Incident Cost Tracking Form

Last Report Generated (click to view or download)
  Incident Summary  
 Report Number  2012-33
 FROL ID Number  1003776
 Date Of Injury  01/05/2012
 Jurisdiction  AZ
 Carrier Claim Number  
 Claim Status  Open
 Employee Name  Test Dummy
 Date Of Hire  
 Employer  Lorien, Inc.
 Location  AZ Location
 Department  AZ Department
 Type Of Injury  Type Of Injury 2
 Cause of Injury  abc
 Part of Body  New AZ Part (right side)
How Incident Occurred
        Incident Cost Data

Summation Basis for Individual Cost Items

[Total] = [Paid] + [On Hold]


Health Cost
 Total
 Paid
 On Hold
Details for Health Cost Amount



  • Salary Payments
     Total
     Paid
     On Hold

    Legal Expenses
     Total
     Paid
     On Hold
    Details for Legal Expenses Amount



  • Other
     Total
     Paid
     On Hold

    TOTALS
     Total
     Paid
     On Hold
            Report History
    Report History (click to view or download)