ELECTRONIC DATA INTERCHANGE BUREAU OF WORKERS’ COMPENSATION Transaction Title: (e.g. SROI) Transaction Type: (e.g. Denial 04) Subsequent Report of Injury Jurisdictional Claim Number: (e.g.CLM-2012021312345) Date Transaction Submitted to BWC: May 8 2012 01:30 PM Employee Information First Name: Middle Name: Last Name: Last Name Suffix: Employee ID: ID Type: Date of Birth: Date of Death: Number of Dependents: Employee Marital Status Code: Claim Information Date of Injury: Jurisdiction Claim Number: Jurisdiction: Initial Date Disability Began: Claim Type Code: Type of Loss Code: Death Result of Injury Code: Claim Status Code: Late Reason Code: Permanent Impairment Percentage: Permanent Impairment Body Part Code: Date of Maximum Medical Improvement: Initial Return to Work Date: Current Return to Work Date: Initial Date Last Day Worked: Initial Date of Lost Time: Current Date Last Day Worked: Current Date Disability Began: Dependent Payee Relationship Code: Average Wage: Employment Status Code: Employer Paid Salary in Lieu of Compensation Indicator: Wage Period Code: Agreement to Compensate Code: Date Employer Had Knowledge of Date of Disability: Non-Consecutive Period Code: Estimated Gross Weekly Amount Indicator: Award/Order Date: Claim Transaction Details-SROI (LIBC-498, LIBC-392A, LIBC-761, LIBC-762, LIBC-763) LIBC-91 REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com Benefit Information Benefit Type Code: Benefit Period Start Date: Benefit Period Through Date: Benefit Type Claim Weeks: Benefit Type Claim Days: Benefit Type Amount Paid: Benefit Payment Issue Date: Calculated Weekly Compensation Amount: Full Wages Paid for Date of Injury Indicator: Gross Weekly Amount: Gross Weekly Amount Effective Date: Net Weekly Amount: Net Weekly Amount Effective Date: Benefit Adjustment Code: Benefit Adjustment Start Date: Benefit Adjustment End Date: Benefit Adjustment Weekly Amount: Benefit Credit Code: Benefit Credit Start Date: Benefit Credit End Date: Benefit Credit Weekly Amount: Benefit Redistribution Code: Benefit Redistribution Start Date: Benefit Redistribution End Date: Benefit Redistribution Weekly Amount: Other Benefit Type Code: Other Benefit Type Amount: Payment Information Payment Reason Code: Payee: Payment Amount: Payment Covers Period Start Date: Payment Covers Period Through Date: Payment Issue Date: Lump Sum Payment Settlement Code: Claim Transaction Details-SROI (LIBC-498, LIBC-392A, LIBC-761, LIBC-762, LIBC-763) LIBC-91 REV 09-13 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com Reduced Earnings Information Reduced Earnings Week Number: Actual Reduced Earnings: Deemed Reduced Earnings: Denial Information Denial Reason Code: Denial Reason Narrative: Partial Denial Code: Full Denial Effective Date: Suspension Information Suspension Reason Narrative: Suspension Effective Date: Return to Work With Same Employer Indicator: Return to Work Code: Physical Restrictions Indicator: Other Party Information Insured Report Number: Insurer FEIN: Employer FEIN: Employer Physical Postal Code: Concurrent Employer Name: Concurrent Employer Contact Business Phone: Concurrent Employer Wage: Claim Administrator Information Claim Administrator Name: Claim Administrator FEIN: Claim Administrator Postal Code: Claim Representative Business Phone Number: Claim Representative Name: Claim Representative Email Address: Claim Representative Fax Number: Claim Administrator Claim Number: Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program Claim Transaction Details-SROI (LIBC-498, LIBC-392A, LIBC-761, LIBC-762, LIBC-763) LIBC-91 REV 09-13 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com