Torrance City Council
June 3, 2025

140
190
State of California
Certiflcal1on By Authorized Representative·
Company Name
Name
Phone
Email Address
Address 1
Address 2
City
City of Torrance
Kimberly Thompson
(310) 618-2950
[email protected]
3031 Torrance Blvd
Torrance
Name of Person Legally Responsible for this Electronic Signature:

Kimberly Thompson ( DatefTirne of Signature) - 09/30/2019 13;09 Tille Claims Manager
Fax (310) 618-2927
State CA Zip 90503

141
191
State of California
Report Location Number:
7110-01-099 A
Identification of Location
CITY OF TORRANCE at TORRANCE
CASES AND BENEFITS (to the nearest dollar)
Incurred Uabiflty
Certificate Holder
City of Torrance
From Date~-[±~~::~~? ___ I
Paid To Date
, To Date- I
....•. I.,.

Future Liability
Date # Indemnity Medical Indemnity Medical Indemnity Medical 1) Cases open as of 06/30/2019
reported prior to 2014/15
,L __ 4.2.~!._1 __ $2_2_.2_1_6_,8_88-'l __ i __ $4_3_,6_9_1_,0_86-'l'-I __ $1_1_,5_9_6_.4__,13 [jl $2i2:i5,999 ll · .... _· ·_-··-_i4_._6a_· o_.4_1_s,1jL __ $_16_,4_5_5_,o_s1_,] 2) Open and closed Liabilities
A) All Cases reported in 2014/15
2014/15 Cases open
184 J1'::: ==$=1=,2=2=2=,2=0=7!!'::l ==$=1,=4=96=·=71=5⇒!1;::::=$=1=,0=9=8=,9=-1=0~1!~ :-::::::-:::::=$=9=54=·:-:::::715T $123,297 i;·-- ' $54i:O??] 48i: $824,8111\ $1,229,365!1 $701,514{ $687~:365[=. $123.2971! $542,0001 B) All Cases reported in 2015116
2015/16 Cases open
I 1671;:: ===$2=,4=o=o=.o=3::::7!l $2,074,3061_1 $1,833:43·111 $1,108,08_4 __ '1;_[- $566,606]''1•.... ,, .... , - ' '' --- ' -~~ :QlL __ $2.m.011'! $1,84o,91s11 $1,606,46511 ·- $874.694fl "i's66.606!f $966:222] ,~[-=·-·=·--=17=·,:::··i==$=1,=3=14=.4=4=7;::::;i ==$=1=,3=4=7,=12=6⇒[:l;:::::=$=1,=09=2=,8=3=2'.l;:I ==$=6=4=2,=34='.7rr $221,6151[~" ~!?~·?7.~l C) All Cases reported 10 2016/17
2016/17 Cases open ,1_ 55,:;:::: ==$=1.=13=-4=.5=·~:::;··,;::1 ==$=1.=2=15=.5=6=5':~1 ==$=9=12=.9=7=41:~' ===s=s_1a=:.7=8=6r- $221.61s1[. __ $704.7791 [ __ _2,?2li $1,141,1s9jl $1,149,26ojj $776.o31j[ __ S4~2.44Si~-~3s's:§I $686.81s! D) All Cases reported in 2017/1 S 2017/18 Cases open __ 70J1 s1.oas.12sil $1.os9,116!f •• s119.398ff- $372,361J1 s36_::~:i~j[ ····· ·· $686.81s1 E) All Cases reported m 2018/19
2018119 Cases open
L_ . 158Ji_ $805,094,j $1,160~[- $326,9291! $227,56811 $478:1651! $932,4871 i 9ej! $802,801 j1 $1, 130,52811 S324.63_6JL. $198,?41J[- $478, 1651:___ _$932,4871 $ Indemnity $ Medical
SUBTOTAL I $6,435:~cil! $-2-0,-28-7-,3-9~01
TOTAL =,_ =_=:_=_= .. = .. ====~-'===:::::::-=:.= .. =:.$=:::26:i23,2761 3) Estimate Future Liability (Indemnity Plus Medical) 4) Total Benefits Paid During 2018/19 (Including all case expenditures). The indemnity amount includes the amount of LC § 4800/4850 benefits paid for the year (total of Lines 11 and 12)
5) Number of MEDICAL-ONLY Cases Reported in 2018/19
6) Number of INDEMNITY Cases Reported in 2018/19
7) Total of 5 and 6 (Also entered in 2E above)
8) Total Number of open Indemnity Cases (All Years)
9) Number of Fatality Cases Reported In 2018/19
10) (a) Number of FY 2018/19 claims for which the employer or administrator was notified of representation by an attorney or legal representative in 2018/19
1 O) (a) Number of non-FY 2018/19 claims for which the employer or administrator was notified of representation by an attorney or legal representative in 2018/19
11) Amount from salary continuation payments made pursuant to LC§ 4800/4850 that is in excess of the applicable temporary disability rate for the period paid. 12) Amount from salary continuation payments made pursuant to LC § 4800/4850 capped at the temporary disability rate for the period paid.

FJlestJploaded
ALL Open Jndernn,ty Claims (by reportmg and by year) reported and with claims: Copy of SIP _Public __ List __ Of __ Cpen_ Cases.xlsx 158i
:..::::.:.~ .... :!
481 i
0 35
$485,766 1
$723,152
Fag12 6 of 7
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192
State of California
Dual Jurisdiction Claims
Please note that Calitomia Labor Code Sectton 3702.2(b} requires that·· __ !he annu:11 repon or .a se!f-111sured employer who h3S self-insured both s:ate and federal •NorY..ers· comµen:;ation liability shall al~o be set forth (1) amount ct all comptnsation !;ability incurred. paid .. to-date. the estima!ed future liability under beth this chapter ancl under the federal Jongshore and Harbor Worker's Ccrnpensalion Act (33 U.S.C Sec. 901 el seq.). and (2) lhe identity and tt,e amount of the se,;uri?y dc~sesil securing the employer's ltab1lity under stale and federal self-insured programs." Accordingly, please indicate ail California e>posure on your Self Insurer's Annual Report. and, in addition identify each Claim with dual jurisdiction on Separate List of Op~n ldemruty Claims. For those claims, 1ndie21e the incurred. paid-to-date, and est.mated future liab1l1ties for federal exposure. Please also 1nd1cale the amount and the type of secun1y deposit securing those claims.

Instruction,; .IQ...Claims Administra\pr For Specific Excess Insurance The TPA should provide a sum of the unpaid excess carrier excess liability under "Calculauon of Specific Excess Coverage Entry for the Annual Reports".

In addition. provide a list of claims for which specific excess credit is being claimed. fhis rn.:iy be provided as a spreadsheet. Indicate in the list of claims the following information
The !!st shall include the name of UH:~ cti1mant, cla:m number, date of injury, description of injury, camer name and policy numt•er policy 0:,1,,•eragc pcrtect_ retenlicn level of policy and p3id to date in indemnity or medical benefits. and the estimated future liability of the claim minus the total unpaid employer retention, which equals the total unpaio urrier liability. whether the claim has oeen reported to a carrier. if the claim h.;,s been ~ccepted by !he earner. 1f the earner has ,jen1ed ,my part of lhe liability of the cl:i1m.

Refer to OSIP website for sample format of the Excess Credit Ca!culation form.

Calrnlation Of Specific Excess Coveraae Entry For Annual Reports:

Enter the sum of the total unpaid carrier excess liability claimed from the "Specific Excess Insurance Policy Coverage". If none enter "O".

Files Uploaded
i&.l1ll.L\;.filtQ!!
Administrating Agency's Certificate Number 099
Q] Or Self Administered
I declare under penalty of perjury that I have prepared or caused this report to be prepared and I have examined this liabilities report to be prepared and I have examined this liabilities report of this self insurer's worker's compensation liabilities. To the best of my knowledge and belief this report is true, correct and complete with respect to the worker's compensation liabilities incurred and paid. I further declare under the penalty of perjury that the estimates of future liability of worker's compensation cla1111s made in this report reflect the administrator's best judgement as to the future liability cf claims, using prevailing industry standards, and !he si9natory intends Self Insurance Plans lo rely upon the representation.

Agency Name
Name
Phone
Email Address
Address 1
Address 2
City

CITY OF TORRANCE
Kimberly Thompson
(310) 618-2950
[email protected]
3031 Torrance lllvd
Torrance
Name of Person Legally Responsible for this Electronic Signature:

Kimber'v Thompson ( Date/Time of Signature) 09/30/2019 13: 12 Fax
State CA Zip 90503
Pa<Jt: 7 of l
143
193
Thompson, Kimberly
From:

Sent:

To:

Subject:

Attachments:

WARNING: External e-mail
[email protected]
Monday, September 30, 2019 1:16 PM
Thompson, Kimberly
OSIP Annual Report
AR-7110-2019.pdf
Please verify sender before opening attachments or clicking on links.

Hello Kimberly Thompson,
The requirement for submitting the Annual Report for the reporting period has been satisfied.

Attached is a copy of the 07/01/2018 - 06/30/2019 Annual Report generated 09/30/2019.

If your self-insurance certificate has multiple TPA Adjusting Locations, the claim liabilities from each have been summarized.

Thank You for your participation.

Sincerely,
Office of Self-Insurance Plans
144
194
RFP B2022-28
Customized Program Design a
Contract term: July 31, 2022 - July 30, 2025 {with the possibility to extend for two additional one-year terms; July 31, 2025 - July 30, 2026 and July 31, 2026 - July 30, 2027) Servicing offices
All workers' compensation claims will be managed centrally from our Rancho Cucamonga, California, servicing office.

Sumrnary of first year fees: police departrnent
111The fees quoted below are applicable as long as the number of takeover claims does not differ more than 10% from the estimates shown below. All fees assume the full deployment of Sedgwick managed care services.

Per claim fee pricing
Indemnity claim 215 $1,575
MectiJalbnly claim 75 $165
Incident only 2 $40
Takeover indemnity claim(11 112 $290
Takeover medical only claim' 11 86 $85
Future Medical Only 112 $270
Annual f!otf1;.:e option**
Sedgwick offers an annual flat fee pricing option in the amount of $451,000 based on the estimated claim volumes outlined above and the estimated required staffing to service those claims. Under this option, Sedgwick reserves the right to modify the annual flat fee if acquisitions, divestitures, changes in program requirements, or an increase in claim volume of greater than 10% impacts the staffing requirements of the unit. Claims open at contract termination will either be transferred to the new administrator or handled by Sedgwick for an additional annual fee.
**Please note the flat fee option only one year can be provided. This is because pending claim figures are subject to change for fire and other, which may be a material impact because pending claim figures are subject to change for Fire & Other, and this may be a material impact for the following year's pricing. Subsequent years the flat fee will have to be recalculated, based on the current pending claims, with the addition of fire and other. ~,"l'.ipvick(opyright £ 2022
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RFP 82022-28
Saas Pricing Information
Sun1mary of first-year fees
Implementation
There is a one-time implementation fee of $15,500 payable upon notification of award if migrating to Sedgwick's systems upon inception of contact. If the City opts to migrate later during the contract term, the one-time implementation fee will be payable upon initiation of system migration. The implementation fee includes the following:
• Implementation team responsible for change management transition for project management and technology infrastructure
0 Set up of up to two outgoing data feeds in Sedgwick's standard format to either carrier, broker, or RMIS system aggregator
"' Historical data conversion from one data source (not including images) first-year claim fee estimates
Workers' compensation $351,080 $451,000
Workers' compensation takeover (annual) $70,030 NA
Program management fee (annual) $30,000 NA
RMIS (annual) Included Included
Implementation fee (one-time)* $11,000 $11,000
Total estimated first year fees $462,110 $462,000
*The one-time implementation fee would only apply to year one if the City opts to have the claims managed by Sedgwick transitioned to Sedgwick's claims system.

Items included in the quoted fees include:
0 Implementation team: Team responsible for change management transition for project management, technology, and program infrastructure
, , New program kick-off meeting
SMgwick Copyright ,'fJ 2022
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RFP 82022-28
u Historical data conversion from one data source, including the conversion of images within Sedgwick's best practice standards
" RMIS access (applies only if and when the City opts to migrate the claims managed by Sedgwick to Sedgwick's systems): viaOne access for four users, which provides a platform-independent, web-based suite of services for viewing and analyzing claims data. Access provides secure, near real-time information from Sedgwick's proprietary claims information systems, including:
, , Customizable dashboards with drill-down capabilities Detailed information about the incidents, claimant work status, and time tracking information
u Financial information about an event, including the claim's payment history and available reserves , 1 Client diary capability, allowing for the creation of client diaries and customized alerts o Access to viaOne reports, which create ad hoc detailed reports with user-specified fields and filters u Access to Sedgwick's advanced analytics portal, a data warehousing platform that takes a deep dive to discover meaningful risk information at the program level " RMIS data outgoing feed (applies only if and when the City opts to migrate the claims managed by Sedgwick to Sedgwick's systems): Monthly data file to a single carrier • Claims reporting: Sedgwick pricing includes the use of the Sedgwick call center and/or web reporting technology. Any other method (i.e., fax, email, land mail) will incur a fee of $24 per reported incident * Claim reviews: In-person quarterly claim reviews with electronic status reports Additionol bundled services andfees
" Data conversion of additional sources of historical data for handling by Sedgwick Conversion of imaged documents beyond Sedgwick's best practice standards will incur additional fees Optional subrogation and other recovery services (second injury funds and other special funds) will be charged 25% of recoveries
Special investigation unit (SIU) services will be charged at prevailing rates " RMIS data feeds: Additional interface files are $225 per month for monthly files, $645 per month for a weekly file, or $1,945 per month for daily file
" RMIS: System interfaces or custom programming charged at $185 per hour • Optional risk control services are available for $155 per hour plus direct expenses for general safety personnel, $170 per hour plus direct expenses for specialized industrial hygiene, and $180 per hour plus direct expenses for ergonomists/analytics
SedpvkkCopyright 'L' 2022
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RFP 82022-28
" MMSEA/SCHIP Medicare reporting fee: One-time $9 charge per claim for claims involving bodily injuries (workers' compensation, liability, no-fault)
® Optional escheatment services are charged $15,850 per year for claim-related payments issued from an escrow account in Sedgwick's tax ID. Under this process, Sedgwick reports un-cashed claim-related payments to the appropriate state according to each state's unclaimed property law. Sedgwick offers an alternative escheatment service for free; however, the City is responsible for filing unclaimed property to the states
® Optional OSHA services: Sedgwick provides flexible OSHA recordkeeping solutions. The City has the option to select one of two levels of service to suit their preferences through our viaOne OSHA proprietary application. The system can generate standard reports such as the OSHA 300, 300A, 301, and Sharps logs, as well as generate standard reports such as the OSHA 300, 300A, 301 and Sharps logs, along with other reports, such as DART and BLS surveys. Our service levels include:
u Basic - Sedgwick provides initial and ongoing demographic data updates to the application. The City retains responsibility for other record keeping decisions, including time tracking, privacy case designation and recordability. Fees are $6,600 for implementation, $460 per user per year and $15 per incident set up in viaOne OSHA
o Advanced - Sedgwick's trained OSHA analysts assume responsibility for all recordkeeping updates, including time tracking, recordability, injury type designation and privacy. Fees are $6,600 for implementation, $460 per user per year and $31 per incident set up in viaOne OSHA Optionof: softwore as a service (SaaS)
If the City opts to fully migrate all claims, including those administered by the City's in-house claims team during the term of the agreement, the Saas subscription access to our JURIS claims system is outlined below.

Subscription access is provided on a named user basis.

JURIS Saas includes:

Sedi;:wids (op,,riqht I 2022
" Fully-hosted software solution
" Sedgwick best practice for data storage, maintenance, security and encryption
"' Quality management features
® Industry-leading JURIS reporting features
" Upgrades and enhancements made to JURIS by Sedgwick
as part of normal development process
IT support during core business hours (7 a.m. - 7 p.m. CST $12,000 Per named
user per year
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RFP B2022-28
Sedgwick best practice standard SIR inbound document
scanning and indexing, mailing services for outbound,
correspondence, materials
Sedgvvick rna nagcci ca re
In the event that the City opts to transition the claims to Sedgwick's proprietary claims and RMIS platforms, all claims administration fees ;:rnd services contemplate the deployment of Sedgwick's managed care services for all bill review and case management services.

State fee scheduling/usual, customary and
reasonable; sti;ite reporting
California outcomes-based statewide MPN (all
California bills)
TCM:

Telephonic nurse case manager
Surgery nurse case manager
Behavioral health specialist
Customized nurse services
UR
$9 per bill
PPO networks/out of network services - 28% of savings
Telephonic clir\i rvices
Evaluation and recommendation $150
1-30 days: $395
Every 30 days thereafter: $295
$105 per hour 11l
$105 per hour Ill
UR ancfphysician advisor
$125 per review
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RFP 82022-28
Physician advisor/peer review
Physician review of records
Physician advisor appeal
Complex pharmacy management
Medical FCM: Full field
Crisis care RN
FCM tasks:
· One visit clinical assessment
Limited assignment task
Spe{ialty task services: life care plan, expert
testimony, customized services
$275 per review
$275 per hour
$350 per review
Pharmacy nurse management/pain coaching: $115 per hour
Physician and PharmD managen:i~nt(as
needed): $275 per hour
$105 per hour, plus direct expenses 11l
Urgent/catastrophic case management: $165 per hour {ll
$165 per hour {ll
$720 flat fee
$105 per hour Ill
$165 per hour
. ..)!i\''f~. . ·.

Vocatl~l'}al and work placel'TlE?nt solutions
Transitional work placement (at not-for-profit)
RTW specialist
Workplace consultation - program/policy design
and planning
Vocational - full FCMA
Sed&wick Copyright if 2022
$900 for placement or no-show
$105 per hour (ll
Telephonic RTW
$200 per hour, plus direct expenses
$105 per hour, plus direct expenses {ll
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150
200
Vocational field tasks.·
Vocational assessment/testing
Labor market survey
Automated transferable skills analysis
Job analysis or ergonomic evaluation
Clinical consultation
Lien resolution
Sedgwick standard medical card
Mandatory state panel postings
Non-mandatory state panel postings
$950 flat fee
$640 flat fee
$360 flat fee
S 790 flat fee
Clinical consultation services
RFP B2022-28
Standard (24/7/365 access to nurse): $90 per triage call Premium (blended nurse intake option): $105 per triage call Advanced (ability to customize workflows): $115 per triage call* * leveLof customization may warrant additional fees
dgwick'managea··•care
28% of the below fee
of $125 and cap of
ule savings subject to minimum fee
er lien
Expert witness testimony or hearing representation charged at $125 per hour plus direct expenses
No charge; customization starts at $3,500
Included in Sedgwick bill review program fees
$9 per panel
(1) Alaska, California, Hawaii, New York@ $135 per hour; CAT@ $185 per hour 151
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RFP B2022-28
Definitions, terms and condition',
Life of contract: Sedgwick will administer all claims received during the contract for the quoted fee. Claims open at contract termination will either be transferred to the new administrator or handled by Sedgwick for an additional annual fee.

Indemnity claim: An indemnity claim shall mean any workers' compensation qualified claim as follows:

For which a payment is made or reserve is posted under the indemnity portion (i.e., not medical and not expense) of the qualified claim or there is time lost from work For which an application for adjudication of a claim or hearing notice is received or otherwise involves litigation or communication from or to a petitioner's attorney Where incurred medical costs exceed $3,000
That is denied but otherwise would have been classified as an indemnity claim For which the City requests to be investigated or classified as an indemnity claim That Sedgwick determines additional investigation is necessary to determine compensability, to comply with applicable laws or both
For which subrogation is investigated or pursued
That is open longer than 12 months
Medical only claim: A medical only claim is defined as any claim that is not an indemnity claim or an incident only claim.

Incident only: Incident only claims are claims reported by the City that require no payment or activity other than generating a record in the claims administration system. These claims carry no reserves and no contacts are made by Sedgwick. If contacts are required on incident only cases, additional fees will apply.

Future medical file: An Indemnity file on which there is an award for on-going future medical care and/or the payout of Permanent Disability or a Life Pension.

Allocated expenses: The claim fees agreed to shall include all costs incurred by Sedgwick in handling claims submitted except those costs normally referred to as "allocated expenses." These expenses will be billed to the individual claim file when incurred.
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11 r P B 2 0 2 2 - 2 8
In some cases, Sedgwick engages subcontractors to assist us in providing services. In order to hold down the cost to our clients, Sedgwick may have arrangements with these subcontractors to cover expenses for certain activities including, but not limited to development of integrated data systems, account management, quality oversight and ongoing projects that improve penetration and efficiency for our examiners. These cooperative service agreements are not transactional-based and are not dependent on any activity generated by the City. In fact, the flat cooperative service fees remain the same regardless of whether the City uses these vendors on their program or not.

Allocated expenses include but are not limited to:

Attorney fees and costs
Hearing representation in lieu of attorney fees including preparation, travel expenses, attendance and system notations
Court costs and appeal bonds
Cost of providing rehabilitation services
Cost of surveillance activities and other outside investigations Cost of expert witnesses, accident reconstruction specialists or any other specialist necessary for the investigation and/or defense of a claim
Cost incurred to obtain statements, photographs, records, transcripts, depositions, digital call recordings, etc.

Cost of inspections, appraisals, repair management, rental/replacement, etc.

Cost of independent medical exam
Cost of medical bill review, PPO, managed care and other similar programs Cost of medical experts, peer review, UR, case management, pre-certifications and medical necessity evaluations
Cost of translation services
Medicare reporting and compliance services fees and costs Index filings
Cost of vocational evaluations, vocational services, training or other vocational activities Cost of outside assistance necessary to prepare or protect the City's subrogation right or Special Disability Trust Fund claim
Expenses for travel to depositions, mediations, arbitrations, hearings or other legal proceedings ,1t the City's request or as required by law or rule of a federal, state or local agency 153
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RFP B2022 28
Terms ond conditions
Quotation expiration: All pricing quoted is valid for a period of 180 days from submission unless a written extension is requested.

Takeover of existing claims: Takeover claims are anticipated for workers' compensation and liability and pricing and parameters for such takeover have been included in the pricing section of this document.

Payment terms: All one-time implementation and data conversion fees are billed upon notification of award. All recurring fees such as claims service, program management and information technology fees are billed on actuals on a monthly basis in arrears. If a flat fee pricing option is selected, all recurring fees are billed on a quarterly basis in advance based on annual estimates. The estimates are subject to audit 30 days after the conclusion of each contract year. All invoices are payable upon receipt
Takeover claims are billed annually based on the number of takeover claims open at the beginning of each contract year or reopened during the year. Invoices are payable upon receipt.

All service fees contemplate program service commencing on July 31, 2022. In the event the effective date of services is delayed at the request of the City, Sedgwick reserves the right to bill the City for progrJrn deployment expenses incurred outside of the scope of agreed implementation period, up to and including full fees for service on the
originally scheduled implementation date with invoices payable upon receipt.

Taxes: All applicable taxes will be added to the service fees where this is required. Sedgwick may be required, in some jurisdictions, to collect and remit sales tax on the services provided to the City. If billed, the taxes will be stated separately on the invoice. If Sedgwick is provided an exemption certificate, in good faith, tax will not be charged. In the event that a jurisdiction invalidates or does not accept the exemption certificate, Sedgwick will not be liable for any penalty or interest that may be charged.

Early termination: Should the City terminate for convenience within the first 12 months of the agreement, the City shall pay Sedgwick fees equal to three months of the service fees. Should the City terminate during the second 12 months, the City shall pay fees equal to two months of the services fees. Termination fees are payable within 30 days of the date of notice of such termination.

File storage: The City is responsible for storage of claim files closed at the time that Sedgwick begins claims administration.

Submission of all applicable claims (not applicable if a flat fee is chosen): The fees quoted are bJsed on the assumption that the City will forward to Sedgwick all claims arising during the applicable time per rod for· the respective department(s) that is/are being managed by Sedgwick. In the event that the City does not forward all such claims to Sedgwick, we reserve the right to adjust the fees accordingly. 137
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RFP B2022-28
Contract term: All fees assume that the parties will enter into a three-year contract ( contract term: July 31, 2022 - July 30, 2025, with the possibility to extend for two additional one-year terms; July 31, 2025 - July 30, 2026 and July 31, 2026 - July 30, 2027) with an annual increase to all fees of the greater of three percent (3%) or the percentage increase as reported by the U.S. Department of Labor - Bureau of Labor Statistics (http://www.bls.gov/cpi/home.htm) for the Consumer Price Index fqr All Urban Consumers (CPI-U) for the U.S.

City Average, All Items, unadjusted and published during the month ending three months prior (to allow time for reports to be published) to the anniversary date of the contract. 138
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205
d
" Bio_Alicia Badillo
,. Bio_Bernadette Bates
" Case study_L.A. County
Claim status report and file strategy
,. Complaint acknowledgment letter
" Complaint resolution letter
" CSI template final
<> Escalation policy
, JURIS report sample book
Litigation management guidelines
" Sedgwick subsidiaries and affiliates
" Workers' compensation best practices
,. Workers' compensation sample reserve worksheet
SNi,::wtck Copyrir;ht ·1; 2022
RFP B2022-28
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ATTACHMENT 1

STATE OF CALIFORNIA

COUNTY OF LOS ANGELES

PROPOSER'S AFFIDAVIT
_____ s_c_ot_t_R_o_ge_r_s ____ being first duly sworn deposes and says:

1. That he/she is the Chief Client Officer
(Title of Office)
of Sedgwick Claims Management Services, Inc.
(Name of Company)
Hereinafter called "proposer," who has submitted to the City of Torrance a proposal for RFP B2022-28 for Workers' Compensation Claims Administration Services (Title of RFP)

2. That the proposal is genuine; that all statements of fact in the proposal are true;

3. That the proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not named or disclosed;

4. That the Proposer did not, directly or indirectly, induce solicit or agree with anyone else to submit a false or sham proposal, to refrain from proposing, or to withdraw his proposal, to raise or fix the proposal price of the Proposer or of anyone else, or to raise or fix any overhead, profit or cost element of the Proposer's price or the price of anyone else; and did not attempt to induce action prejudicial to the interest of the City of Torrance, or of any other Proposer, or anyone else interested in the proposed contract;

5. That the Proposer has not in any other manner sought by collusion to secure for itself an advantage over the other Proposer or to induce action prejudicial to the interests of the City of Torrance, or of any other Proposer or of anyone else interested in the proposed contract;

6. That the Proposer has not accepted any proposal from any subcontractor or materialman through any proposal depository, the bylaws, rules or regulations of which prohibit or prevent the Proposer from considering any proposal from any subcontractor or material man, which is not processed through that proposal depository, or which prevent any subcontractor or materialman from proposing to any contractor who does not use the facilities of or accept proposals from or through such proposal depository;

7. That the Proposer did not, directly or indirectly, submit the Proposer's proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative thereto, to any corporation, partnership, company, association, organization, proposal depository, or to any member or agent thereof, or to any individual or group of individuals, except to the City of Torrance, or to any person or persons who have a partnership or other financial interest with said Proposer in its business.

8. That the Proposer has not been debarred from participation in any State or Federal works project.

Dated this _2 _ day of June , 20E_.
~ ud-~ ~7or:1
(Proposer Signature)
Chief Client Officer
(Title)
17 157
207
sedgwick
Vice President,

ALICIA BADILLO
Alicia is assistant vice president of operations and claims director located in Sedgwick's Riverside, California, office. She has more than 25 years of experience in the workers' compensation industry, working with insured and self-insured clients. Alicia is responsible for the technical and operational functions within our Riverside and Rancho Cucamonga offices, including compliance with company standards and industry best practices. She ensures consistent delivery of quality services to Sedgwick's clients and has direct responsibility for more than 90 colleagues.

Prior to joining Sedgwick, Alicia was the director of complex claims for a major insurance carrier. She was responsible for staffing and training technical examiners managing cases with high-dollar exposure with complex medical and legal issues. She was also accountable for the disposition of complex cases in the California region.

Training and education
Alicia earned a master's degree in international business at San Diego State University. She also holds a workers' compensation claims professional designation
158
208
sedgwick

BERNADETTE BATES
Bernadette has worked in the claims and insurance industry for more than 25 years. Throughout her time in the industry, she has worked with both insured and self-insured employers, including CKE Restaurants, EDCO Disposal, Garnet Captive Program - to name a few. Bernadette has also worked with a number of school district clients.

As an examiner, Bernadette focused on settling claims early for a nominal amount to avoid further litigation. She also assisted in training new employees to help them become familiar with the claims system and the industry. Bernadette participates in conference calls clients, attorneys and adjusters to ensure action plans are addressed and that the claim is headed toward a timely resolution. She also participates in regular claim file reviews and attends regular training sessions to ensure the laws, rules and regulations for California claims are being adhered to.

Bernadette is dedicated to continuing professional growth. She was promoted to team lead in July 2021 and currently oversees a team of five examiners, consisting of individuals with up to 30 years of experience in the industry, as well as trainees.
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209
CITY OF! LOS ANGELES
County of Los Angeles
Sedgvvick began patinership \Vith the County of Los Angeles (Countyi, handling workers' compensation for two of the County's four units on january 1, 201.1. On Jul•r· 1, 2019,. Sedgwick assumed an additional 16,000+ open claims and is now responsible for administering claims for a!I four County units, encompassing the entire 1Nor-kers' compensatJon program for all County departments from four Sedgwick offices located with•n the County.

Throughout the implementation process a,1d to date, we have accoP1plished the follovving:

Soned and filed hundreds of boxes of loose mad rece:ved fror', p<or TPAs ., All 16,000+ assumed clai.ms were alphabetized and re-organized before July 1, 2019 ., Hosted multiple open houses and successfully recruited over 200 colleagues .. bringing the total coHeague count for the County's program to 371 colleagues " All 200+ new Sedgv1ick colleagues were h;red and ready to start \Nork on the County program when new units went live on July 1 .. 2019
~ Hosted a one-week orientation of ail ne1.v hires a: the Ontario Convention Center with subject matter experts and key Coun:y personnel
❖ 99% of Sedgwick examiners earned the SIP certi'icate by the first year of the program " Maintained staff at 94% as of October· .2020
• Claims reviews and disabiiity status rnee:rngs for 2ve 0y County department on a rnonthly or quarterly basis for 32 departments
0 Established monthly managemer': meet:ngs v,i:h Count•i-CEO-Risk ~.:lanagement Branch , To promote quicker closures, Sedgvnck obtained DV'JC audit approval in writing to forego stipulated awards on 0%) PD \Vith future rT1ecl:cal c!airns. The County approved Sedgv,,.ick's proposal for issu ng a PD denial and closinf the fie in-i;~,ed:ately Establishment of an independent medical exam flfv1E) appcintment desk to set all initial appoin:1~1ents and track seque,1tial da:es iea,ji·,g tc reso!ution of disputes ·or mor'itor.ng the effectiveness of the fire carve-cut progr·arn for Unit C, foe department Es:atJlishmen: cf a three-point con,ac: desv t:=, e'75W"' ,irn2\ ,n,tia co--itac:s and prepar·e the mes •Ni,h an ISO claims index, EJiJ,1S check and :mor Coumv claims meek for Units C and D
* Es:ablishrnent cf fraud interdic:ion progr·arn tl":at con-1bi11es the capture of surverilance results on a master sveadshee: ,'.·'tl· prn,,-pt s:u 1·ou1'dt;i:,le s-:rntegy sess1:,11s, pus fraud 160
210
CITY Oft !.OS ANCEi.ES
questionnaires for daimants
0 Establishment of IMR desk to timely process and log all il'v1R requests for Units C and D a Developed paperless mail process with revised workflov,s to accommodate paperless file management
• Creation of a COVID-19 secure portal for c!ient reporting of positive cases to determine outbreaks
ouu!ity
• Establishn,ent of centralized tracking tools to manage time sensitive items ln the paper environment, including the fotlmving office wide documents: master hearing log, LC4850 and salary continuation tracking log, :'aims assistant task assignment log, LC4850 and salary continuation track,r~g log and roundtabie discussion tracking log ~ Testing of nev;- iVOS c!aim system and development of nevi value-added system tools ,, Initiated a he1pline dedicated number for tracking complaints, featuring the tracking of incident and resolution details to assess customer service • On-demand injured employee surveys to assess customer service 11 Q_uality assurance team to supervise an accurate calculation of awards and commutations, dairns coding, timely initial DV\/C benefit notices and compensability deterrnina:ions
~ Monthly self-audits in line with Sedg;,vick and the County's best practices Bi-weekly in-house staff training on :ne elements of workers' cor'1pensat•on claims best practices
• Established monthly train,ng topics 011 :he County-'s best pr-actices and expectations • In-house industry advancement progr,=i1-r1 (IAP) to generate a pipeline of well-trained, SIP­ certified college graduates to fill spec ai pr·oJect needs and immediate back-fi!I for claims desk vacancies
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211
CITY OF I.OS ANGELES

RESULTS
" Sedgwick's claim administration for the fire department is experiencing year-over-year reductions in personnel receiving LC4850 benefits. During the first 18 months, the number of firefighters on lC4850 dropped 13%. Sedgwick's aggressive early investigation, combined \Vith strong
coordination of return-to-work strategies, has produced excellent cost savings
" During the first year on the program Sedgwick recovered $1,762,000 in subrogation reimbursement {excluding
subrogation credit). Our continued focus on subrogation training has heightened the claims examiner's awareness of subrogation potential and improved recovery strategies.

Success identified for all units with reimbursements
includes:
" Unit A: $738 1 000
" Unit B: $24,000
" Unit C: $531,000
" Unit D: $469,000
I
During the first 18
months, the number
of firefighters on
LC4850 dropped
13%
• In the first 12 months of the newly assumed prograrns, Sedgwick achieved a net claim reduction of 1,836 claims for Unit B Mental Health and Unit C Fire, between July 1, 2019 and June 30, 2020
* Sedgwick implemented a County-specific COVlD-19 business continuity plan to ensure Sedgwick's response to the COVID-19 pandemic was swift and effective; in addition, 1.ve transitioned 164 claims examiners to work from home within seven days 162
212
Workers'
Location and description ot accident:
(Examiners: Make sure this section accurately describes how the injury occurred and where it occurred.) R
Cornpensability analysis:
(Examiners: Make sure this section accurately describes why you accepted/denied the claim, and list all accepted/denied body parts.)
X
Medical sumrnary:
(Examiners: Make sure this section clearly indicates the treatment the employee has had, their current medical status and their anticipated treatment needed to reach MMI.} Diagnosis: ICD10 Primary
Current medical status:

MMI attained or anticipated:

Active providers:

IME name and results (if applicable):

CA only~ PTP name/specialty:
163
213
CA only- AME name/specialty:

CA only- QME name/specialty:

TCM/FCM on file:

Surgery date:

Surgery type:

Last visit date and treatment plan:

Next scheduled visit:

Claim status:

Current work status: X
Temporary or permanent restrictions:

Anticipated RTW modified and full duty:

Reemploy ability considered status:

Subrogation: R
Referred for subrogation pursuit:

Second injury fund:

Litigation ~,ratus:

R
Next hearing/deposition:

Settlement authority needed
Release needed:

CA only- next PQME/AME evaluation
(Examiners: Please enter the bullet points from the end of your most current Action Plan note. This section should reflect your plan to move the case forw,ird.)
Anticipated P&S date/settlement date/closure date:

Strategy for resolution - target dates
2 164
214
Current reserves
Reserve rationale:

TTD - number of weeks, rate:

PPD - percentage, number of weeks, rate:

Closed claims
Final incurred: R
Closure date: X
Scarlg-wick Copyright rt 2021
3 165
215
Sedgwick Claims Management Services, Inc.

P.O. Box 51350
Ontario, CA 91761
Phone: (855) 238-4936 • Fax: (909) 942-8918
www.sedgwick.com
June 6, 2022
«EE Name»
«Claimant_ Or _Foreign_ Address _1 » «Claimant_ Or _Foreign_Address _2 » «Cla ima nt_Address_ CityStateZip»
RE: Employee:

Employer:

Claim No:

DOI:

Tracking No:

Dear Mr./Mrs. «EE_Name»:
«EE_Name»
County of Los Angeles
«Claim_Number»
«lnjury_Date»
[Enter Complaint Tracking Number]
HELPLine Complaint Acknowledgment
@
sedgwick.

Thank you for taking time to contact our customer service team to explain the issues that have occurred recently. We sincerely regret any inconvenience you have experienced, and we assure you that we are anxious to deliver top customer service.

Our customer service team is reviewing the information you provided, and ensuring that our leadership staff resolves this matter quickly. We will be contacting you within the next three business days to report our findings and action steps. We've assigned Tracking Number [Enter Complaint Tracking Number] for future reference of your complaint.

If you have to reach out to us regarding this issue before we circle back with you over the next three business days, please reach out to our customer service team by calling (833) 989-4357 or (833) 989-HELP or emailing us at [email protected].

Sincerely,
Sedgwick Claims Management Services, Inc.
[Enter CSR Name]
Customer Service Representative
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216
Sedgwick Claims Management Services, Inc.

P.O. Box 51350
Ontario, CA 91761
Phone: (855} 238-4936 • Fax: (909} 942-8918
www.sedgwick.com
June 6, 2022
«EE_Name»
«Claimant_ Or _Foreign_Address_l» «Claimant_ Or _Foreign_Address_2» «Claimant_Address_ CityStateZip»
RE: Employee:

Employer:

Claim No:

DOI:

Tracking No.:

Dear Mr./Mrs. «EE_Name»:
«EE_Name»
County of Los Angeles
«Claim_Number»
«lnjury_Date»
[Enter Complaint Tracking Number]
HELPLine Resolution Letter
@
sedgwick(i)
This letter serves to confirm that we recently resolved your complaint regarding: [Briefly explain nature of complaint].

We regret any inconvenience you have experienced, and we assure you that we are committed to delivering world­ class customer service.

If you still have any concerns regarding this issue, or any other aspect of our claims administration, please reach out to our customer service team by calling (833) 989-4357 or (833) 989-HELP or emailing us at [email protected].

Sincerely,
Sedgwick Claims Management Services, Inc.
[Enter CSR Name]
Customer Service Representative
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217
Client Name:

Line of Business: Responsible Office:

Contract#: Account Mgr./ Executive:

EXAMINER HOT SHEET
QUICK LINKS:
• Account Contacts • Carrier Reporting • Program Basics • Banking • Excess Reporting • Recent Changes
• CSI Table of Contents • Polic Information • Servicin Offices SUBJECT (Cilek on the CSI Subject
SUMMARY OF SERVICE REQUIREMENT Heading below to access the full CSI narrative)
Audits / Claim Reviews •
Banking •
Billing •
Carrier ReQorting •
Claim lntake/Set-uQ/Assignment •
/ Conversion
Coordination of Benefits •
Documentation and Coding •
Excess •
File SuQervision •
Investigation and Determination •
Litigation Management •
Managed Care •
Pa)lments •
Performance Agreements •
Preferred Vendors •
ReQort Generation •
Reserving •
ResQonsiveness •
Settlements •
Subrogation and Recover)l •

1. Other: •

2. Other: •

1. Except where client variances are outlined in this document. client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
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218
Client Name:

Line of Business: Responsible Office:

Contract#: Account Mgr./ Executive:

CLIENT SERVICE INSTRUCTIONS

TABLE OF CONTENTS
SECTION 1:

Account Contacts
Policy Information
Preferred Vendors List
Program Basics
Program Changes
Sedgwick CMS Servicing Offices and Contacts
SECTION 2:

Introduction
Audits/ Claim Reviews
Banking
Billing
Carrier Reporting
Excess Reporting
Claim Intake/ Set-up I Assignment
Coordination of Benefits
Documentation and Coding
File Supervision
Investigation and Determination
Litigation Management
Managed Care
Payments
Performance Agreements
Preferred Vendors
Report Generation
Reserving
Responsiveness
Settlements
Subrogation and Recovery

1. Other:

2. Other:

Back to Examiner Hot Sheet

1. Except where client variances are outlined in this document client service standards are in accordance with established Sedgwick CMS Service Expectations.
2 Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
169
219
Client Name:

Line of Business: Responsible Office:

Contract#: Account Mgr./ Executive:

Account Contacts:
(You may use the chart below or insert a hyperlink to account contact information currently saved to the client team site of the portal. Caution! If a hyperlink is used in this section, the name of the file and the location of that file on the portal should remain the same. If the file name or location is changed, the hyperlink will no longer work and will need to be updated.)
Company Title Name/ Address Phone/ Fax I Email
Except where client variances are outlined in this document, client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
170
220
Client
Name:

Line
of
Business:

Responsible
Office:

Contract#:

Account
Mgr./
Executive:

Policy
Information
(You
may
use
the
chart
below
or
insert
a
hyperlink
to
policy
information
currently
saved
to
the
client
team
site
of
the
portal.

Caution!
If
a
hyperlink
is
used
in
this
section,
the
name
of
the
file
and
the
location
of
that
file
on
the
portal
should
remain
the
same.

If
the
file
name
or
location
is
changed,
the
hyperlink
will
no
longer
work
and
will
need
to
be
updated.)

1. Except
where
client
variances
are
outlined
in
this
document,
client
service
standards
are
in
accordance
with
established
Sedgwick
CMS
Service
Expectations.

2. Contact
your
Supervisor
and
Program
Manager
if
you
believe
there
is
a
conflict
between
Client
Service
Instructions
and
Carrier
Claims
Handling
Requirements.

Page
4 of
14 Revision
Date:_MM/00/YYY_Y
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221
Client
Name:

Line
of
Business:

Responsible
Office:

Contract#:

Account
Mgr./
Executive:

Preferred
Vendor
List

1. Except
where
client
variances
are
outlined
in
this
document,
client
service
standards
are
in
accordance
with
established
Sedgwick
CMS
Service
Expectations.

2. Contact
your
Supervisor
and
Program
Manager
if you
believe
there
is
a
conflict
between
Client
Service
Instructions
and
Carrier
Claims
Handling
Requirements.

Page
5 of
14 Revision
Date:

MM/00/YYYY
172
222
Client Name:

Line of Business: Responsible Office:

Contract#: Account MgrJ Executive:

Program Basics
owe
0GL
□ Product
□Auto
□ DB
□ Subrogation
□ Other
□ Other
From:

To:

Lines of Business: □ WC □ LB □ PL □Auto □ DB
States:

Line of Business: □ WC □ LB □ PL □Auto □ DB
States:

OviaOne View
OviaOne Query
Dv viaOne OSHA
□ National Intake Center 1- 866-409-2603
□ Dubuque Service Center
OviaOne Intake
□ Other
□ Yes □ No
Name:

Address:

Phone:

Email:

Name:

Address:

Phone:

Email:

Resource: Client Listing on Sedgwick CMS portal (requires permission)

1. Except where client variances are outlined in this document. client service standards are in accordance with established Sedgwick CMS Service Expectations.
2 Contact your Supervisor and Program Manager 1f you believe there is a conflict between Client Service Instructions and Carner Claims Handling Requtrements.

Rev1s1on Date MM/DD/YYYY
173
223
Client Name:

Line of Business: Responsible Office:

Contract #: Account MgrJ Executive:

Program Changes
Section Effective Date Summary of Change
Except where client variances are outlined in this document, client service standards are in accordance with established Sedgwick CMS Service Expectations

2. Contact your Supervisor and Program Manager if you believe there 1s a conflict between Client Service Instructions and Carner Claims Handling Requirements.

Revision Date: MM/DD/YYYY
174
224
Client Name:

Line of Business: Responsible Office:

Contract#: Account Mgr.I Executive:

Sedgwick CMS Servicing Offices and Contacts
(You may use the chart below or insert a hyperlink to servicing offices and contact information currently saved to the client team site of the portal. Caution! If a hyperlink is used in this section, the name of the file and the location of that file on the portal should remain the same. If the file name or location is changed, the hyperlink will no longer work and will need to be updated.)
Office Contact Name States Serviced

1. Except where client variances are outlined in this document. client service standards are in accordance with established Sedgwick CMS Service Expectations
2 Contact your Supervisor and Program Manager 1f you believe there is a conflict between Client Service Instructions and Carner Claims Handling Requirements.

Revision Date: MM/DD/YYYY
175
225
Client Name: ."" ,
Line of Business: Responsible Office:

Contract #: Account MgrJ Executive:

INTRODUCTION

AUDITS/ CLAIM REVIEWS
Client Audits
Claim Reviews

BANKING

BILLING

CARRIER REPORTING
Resources:
• Underwriting Carrier's Parent Company
• Carrier Reporting Requirements Matrix

EXCESS REPORTING
Resource: Carrier Relations Portal Site

CLAIM INTAKE/ SET-UP/ ASSIGNMENT/ CONVERSION
COORDINATION of BENEFITS
DOCUMENTATION and CODING
Miscellaneous Codes
NCCI Codes

1. Except where client variances are outlined in this document. client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager 1f you believe there Is a conflict between Client Service Instructions and Carrier Claims Handling Requirements

Revision Date MM/DD/YYYY
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226
Client Name:
' Line of Business: Responsible Office:

Contract #: Account Mgr./ Executive:

Class Code Description States
Custom Coding
Time Tracking

FILE SUPERVISION

INVESTIGATION
Initial Contact
Denials / Appeals
Index Bureau
Surveillance
Recorded Statements
Resources:

1. Except where client variances are outlined in this document. client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
177
227
Client Name:

Line of Business: Responsible Office:

Contract #: Account Mgr./ Executive:
• Carrier Relations Portal Site
• ACE/AIG/Zurich Claims Instructions for Investigation

LITIGATION MANAGEMENT
Assignment of Counsel:

Client Communication
Resource:
• Carrier Relations Portal Site
• ACE/AIG/Zurich Claims Instructions for Litigation Management

MANAGED CARE
Resource: Managed Care Portal Site
Medical Bill Review
Resource: Medical Bill Review
Out of Network Bill Review
Pharmacy
Resource: Pharmacy Benefit Cost Management
Physical Therapy
Resource: Physical Therapy Cost Management
Durable Medical Equipment
Resource: DME Cost Management
Diagnostic
Resource: Diagnostic Studies Cost Management

1. Except where client variances are outlined in this document, client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date. MM/DD/YYYY
178
228
Client Name:

Line of Business: Responsible Office:

Contract#: Account Mgr./ Executive:

Telephonic Case Management
Utilization Management
Resource: Utilization Management/ Utilization Review
Field Case Management
Integrated Injury Management - Disability Resolution
Resource: Integrated Injury Management (IIM)
Vocational Rehabilitation

PAYMENTS
System Authority Levels
Compensation and Liability
Coordination of Benefits
Resources: Carrier Relations Portal Site

PERFORMANCE AGREEMENTS

PREFERRED VENDORS
Resources: Carrier Relations Portal Site

REPORT GENERATION

1. Except where client variances are outlined in this document, client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
179
229
Client Name:

Line of Business: Responsible Office:

Contract #: Account Mgr./ Executive:

RESERVING
Reserve Authority Levels
Resources:
• Carrier Relations Portal Site
• ACE / AIG / Zurich Claims Instructions for Reserving

RESPONSIVENESS

SETTLEMENTS
Settlement Authority Levels
Structured Settlements
Resources:
• Carrier Relations Portal Site
• ACE / AIG / Zurich Claims Instructions for Settlements/ Structured Settlements SUBROGATION and RECOVERY
Subrogation
Second Injury/ Special Funds
Resources:
• Carrier Relations Portal Site
• ACE / AIG / Zurich Claims Instructions for Subrogation / Contributions

1. Other:

2. Other:

1. Except where client variances are outlined in this document, client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
180
230
Client Name:

Line of Business: Responsible Office:

Contract#: Account Mgr./ Executive:

1. Except where client variances are outlined in this document, client service standards are in accordance with established Sedgwick CMS Service Expectations.

2. Contact your Supervisor and Program Manager if you believe there is a conflict between Client Service Instructions and Carrier Claims Handling Requirements.

Revision Date: MM/DD/YYYY
181
231
Escalation
Policy
•
Original
emails
should
be
addressed
on
the
"Toh
line
to
the
claims
examiner,
with
a
:cc
to
the
team
lead
(Note:

The
team
lead
is
uniquely
situated
to
know
the
status
of
the
claims
examiner.

In
the
event
the
claims
examiner
Is
out
or
terminated
the
team
lead
can
act
accordingly.

If
the
claims
examiner
is
available,
the
team
lead
can
ignore
the
original
email}.
c,
Examiners
are
required
to
acknowledge
emails
within
1 business
day,
and
to
provide
requested
information
no
later
than
10 days
from
the
request,
unless
the
request
is
identified
as
a
RUSH
request.
•
2'"
Requests
should
be
addressed
to
the
Team
Lead
on
the
"To"
line
with
the
Subject
Line
indicating:
"2'"'
Request".
o
Team
leads
are
required
to
respond
to
all
escalation
calls
or
emails
within
1 business
day,
and
to
provide
a
reasonable
tlmeframe
to
resolve
the
escalation.

In
most
cases,
it
is
anticipated
the
issue
can
be
resolved
within
2 business
days
of
the
escalation.
•
If
an
examiner
is
out
due
to
temporary
PTO
absence:
c,
Team
leads
will
ensure
that
the
Out
of
Office
is
activated
with
information
on
whom
to
contact
as
a
back-up
•
If
an
examiner
is
going
to
be
out
permanently:
o
Team
lead
will
ensure
the
departing
examiner
updates
their
Outlook
email
to
indicate
the
effective
date
this
colleague
is
leaving,
and
whom
to
contact
thereafter
{It
will
be
decided
immediately
whether
the
back-up
contact
is
a
replacement
colleague,
temp,
team
lead
or
other
designated
colleague)
o
As
indicated
in
the
first
point
above,
lf
it
is
known
a
colleague
is
leaving
Sedgwiclc,
the
team
lead
can
be
copied
on
emails
to
ensure
a
request
is
handled
expeditiously
Our
goal
is
to
ensure
that
all
escalations
are
expeditiously
handled
at
the
team
lead
level.
')i'ti!;!Wl(k
(opynght
-,-
2022
182
232
JURIS®
port
mples&
Descriptions
sedgwick
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
183
233
sedgwick
..

Adjustment
Report
Applicable
Lines:

All
Report
Overview:

The
Adjustment
report
displays
all
adjustments
made
to
claims
or
payments
for
a
particular
client.

This
report
is
run
for
a
specified
time
period
at
the
client
level
and
will
break
by
account
and
unit.

The
purpose
of
this
report
is
to
display
which
allocations
and/or
claims
have
been
moved
from
one
account
and
unit
to
another.

Deleted
claims
opened
in
the
current
period
will
also
appear
on
this
report.

The
report
indicates
whether
or
not
claims
have
been
mini-converted
or
moved
from
one
office
to
another
for
a
particular
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
184
234
sedgwick,
Claim
and
Exp~nse
Report
Applicable
Lines:

All
Report
Overview:

The
Claim
and
Expense
report
provides
our
clients
with
detailed
claims
information
for
all
open
claims
at
each
level
of
the
corporate
structure,
and
lists
closed
claims
with
current
activity during
the
month.

The
report
provides
current
period
financials,
as
well
as
total
incurred,
future
reserves
and
paid
to
date
amounts.

It
also
tracks
new
claims
and
closures
for
the
period
and
contains
important
recovery
financials
broken
out
into
the
appropriate
categories.

The
Claim
and
Expense
report
also
provides
summary
financial
and
claim
count
data
at
each
level
of
the
client's
structure.

Since
this
report
can
become
quite
large,
a
table
of
contents
is
available
to
provide
quick
location
look-up.

The
sample
below
represents
a
Detail
Listing
page
for
workers'
compensation
claims.

J;,:,3,•.
"h~.,ld,,1
r<tt,\ln
H0•1
Sh,:.i:der(;,I
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.,
· ~••.>('
t_·,,r.
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f{u,;t:
or,n,.,.·
<:,r-11
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r
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r,,,
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ta
',
01,
,5,;>'74,,iS
1,oor,,r,r, l,,
o9i,
~o
,?~,
l IL~~
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
185
235
•
•
I
seogwio<.·
Loss
Analysis
I
Applicable
Lines:

All
Report
Overview:

The
Loss
Analysis
I report
provides
our
clients
with
a
quarterly breakdown
of
the
top-ten
injury/loss
codes
for
cause,
result/nature,
and
part/target
within
each
line
of
coverage
and
it
subtotals
at
each
level
of
the
corporate
structure.

The
report
also
supplies
the
actual
payout
and
total
incurred
amounts
for
each
injury/loss
category
and
is
useful
for
frequency
-vs-
severity
analysis.

A
monthend
version
is
processed
on
the
quarter-ending
dates
of
the
client's
fiscal
year
and
is
run
by
the
corporate
structure
with
totals
at
the
unit,
account
and
intermediate
levels.
'1.JF:NT
C'1<tl~.1c•,:.o;
r'ilhnrc11.,u,,
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LOSS

ANAI,YSIS
REPORT
LOS3
01/01/2004
-
O'l/07/2004
AS
OP
09/07/2'.104

EXPECTED
WC
RF.PORTED
BY
EXPEC:'EO
70TAL
TOTAT,
CODE
DF:SlRll'TION
·-·-·
CA!JSE
•••••
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c;,;ao
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Fall
On
the
Same
Level
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l,
717,054.64
J:GO
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tp
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By
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7,;
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Leg
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CODES

2.594
040,99
ll
6 0

01.0l
TOTAL
F
JURIS
Report
Sample
Book
-Page
3 COljNT
en 380 5'0 ~
64 m :n2 "' Hi,.
1 "
111r, 437 322 342 20 17
579/ 390 rn '" ll.4 511 1'1 " 222 14' 198 2162 ill1
PRE<'Al<F::J,
o~,10..,/2004
PAID
70 DATE
'.,58,595.7S 4.20,355,44 105,754.20 106,5::35.73 lf>C,,612.56 :.99,635.17 '::.7,8Sl.4q l.25,676.11 A',',]6
Al
o.oc
lS
46,074.4C 47,076.37 1','l,..!'i7.44 :21~.1;%.'."4 Cl(),5;:s.H 0 .
() :~
4:,9J5.14 ll,290
.37
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2 594
040.9S>
282,367.02 l r,
q,
P
~
'.:
qJ
lC4,258.SG :::,C":4.5" :3),:27.20 4'.J,'i:6.:7 16,117.56 4.'l,3,,.4.19 107,705,17 79,982.8:f 103,606.25 104,344.7'1 95,774.12 61<4,400.45 5S4 040.9S
,')\GE:
1 199

EXPECTED
TOTAT,
2,
S 7(),
R5

0. i,.R
1,7l7,0S4.64
AlR,7Al,6'f 614,43l.94 ".4".,00(,.71i 4Bl,Ol7.5(1 4 ,~.ct'"' 6 '•
47~.
181.
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:
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620
401.
01 Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
186
236
Transaction
Repo~
(Check
Register)
Applicable
Lines:

All
Report
Overview:

The
Transaction
report
displays
allocations,
payments
and
adjustments
entered
in
the
system
during
the
.
specified
date
range
for
a
specific
bank
account.

It
consists
of
a
Check
Register,
which
lists
all
checks
issued
during
the
Sedgwick,
specified
period,
with
each
separate
allocation
(or
line
item)
listed
for
each
check.

Also
included
is
the
Check
Transaction
Summary,
which
lists
paid,
voided,
refunded
and
net
totals
by
line
&
coverage.

Lastly,
the
Bank
Account
Reconciliation
page
is
useful
for
balancing
purposes,
and
includes
a
section
that
can
be
matched
with
the
Claim
&
Expense
report
financials.

The
page
displayed
here
is
a
sample
of
the
Check
Register;
the
following
two
pages
display
samples
of
the
Check
Transaction
Summary
and
Bank
Account
Reconciliation.
,,~,.
':
•~
.
, ,r,;-:
z~
,,.
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,;cc-::.~co~n
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
187
237
Transaction
Reportj_Check
_Transaction
Summary)
Applicable
Lines:

All
Report
Overview:

The
Transaction
report
displays
allocations,
payments
and
adjustments
entered
in
the
system
during
the
specified
date
range
for
a
specific
bank
account.

It
consists
of
a
Check
Register,
which
lists
all
checks
issued
during
the
specified
period,
with
each
separate
allocation
(or
line
item)
listed
for
each
check.

Also
included
is
the
Check
Transaction
Summary,
which
lists
paid,
voided,
refunded
and
net
totals
by
line
&
coverage.

Lastly,
the
Bank
Account
Reconciliation
page
is
useful
for
balancing
purposes,
and
includes
a
section
that
can
be
matched
with
the
Claim
&
Expense
report
financials.

The
page
displayed
here
is
a
sample
of
the
Check
Transaction
Summary;
the
previous
page
displays
a
sample
of
the
Check
Register
and
the
following
page
that
of
the
Bank
Account
Reconciliation.

Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
188
238
2 .,· k
t\.-,'\.
t~.-·'
Transaction
Report
(Bank
Account
Reconciliation)
Applicable
Lines:

All
Report
Overview:

The
Transaction
report
displays
allocations,
payments
and
adjustments
entered
in
the
system
during
the
specified
date
range
for
a
specific
bank
account.

It
consists
of
a
Check
Register,
which
lists
all
checks
issued
during
the
specified
period,
with
each
separate
allocation
(or
line
item)
listed
for
each
check.

Also
included
is
the
Check
Transaction
Summary,
which
lists
paid,
voided,
refunded
and
net
totals
by
line
&
coverage.

Lastly,
the
Bank
Account
Reconciliation
page
is
useful
for
balancing
purposes,
and
includes
a
section
that
can
be
matched
with
the
Claim
&
Expense
report
financials.

The
page
displayed
here
is
a
sample
of
the
Bank
Account
Reconciliation;
the
previous
two
pages
display
samples
of
the
Check
Register
and
Check
Transaction
Summary.

Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
189
239
sedgwick.

Accumulative
Loss
Analy:sis
Applicable
Lines:

All
Report
Overview:

The
Accumulative
Loss
Analysis
report
performs
a
five-year
comparison
against
the
frequency
and
total
cost
of
claims
within
each
injury/loss
category.

This
report
lists
the
total
number
of
claims
and
the
total
amount
paid
in
a
loss
year
against
each
injury
code.

This
is
a
great
tool
for
injury/loss
type
trend
analysis,
and
is
often
used
to
identify
locations
that
are
complying
with
accommodations
and
return
to
work
programs.

The
sample
provided
here
reflects
Workers'
Compensation
claims
causes
only,
and
shows
totals
paid
for
each
cause.

The
report
will
also
generate
a
page
for
incurred
totals.
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
190
240
\
.I,
f
\' 1;
Allocation
Report
Applicable
Lines:

All
Report
Overview:

Similar
to
the
Transaction
Register
report,
the
Allocation
report
lists
allocation
amounts
by
check
for
a
given
period
and
may
be
sorted
by
the
corporate
structure.

This
report
is
particularly
useful
for
firms
who
charge
back
losses
to
different
divisions,
departments,
etc.,
based
upon
the
actual
amount
paid.
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;,,c
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L,•,·1•_1~·
•. ~
1-,.J
c::n,
SC:c1S
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
191
241
Cause
Code
Analysis
Applicable
Lines:

All
Report
Overview:

The
Cause
Code
Analysis
report
provides
data
based
on
Cause,
Nature/Result
and
Target/Part
codes
assigned
to
claims.

This
report
lists
information
on
any
or
all
of
these,
as
well
as
specific
codes
within
each
category.

For
example,
the
report
can
be
requested
to
list
all
claims
with
specific
injuries,
or
due
to
specific
reasons,
to
certain
parts
of
the
body.

This
report
differs
from
others
in
that
it
actually
generates
four
separate
reports.

When
requested,
a
Cause
Code
Loss
Analysis
I,
Cause
Code
Loss
Analysis
II,
Cause
Code
Claim
&
Expense,
and
a
Cause
Code
Analysis
report
are
all
generated separately
and
simultaneously.

The
first
three
reports
are
identical
to
their
standard
counterparts,
while
the
Cause
Code
Analysis
report
lists
the
options
specific
to
this
report
chosen
when
it was
requested.

A
sample
of
the
Cause
Code
Analysis
report
is
included
here;
refer
to
the
standard
versions
of
the
Loss
Analysis
I,
Loss
Analysis
II
and
Claim
&
Expense
reports
for
further
information
on
each
additional
report.

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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
192
242
Claim
Re~ort
Applicable
Lines:

All
Report
Overview:

The
Claim
report
provides
a
basic
list
of
claims
that
can
be
requested
using
specified
date
criteria.

As
with
many
JURIS
reports,
the
Claim
report
can
be
subtotaled
by
almost
any
major
data
attribute
captured
in
the
system.

This
report
can
also
be
run
to
break
by
custom
dates
and
it lists
summary
financial
information
for
each
claim.

Additionally,
this
report
enables
us
to
isolate
claims
with
important
cost-driver
indicators,
such
as
litigation
and
rehabilitation.

The
Claim
report
is
the
best
all-around
report
to
run
for
a
variety
of
needs.

Depending
on
the
search
criteria
selected when
requesting
the
report,
the
report
returns
data
on
all
manner
of
claims,
such
as
claims
in
litigation,
'large
loss'
claims,
claims
of
a
certain
status
(Accepted,
Denied,
Deferred)
or
claims
in
excess.

Additional
detail
for
each
claim
can
also
be
included,
such
as
loss
description,
or
it can
be
run
as
a
summary
report.

The
sample
below
is
the
standard
format
used
for
this
report.
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Report
Sample
Book
-Page
10 11
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
193
243
glaim
and
Expense
II
Report
Applicable
Lines:

All
Report
Overview:

The
Claim
and
Expense
II
report
provides
our
clients
with
summary
financial
data
by
line/coverage
or
by
state.

The
report
provides
current
period
financials,
as
well
as
total
paid
to
date,
future
reserves
and
total
incurred
amounts.

This
report
also
tracks
new
claims
and
closures
for
requested
period
and
contains
total
recovery
amounts.

The
sample
page
below
displays
totals
separated
by
coverage
code.
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""'·',%,:4a.9a
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
194
244
Applicable
Lines:

All
Claifll
Status
History
Report
~-=----=--==----=--=--=--~=---=---==-----=----=---=---=========== Report
Overview:

The
Claim
Status
History
report
provides
a
history
of
claim
status
changes
for
individual
claims.

It
displays
each
claim
that
meets
the
selection
criteria,
standard
claim
information
and
the
dates
of
the
claim's
status
changes
within
a
specified
range.

The
report
can
be
requested
for
both
open
and
closed
claims
at
all
levels.

This
report
is
useful
for
evaluating
claim
activity
details.
ensuring
accurate
claims
handling
by
examiners
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
195
245
Claims
Log
Applicable
Lines:

All
Report
Overview:

The
Claims
Log
report
provides
a
list
of
incidents
created
and
claims
opened
within
a
specified
date range
and
is
used
for
billing
purposes.

This
report
may
be
run
to
reflect
data
for
disability,
workers'
compensation
and/or
liability
claims
and
incidents.

The
sample
report
below
reflects
workers'
compensation
claims
only.
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
196
246
\,'\'
gost
Rang~
Ana_!ysis
Applicable
Lines:

All
Report
Overview:

The
Cost
Range
Analysis
report
includes claims
with
loss
dates
within
the
date
range
specified
and
will
segregate
them
into
value
categories
by
loss
amount.

The
cost
range
is
a
value
category.

The
categories
are
segmented
into
values
from
O
to
over
1 million. This
report
breaks
by
major
classification
(AU,
OS,
GL,
PR
and
WC).

Comparative
incurred
and
average
cost
information
can
be
viewed
for
as
many
years
as
needed.

TN1:;:tll<IIEJl
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
197
247
W:

Hard
Copies
By
Client
~eport
Applicable
Lines:

All
Report
Overview:

The
Hard
Copies
by
Client
report
provides
menu-specific
information
of
selected
claim
screens
for
a
client,
account
or
unit.

You
can
select
to
run
this
report
for
any
of
the
following
JURIS
screens/information
for
the
claim:
-Address
Book
-Managed
Care
-Investigation
-SS
Status
-Work
Status
-Claim
-Diary
-Legal
-Reserving
Factors
-Return
to
Work
-Claim
Status
-Notes
-Misc.

Client
Fields
-Reserve
Worksheet
-Financial
Overview
-Index
System
-Alt
Claim
Numbers
-Misc.

State
Fields
-Transaction
History
-Claim
Number
This
report
is
useful
for
printing
claim
information
for
claim
audits
and
reviews.

The
sample
shown
below
displays
claim
note
information.

Date:
08/31/2004
11:11am
User:

Page,
l
Claim
Numbe'!::'
Client Account
W000000000-0001
Date
Loss
07/01/2004
Unit. Claimant
9000 80000000 AR
Fictitious
Fabricators,
Inc.

Fictitious
Fabricators
All
States
-
.il.RKANSAS
Claimant,
John
· -
------· ·
-
·
-
-
----
----· --
· - - -
--
---
- -
NOTES
Bvent/Clmnt/Claim
Date
Tp
Examiner
FOR
FOLLOW
UP
DIAG

SPRAIN/STRAIN
KNEE
AND
.;..l\IKLE
W1
LL
PAX
ME
THE
OFFICE
!\0TES
~Time
Note
Created
:
4:03
PM
CST]

AOOOOOOOOO
1JOOl-Ol
D7/07/2004
CM
EEXAMlNER
SPOKE
WITH
EE,
LAST

THURSDAY
HE
WAS

HELPING
TO
UNLOAD
A
CAN
ON
THE
DOCK
ROLLER.

THE
DRIVER
DROVE
OFF
AS
HE
WAS
ABOUT
TO
GET
DO\'IN
AND
IT
G..t.VE
HIM
NO
PLACE
T()
GO
BUT
TO
~UMP
5 FT.
:IE

SPRAINED
EIS
KNEE
AND
ANKLE
.DOING
~~C.

EE
WE!-"':'
TO
fiOSPlTAL
AND
X-P
... ;YS
WERE
>1.."'.D2
A!\D
NO
FRACTU!<ES.

HE
IS
TAKING

PHYSICAL
THERAPY.

HE
WILL
RETURN
TO
THE
DOCTOR
ON
FRIDAY
AND
THINKS
HE
WILL
BE

RELEAED
TO
REG
DUTY
ON
MONDAY
7/12/04.

HE
IS
A
F'!JLL
TIME

EMPLOYEE
AND
IS
A
COU?.IER.

HAS
BEEN

WORKING
FOR
CLIE!iT
FOR
7 YRS
A.1',jD
1\0!<.KED
FOR
ABC
CCJRP.

BEFORE
THAT.

HE
DENIES
ANY
PRIOR

WCRKERS

COMPENSATION
CLAIMS
-
DID
HA'/E
AN
MVA
BUT
NO
INJURIES.

DENIES
ANY
HEALTH

PROBLEMS,
HE
IS
NOT

MARRIED
AND
HAS
NC

DEPENDANT

CHILDREN,

BENEFITS
NERE

EXPLAINED

INCLUDTNG
HTS
MAP
PAY.
[Time
Note
Created
:
4:01
PM
CST]
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
198
248
sedgwlck,
Incident
to
Claim
Conversion
Report
Applicable
Lines:

All
Report
Overview:

The
Incident
to
Claim
Conversion
report
lists
claims
converted
from
incidents
during
a
specified
period
of
time
that
were
created
during
another
specified
period.

The
report
lists
basic
claim
information
such
as
the
claim
number,
claimant's
name
and
the
date
of
loss,
along
with
the
dates
the
incident
was
initially
created
and
converted
to
a
claim.
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
199
249
gwick '-,>
!-ag_~eport
Applicable
Lines:

All
Report
Overview:

The
Lag
report
calculates
the
number
of
days
between
the
primary
report
dates
found
on
the
JURIS
claim
screens.

It
considers
the
following
dates:
• Date
of
Loss
&
Date
Reported
to
Employer
• Date
Reported
to
Employer
&
Date
Reported
to
CMS
• Date
Reported
by
Client
&
Date
Reported
to
Employer
• Date
Reported
to
CMS
&
Date
Opened
This
report
is
used
to
determine
how
much
time
elapsed
between
the
date
the
incident
was
reported
by
the
client
and
the
date
the
claim
process
began.

Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
200
250
Vil(!(
Loss
Analysis
II
Applicable
Lines:

All
Report
Overview:

The
Loss
Analysis
II
report
displays
claims
information
for
either
claims
opened
or
claims
with
loss
dates
during
the
reporting
period.

An
excellent
supplement
to
our
client's
safety
data,
the
report
lists
claim
totals
based
on
various
criteria,
such
as
claims
occurring
on
certain
days
of
the
week
or
the
number
of
claims
within
various
age
groups.

Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
201
251
Loss
and
Claim
Experience
Report
Applicable
Lines:

All
Report
Overview:

The
Loss
and
Claim
Experience
report
summarizes
the
all-time
financial
activity
and
breaks
it
out
by
coverage.

This
report
also
includes
the
financial
net
of
recoveries.

A
current
period
may
also
be
defined
within
the
report
and
the
report
contains
a
financial
summary
section
isolating
only
the
financial
activity
occurring
in
that
period
(usually,
one
month).
i,<,'{),\'!>"./>i
Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
202
252
Loss
Run
Summa!Y_
Report
Applicable
Lines:

All
Report
Overview:

The
Loss
Run
Summary
report
provides
a
quick
summary
of
the
client's
losses
as
a
whole
for
each
policy
year.

It
includes
data
for
the
current
period
defined
in
the
request,
summary
activity
for
the
year
to
date,
and
all-time
experience
on
the
report
end
date.

The
report
also
features
a
by-line
breakout
as
well
as
recovery
blocks
for
actual
and
estimated
recoveries.
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
203
253
sedgwick,
Loss
Summary
Report
Applicable
Lines:

All
Report
Overview:

The
Loss
Summary
report
enables
the
client
to
view
a
summary
snapshot
of
financial
and
claim
inventory
data
by
single
or
multiple
policy
years.

It
also
nets
the
total
financial
experience
and
displays
it
as
a
percentage
of
the
existing
loss
fund.

This
is
a
useful
report
for
clients
who
wish
to
track
loss
fund
erosion
.

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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
204
254
sedgw1ck.

Miscellaneous
Client
Fields
Report
Applicable
Lines:

All
Report
Overview:

For
clients
utilizing
JURIS's
custom
client
fields,
the
Miscellaneous
Client
Field
report
provides
a
versatile
reporting
mechanism
to
compile
data
on
these
specific
fields.

The
report
may
be
run
for
only
one
field,
a
combination
of
fields
or
even
blank
fields,
and
may
be
broken
a
variety
of
ways
including
location
and
line
of
business.

As
with
some
other
JURIS
reports,
financial
parameters
may
be
used
to
narrow
the
report
further.

This
report
returns
the
information
listed
in
the
sample
below
for
each
custom
client
field
requested
in
the
report's parameters;
as
such,
while
the
data
returned
will
resemble
the
example
below,
the
fields
available
will
vary
widely
based
on
client's
needs.
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
205
255
sedgwick.

Overpaid
Claims
Report
Applicable
Lines:

All
Report
Overview:

The
Overpaid
Claims
report
lists
all
claims
with
overpayment
tracking
records
that
do
not
have
a
claim­
level
diary
type
of
FN
-
Financial.

This
report
can
be
requested
at
regular
intervals
to
ensure
proper
documentation
of
over­
paid
claims,
aiding
in
the
timely
recovery
of
funds.

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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
206
256
k
Overpayment
Tracking
Report
Applicable
Lines:

All
Report
Overview:

The
Overpaid
Claims
report
lists
all
claims
with
overpayment
records
beginning
or
ending
during
a
specified
period.

Overpayments
can
be
tracked
in
JURIS
for
each
claim;
the
total
amount
overpaid,
the
amount
to
be
recovered,
the
reason
for
the
overpayment
and
the
period
during
which
the
overpaid
amount
was
issued
are
among
the
data
included
in
this
report.
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Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
207
257
Paycode
Analysis
(Summary)
Applicable
Lines:

Alf
Report
Overview:

The
Paycode
Analysis
report
groups
payments
according
to
their
paycode
and
can
be
flagged
to
list
detailed
payment
transactions
or
only
the
summary
for
each
code.

The
report
can
be
requested
for
a
single
paycode,
a
combination
of
different
paycodes,
all
paycodes
under
a
particular
loss
bucket
(series),
or
all
paycodes.

Several
different
break
levels
may
be
selected
including
line
of
business
and
state.

This
is
an
excellent
report
for
clients
who
are
attempting
to
stratify
actual
payout.

The
page
displayed
here
is
a
sample
of
the
Paycode
Analysis
summary
report;
the
following
page
displays
the
detail
report.
, ;
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it
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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
208
258
Paycode
Analysis
(Detail)
Applicable
Lines:

All
Report
Overview:

The
Paycode
Analysis
report groups
payments
according
to
their
paycode
and
can
be
flagged
to
list
detailed
payment
transactions
or
only
the
summary
for
each
code.

The
report
can
be
requested
for
a
single
paycode,
a
combination
of
different
paycodes,
all
paycodes
under
a
particular
loss
bucket
(series),
or
all
paycodes.

Several
different
break
levels
may
be
selected
including
line
of
business
and
state.

This
is
an
excellent
report
for
clients
who
are
attempting
to
stratify
actual
payout
The
page
displayed
here
is
a
sample
of
the
Paycode
Analysis
detail
report;
the
preceeding
page
displays
the
summary
report.

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Sedgwick
Copyright©
2016
The
information
contained
herein
is
confidential
and
proprietary
to
Sedgwick.

It
is
being
provided
in
order
to
allow
evaluation
of
Sedgwick's
services
and
capabilities.
209
259
sedgwick,
Paycode
Sul"r'lm_ary
Report
Applicable
Lines:

All
Report
Overview:

This
report
lists
the
total
amount
paid
for
each
indemnity,
medical
and
expense
paycode,
a
subtotal
by
type
and
a
grand
total
for
all
types.

In
addition,
this
report
indicates
what
percentage
of
the
subtotal
and
grand
total
each
paycode
represents.

This
report
can
help
analyze
how
money
is
being
spent,
provide
backup
data
for
state
and
excess
reporting
and
substantiate
budget
expenditures.
<']
TF.N':'
Fie'•
l'i,YJS
'°' 100:: 11; lll uo 175 17; 706 l]', i;,,1 HS )5~ "' 72S H':> D_g_,c;1-p1rnm1 Tempor:u:y
Tot.al
Di8abil1ty
TF-rlOf,,'l
1::,
;:-art;.a]
l)1nc1hi:ity
Temporary
Partial-Modified
Dclty
rer:-,,
f',-nt1al-U1,isr.hcdulec:!
Penn,
ilart.ial-Scheduled
Lump
5um-rerm
Paitial
iSch,
Settlement Wage
;_,:,n:J
:r:-.pairment
fF'LJ
Impairment
Income
Benefits
(TXl
Voe.

Reh-~b.

Other
Employer
Legal
Expense
/Indemrtityl
Family
l'livb,;on.
!Lien/r.oin-t,
-T':':J
Subroq~tion-Other
-
Indemnity
Doctor HospJt,il Phe1rtr1.-'lcy Rcdlal,g1c,r ne-nt1st H"c;J.\ta~ ,\r,,tten~
Ch11·:::ipract-:ir 1'11:nd
,,,j
Th,'l
,1py
Optb<1mol
"$1ist/Opt
ician
'",!
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-
• I
J \
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t'
l
Medic:i.:.

Appl
i,111c·e.'Device
t,
Equipnv~nt.

Lstb
fr>e/l
,,.-,,
F'ree11t
lndir.a
l"nl,1.l;;lory
Si.l!'qeq,
Case
Mo1naqement
F~e
s,·<"n/EM,;
,r:,
Meil
1,:
...
!;;~elm·
I1vl<'l->endent
/A<1i-i~ed
Medic.-1l-Le<1o1l
(C,\I
l,•irn;, M€-d
j c-1:
p.,,
imbut
.<.-mant
Excc,,-,,1
;-1,-,u,a1
Telep::onic
C.:ise
Mani\g(•ment
Fee

PAYCOOR

SUMMARY
REPORT
PRF.PARED:
09/13/~rJ04
LOSS
IJl/111/.::'l'H
l'lS/3li2rJ◊4
PN;E•
e·r.Y~f':NT
r>1
f'll?""~
'1S/3lf;J~,,4
;..s
OF
11'!/l'/~~"4
<"M,3
lTNIT
!'i:'.l
INOEMNlTY
SVcl•TOTAL:

T,·7,;;.

Jl.M<)l_1!:IT.
440,245.38 8r"l,1}92.92 7!1,
523,
70 7]9.S2
23,84ti.l7 2,726.80 4,9SL70 4,335.03
772.00 908.40
l,110.02
875.00 3-0.89
639,502.?l 204,29:9.
78 17,
1£0.6'1
64,l)OS,89 ll'J,847.7<) 6,897.21}
824.84
,1,126.or,
291.54
'I.
1,,~.
4"
0,ti35.17 ~,
S7S.
4!5
31,),Hi.45 :t,,:n
cq
52,HS.H
IL'
r·

05.0D
l",,1,;;
,,,,
125,724,
25 1•
5,-3..<;S.!l:' 2,
':100.00 '·'
l ,
~
,,
2,'J48.B ,!'1,J)l
. .'l
1,105.05
Jq]
,,-.
',E'l4.lJ
7,J'/
129,
731.2~
1'
OF'
Sl1R-70TA!,
\
OF
C,f<,\Nfl
"'.'OTA:

68.S-t

20.97 !2.5::

3.82 12
.28
) . 'H
0 °'

3. 73

1.14 0
r;