign contribution or cumulative contributions greater than $249 to any city council member in the twelve months prior to submitting an application, proposal, statement of qualifications or bid requiring approval by the City Council.

Date Name of Donor
Company/Business
Affiliation
Name of
Recipient Amount
Except as described above, I/we have not made any campaign contribution in the amount of $250 or more to any Costa Mesa City Council Member in the twelve months preceding this Application/Proposal.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Bidder/Applicant/Proposer
Date
None.
- AdminSure Inc. - Alithia Vargas-Flores
3/1/23

EXHIBIT C

FEE SCHEDULE
Third Party Workers’ Compensation Claims Administration Request for Proposal Response – City of Costa Mesa
March 1, 2023
 

Page 1 of 1 ends

COST PROPOSAL
Third Party Workers’ Compensation Claims Administration Claims Administration  Year one: $16,640 per month
 All future years: 3% increase each year
Bill Review  $6.50 per bill for full services, at-cost PPOs, negotiation services, reports, and transmitting medical billing
information on behalf of the City to the Workers’
Compensation Information System (WCIS) as required by
State Law, i.e. Medical Bill Review EDI (Electronic Data Interchange); or $5.85 per bill for partial services
Utilization Review  Utilization Review – 5% of total charges capped at $750 per bill
 Physician Review – $200 per hour, billed in 10-minute increments
 It is important to note that neither AdminSure nor
MedReview receive a share of the physicians’ fees
Electronic 5020 Process  No Additional Fee
City On-Line Access
(All Data)
 No Additional Fee – Unlimited Number of City Read-Only Users
All Reports & Custom/Ad Hoc Reports  No Additional Fee When Data is Already Captured; At- Cost When Data is Not Captured
MMSEA, WCIS, ISO & 1099s  No Additional Fee
Training & Development of Special
Account Instructions/Procedures,
Internal MPN/PBN/Banking
Management
 No Additional Fee. Please note that any MPN, PBN, or
banking fees charged by the City’s choice of MPN, PBN,
or bank, if any, shall be at-cost as we will not add on any fee for our internal assistance/services
All Meetings, Claim Reviews,
Forms, Correspondence, Pamphlets,
Checks, and Storage of Claims

 No Additional Fee

EXHIBIT E
CITY COUNCIL POLICY 100-5

CITY OF COSTA MESA, CALIFORNIA

COUNCIL POLICY

BACKGROUND
Under the Federal Drug-Free Workplace Act of 1988, passed as part of omnibus drug legislation enacted November 18, 1988, contractors and grantees of Federal funds must certify that they will provide drug-free workplaces. At the present time, the City of Costa Mesa, as a sub-grantee of Federal funds under a variety of programs, is required to abide by this Act. The City Council has expressed its support of the national effort to eradicate drug abuse through the creation of a Substance Abuse Committee, institution of a City-wide D.A.R.E. program in all local schools and other activities in support of a drug-free community. This policy is intended to extend that effort to contractors and grantees of the City of Costa Mesa in the elimination of dangerous drugs in the workplace.

PURPOSE
It is the purpose of this Policy to:

1. Clearly state the City of Costa Mesa’s commitment to a drug-free society.

2. Set forth guidelines to ensure that public, private, and nonprofit organizations receiving funds from the City of Costa Mesa share the commitment to a drug-free workplace.

POLICY
The City Manager, under direction by the City Council, shall take the necessary steps to see that the following provisions are included in all contracts and agreements entered into by the City of Costa Mesa involving the disbursement of funds.

1. Contractor or Sub-grantee hereby certifies that it will provide a drug-free workplace by:

A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in Contractor’s and/or sub-grantee’s workplace, specifically the job site or location included in this contract, and specifying the actions that will be taken against the employees for violation of such prohibition;
B. Establishing a Drug-Free Awareness Program to inform employees about:

SUBJECT

DRUG-FREE WORKPLACE
POLICY
NUMBER
100-5

EFFECTIVE
DATE
8-8-89
PAGE
1 of 3

SUBJECT

DRUG-FREE WORKPLACE
POLICY
NUMBER
100-5

EFFECTIVE
DATE
8-8-89
PAGE
2 of 3

1. The dangers of drug abuse in the workplace;

2. Contractor’s and/or sub-grantee’s policy of maintaining a drug-free workplace;

3. Any available drug counseling, rehabilitation and employee assistance programs; and

4. The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
C. Making it a requirement that each employee to be engaged in the performance of the contract be given a copy of the statement required by subparagraph A; D. Notifying the employee in the statement required by subparagraph 1 A that, as a condition of employment under the contract, the employee will:

1. Abide by the terms of the statement; and

2. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction; E. Notifying the City of Costa Mesa within ten (10) days after receiving notice under subparagraph 1 D 2 from an employee or otherwise receiving the actual notice of such conviction;
F. Taking one of the following actions within thirty (30) days of receiving notice under subparagraph 1 D 2 with respect to an employee who is so convicted:

1. Taking appropriate personnel action against such an employee, up to and including termination; or

2. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health agency, law enforcement, or other appropriate agency;

SUBJECT

DRUG-FREE WORKPLACE
POLICY
NUMBER
100-5

EFFECTIVE
DATE
8-8-89
PAGE
3 of 3
G. Making a good faith effort to maintain a drug-free workplace through implementation of subparagraphs 1 A through 1 F, inclusive.

2. Contractor and/or sub-grantee shall be deemed to be in violation of this Policy if the City of Costa Mesa determines that:
a. Contractor and/or sub-grantee has made a false certification under paragraph 1 above;
b. Contractor and/or sub-grantee has violated the certification by failing to carry out the requirements of subparagraphs 1 A through 1 G above; c. Such number of employees of Contractor and/or sub-grantee have been convicted of violations of criminal drug statutes for violations occurring in the workplace as to indicate that the contractor and/or sub-grantee has failed to make a good faith effort to provide a drug-free workplace.

3. Should any contractor and/or sub-grantee be deemed to be in violation of this Policy pursuant to the provisions of 2 A, B, and C, a suspension, termination or debarment proceeding subject to applicable Federal, State, and local laws shall be conducted. Upon issuance of any final decision under this section requiring debarment of a contractor and/or sub-grantee, the contractor and/or sub-grantee shall be ineligible for award of any contract, agreement or grant from the City of Costa Mesa for a period specified in the decision, not to exceed five (5) years. Upon issuance of any final decision recommending against debarment of the contractor and/or sub-grantee, the contractor and/or sub-grantee shall be eligible for compensation as provided by law.

Costa Mesa City CouncilApril 4, 2023

Costa Mesa City Council
April 4, 2023