Incident Cost Tracking Form

Use this form to create, edit or print cost tracking data for the selected incident record.

Last Report Generated (click to view or download)
  Incident Summary  

 Report Number  2011-2
 FROL ID Number  1246936
 Date Of Injury  05/01/2011
 Jurisdiction  NC
 Carrier Claim Number  2223334445
 Claim Status  Open
 Employee Name  Dave Smith
 Date Of Hire  
 Employer  FROL Testing Employer
 Location  NC Location
 Department  NC Department
 Type Of Injury  Laceration
 Cause of Injury  Machine or Machinery
 Part of Body  Lower Leg (right side)
How Incident Occurred
     Incident Cost Data

Summation Basis for Individual Cost Items

[Total] = [Paid] + [Reserve]


Medical
 Total
 Paid
 Reserve
Details for Medical Amount



  • Legal
     Total
     Paid
     Reserve

    Indemnity
     Total
     Paid
     Reserve
    Details for Indemnity Amount



  • Miscellaneous
     Total
     Paid
     Reserve

    TOTALS
     Total
     Paid
     Reserve

     Export Data

    Report History (click to view or download)