1. Workers’ Compensation Claims Cycle
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Utilization
Review
Medical Case
Management
Claims
Investigation
24 Hours
MIIA Loss
Control
Dept. of Industrial Accidents
Member
Nurse
Adjuster
1st Report
of Injury
Injury
Occurs
Member Reports Claim On Line
Intake Coordinator
Reviews submitted report
We Take Care Of The Rest
How Does The Program Work?
Claim Information
Employee Name
Organization Employer Name
Accident Time
Loss Date – Date of Injury
Employer Notification – Date Injury Reported
Date Injury Reported as Loss Related
Injured Employee
Address
Home Telephone #
Work Telephone #
Date of Hire
Job Code/Occupation
Wage Amount/Average Weekly Wage
Marital Status
Date of Birth
Gender
Social Security Number
Supervisor’s Name
Dependents
Employer’s Information
All data will pre-fill when Record is saved
Insurance Carrier and Telephone – MIIA
Description
Occupation Injury
Describe how Injury Occurred
Cause/Source of Injury
Part/Description of Body Part
Nature/Type of Injury
Witnesses up to (3)
If Employee Died – Date of Death
Has Employee Returned to Work – Yes
Return to Work Date
1st Day Disability
5th Day Disability
To Whom was Injury Reported
Did Employee Return to Regular Occupation
Accident
Was Employee Inured on Premises – Y/N
Accident Location where Injury Occurred