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r <br />WORKERS' COMPENSATION <br />CLAIMS <br />REPORT <br />i - - --- <br />403 <br />CLAIMB REPORT FOR CITY OF CROW <br />DATE <br />OF WPORT 09/01/84 i <br />GROUP NO. 02 EMP NO. 0004 <br />POLICY YR 02/01/81 TO 02/01/82 <br />_CLSIN ._ <br />DAYS DATE-OF <br />-------PA10- TO, DATE` ---_ <br />TOTAL-CL A <br />NO. CLAIMANT INJURY DESCRIPTION <br />LOST LOSS <br />MEDICAL INDEM. EXPENSE <br />RESERVE <br />COST ST M <br />003413 BENSON. HALTER SPRAINB. STRAINS SACK <br />'140 04/20/61 <br />34260. 32 41693. 47 1202.70 <br />633. 91 <br />77790. 00 0 B <br />904348 CHESNICKi CAR.Y_CONTUSION.,CRVSMINO.BRUISE BAC14 <br />0 97/22/81 0._00 0.00 <br />0.00 <br />0.00 <br />O`00 C - <br />004431 HIGUS. PATRICIA CONTUSION. CRUSHING. BRUISE HEAD <br />0 06/30/S1 <br />90.00 0.00 <br />0.00 <br />0.00 <br />90.00 C <br />004330 SWARTWOOD. STEV POISONING EYE(8) <br />0 08/29/81 <br />0.00 0.00 <br />0.00 <br />0.00 <br />0.00 C <br />004627_ FRITZIOL- 1�1 _SPRAINS. STRAINS SACK <br />s <br />- 0 06/23/01 <br />0.00 O_00 <br />O_00 <br />O. 00 <br />0.00 C <br />- - <br />004803 MOROWCZYNSKI. J CUT. LACERATION. PUNCTURE KNEE <br />0 09/19/81 <br />0.00 0 00 <br />0.00 <br />0.00 <br />0.00-C <br />003274 TOMCZYK. MARK Y SCRATCMES.ASRASIONS EYE(S) <br />0 10/26/01 <br />33.00 0.00 <br />0.00 <br />0.00 <br />33.00 C <br />006013 BENIIQfi. _MALTEII CONTUSION. CRUSHING. BRUISE BACK <br />---------- '----------_-�------------ ----------------- -�»-__ <br />_ _ - _ __ O 03/06/82 <br />- <br />_ - 0.00 0_00 <br />--------- <br />O. 00 <br />0. 00 <br />0-00 C _ <br />TOTALS THIS TOTAL MED ONLY INDEM 'X'i'O' <br />CLOSED DAYS PAID <br />►AID PAID <br />TOTAL <br />POLICY YR. CLAIMS CLAIMS CLAIMS CLAIMS <br />WINO PAY.. LOST _ MEDICAL <br />INDEMNITY___ EXPENSE <br />RVKRVI <br />COST <br />_ _ <br />8 2 1 1 <br />3 340 *34303. 32 <br />041693. 47 •1202. 70 <br />h73. 3 i <br />07" IS. 00 - <br />