Workers222 Compensation Expenditure Report for )raey( )htnom(Claim Administrator Information: Claim Administrator Federal ID No Carrier Code Claim # Name (DBA) Address City State Zip Telephone Number Form Completed By Employer Information:Employer Federal ID No Employer Name (DBA) Employee/Injury Information:Employee/Claimant SSN Date of Injury Body Part(s) Injured Employee/Claimant Name )IM( )TSRIF( )TSAL( Payment Information:DISABILITY ytilibasiD fo etaD No. of Weeks Paid Amount Paid 210 - Temporary Partial 220 - Temporary Total 230 - Permanent Partial 240 - Permanent Total 250 - Rehabilitation 260 - Disability Settlement/Lump Sum FATALITY Date of Fatality: No. of Weeks Paid Amount Paid Amount Paid MISCELLANEOUS EXPENSES:402-Interest to Claimant404 226 Deductible Reimbursement112 - Investigative Fees111 - Legal Fees403 - Penalty Charged to Employer114 - Rehabilitation Consultant401 - Subrogation117 226 Case Management Fees116 - Miscellaneous Expenses(please specify) Amount Paid 312 - Fatality Payments 311 - Fatality Settlement/Lump Sum MEDICAL EXPENSES:102 226 Chiropractor 113 - Counseling Services 103 226 Dentist 104 - Doctor 105 - Equipment 115 - Home Health Care 101 - Hospital 106 - Pharmacy110 - Physical Therapy Fees 109 - Radiology 107 - Transportation 108 - Other Medical Expenses 118 - IME American LegalNet, Inc. www.FormsWorkFlow.com