RFP_5800_SLW3033_ATT_9_v1.pdf
PDF 295 KB Posted
- Solicitation number
- RFP 5800 SLW3033
- Issued by
- Texas
About this file
This is a Loss Run Report attachment for a workers' compensation third-party administration services contract opportunity for the City of Austin, Texas. The report documents historical workers' compensation claims across multiple City of Austin departments, including transferred claims and Austin Energy, as of September 30, 2023. The report spans two pages and details individual claim information including claimant names, dates of loss, claim status, injury descriptions, and jurisdictional information across Texas locations, primarily Austin and San Antonio. Claims documented range from 1989 through 2016, with statuses including denied, closed, and pending claims.
The Loss Run Report provides financial claim data including paid amounts, reserves, and incurred totals for each claim. Notable claims include a transferred claim with $9.45 in incurred costs, another transferred claim with $9.45 in incurred costs, and a 1989 motor vehicle claim with $19,502.18 in total incurred costs. Multiple pending claims from Austin Energy are listed with zero financial activity, including finger laceration, knee strain, and twisting strain injuries. The report identifies specific policy numbers, carriers, plan structures, and organizational hierarchy levels, indicating the City of Austin's established workers' compensation claims history and administrative infrastructure relevant to evaluating third-party administrator qualifications and experience with municipal public sector claims management.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP_5800_SLW3033_ATT_10_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_12_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_6_v1.xls | XLS spreadsheet | |
| RFP_5800_SLW3033_ATT_11_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_2_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_5_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ADD_1_v1.pdf | ||
| RFP_5800_SLW3033_ATT_7_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_1_v1.docx | DOCX document | |
| RFP_5800_SLW3033_PAC1_v2.pdf | ||
| RFP_5800_SLW3033_ATT_4_v1.docx | DOCX document | |
| CSP_6100_CLMB344_BID_DOC_5_v1.pdf | ||
| RFP_5800_SLW3033_0600_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_3_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_PAC2_v1.docx | DOCX document | |
| RFP_5800_SLW3033_PAC1_v1.pdf | ||
| RFP_5800_SLW3033_ATT_8_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_0600_v2.xlsx | XLSX spreadsheet |
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Text version
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI
Client#
Client
Name As of Date
Account
Name
Unit
Name
Formatted
File Number
Claimant Full
Name (Last Then
First)
Date of
Loss
Date Claim
Reported to Client
Date Claim
Reported to TPA
Date Claim
Opened
Date Claim
Closed
Date Claim
Reopened
Claim
Status
State Of
Jurisdiction
State Of
Loss
Line
Type
Line
Code
Coverage
Description Coverage Code
WC Claim
Type as of Query
As Of
Date
WC Claim
Type -
Financial
Definition Subtype
Claim
Substatus Loss Description
Event
Description
Examiner
Office
Name
Examiner
Supervisor's
Full Name
Examiner
Correspondence
Name Litigation Status (Yes/No)
Date in
Litigation
Date Of Attorney
Representation
Settlement
Type
Settlement
Date
Method of
Settlement
A000
CITY OF
AUSTIN
TRANSFERR
ED CLAIMS 9/30/2023
0000 - CITY
OF AUSTIN
TRANSFERRED
CLAIMS
0000 -
CITY OF
AUSTIN
TRANSF
ERRED
CLAIMS 99999 Romeo, Juliet 3/31/2022 3/31/2022 4/22/2022 4/25/2022 10/4/2022 C TX TX WC WC
Workers
Compensation WC MO MO Denied
Unknown work related injury as
I could not read the documents provided from the
Unknown work related injury as I could not read the documents provided from the Urgent clinic.
AUSTIN,
TX Mik Stevens Molly Boot No 0
A000
CITY OF
AUSTIN
TRANSFERR
ED CLAIMS 9/30/2023
0000 - CITY
OF AUSTIN
TRANSFERRED
CLAIMS
0000 -
CITY OF
AUSTIN
TRANSF
ERRED
CLAIMS 88888 Blacky, Joey 3/18/2022 5/3/2022 5/3/2022 5/3/2022 5/16/2022 C TX TX WC WC
Workers
Compensation WC MO MO Denied
Medical bill received only -manual entry Unknown
AUSTIN,
TX Mik Stevens Tevi White No 0
A000
CITY OF
AUSTIN
TRANSFERR
ED CLAIMS 9/30/2023
0000 - CITY
OF AUSTIN
TRANSFERRED
CLAIMS
0000-
TRANSF
ERRED
CLAIMS 77777 Audit, Medical 8/1/1989 8/1/1989 8/1/1989 8/1/1989 5/4/1994 C TX TX WC WC
Workers
Compensation WC IN MO Accepted
Motor Vehicle, NOC All Other
(Specific) Injuries, NOC Whole
Body
Motor Vehicle, NOC All Other
(Specific)
Injuries, NOC
Whole Body
AUSTIN,
TX Mik Stevens Tevi White Yes 0
A011
AUSTIN
ENERGY 9/30/2023
0011 - AUSTIN
ENERGY
0001-
PROFES
SIONAL 66666 Wobegone, Mike 4/26/2012 5/7/2012 5/7/2012 5/7/2012 I TX TX WC WC
Workers
Compensation WC IO IO Pending
Rt Little Finger Abrasioniw Fell
From The Dividing Wall While
Crossing Over It.
Rt Little Finger
Abrasioniw Fell
From The
Dividing Wall
While Crossing
Over It.
Seperates The
Two
AUSTIN,
TX Mik Stevens Deb Woodbe No 0
A011
AUSTIN
ENERGY 9/30/2023
0011 - AUSTIN
ENERGY
0001-
PROFES
SIONAL 55555 Winkers, Kevin 5/24/2012 5/30/2012 5/30/2012 5/30/2012 I TX TX WC WC
Workers
Compensation WC IO IO Pending
Rt Knee Strainiw Was In Pole
Climbing School And While On
The Pole His Repositio
Rt Knee
Strainiw Was In
Pole Climbing
School And
While On The
Pole His
Repositioned
His
SAN
ANTONIO,
TX Mik Stevens Deb Woodbe No 0
A011
AUSTIN
ENERGY 9/30/2023
0011 - AUSTIN
ENERGY
0001-
PROFES
SIONAL 44444 Scott, Betty 3/4/2016 3/7/2016 3/8/2016 3/8/2016 I TX TX WC WC
Workers
Compensation WC IO IO Pending
IW was walking and stepped on a rock. The rock rolled causing him to fall, hitt
IW was walking and stepped on a rock. The rock rolled causing him to fall, hitting the ground on his right knee and hands
SAN
ANTONIO,
TX Mik Stevens Deb Woodbe No 0
CITY OF AUSTIN
EXHIBIT I - LOSS RUN REPORT
AJ AK AL AM AN AO AP AQ AR AS AT AU AV AW AX AY AZ BA BB BC BD BE BF BG BH BI BJ BK BL BM BN BO BP BQ BR BS BT
Subrogation
Status
(Yes/No)
Cause
Description
(Interaction) Result/Nature Description
Target/Part of Body
Description
Last
Payment
Date
Days
Since Last
Payment
Claim
Paid -
Ind/Loss
Claim
Paid –
Medical
Claim
Paid -
Expense
Claim
Paid -
Total
Claim
Future
Reserve -
Ind/Loss
Claim
Future
Reserve –
Medical
Claim
Future
Reserve –
Expense
Claim
Future
Reserve –
Total
Claim
Incurred -
Ind/Loss
Claim
Incurred
– Medical
Claim
Incurred
Expense
Claim
Incurred -
Total
Claim
Recovery -
Ind/Loss
Claim
Recovery -
Expense
Claim
Recovery
– Medical
Claim
Recovery
– Total
Policy -
Policy
Number
Plan -
Carrier
Name
Policy -
Inception
Date
Policy -
Expiration
Date
Plan
Number
Structure Level
Name 01
Structure Level
Name 02
Structure Level
Name 03
Structure Level
Name 04
Structure Level
Name 05 Client Name
Client
Number
Account
Number
Unit
Number
N
Other Injury
NEC All Other (Specific) Injuries, NOC
Multiple
Body Parts 44806 393 0 0 9.45 9.45 0 0 0 0 0 0 9.45 9.45 0 0 0 0 WC2022 44470 44834 1 City of Austin
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS City of Austin 7830 78300001 1
N
Other Injury
NEC No Physical Injury
Low Back
Area (Incl.
Lumbar &
Lumbo-
Sacral) 44694 505 0 0 9.45 9.45 0 0 0 0 0 0 9.45 9.45 0 0 0 0 WC2022 44470 44834 1 City of Austin
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS City of Austin 7830 78300001 1
N
Motor
Vehicle, NOC All Other (Specific) Injuries, NOCWhole Body 36571 8628 0 0 19502.18 19502.18 0 0 0 0 0 0 19502.18 19502.18 0 0 0 0 WC1989 32417 32781 1 City of Austin
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000 - CITY OF
AUSTIN
TRANSFERRED
CLAIMS
0000-
TRANSFERRED
CLAIMS
0000-
TRANSFERRED
CLAIMS City of Austin 7830 78300001 2
N
Fall/Slip
From a
Different
Level Laceration Finger(s) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WC2012 40817 41182 1 City of Austin
0011 - AUSTIN
ENERGY 1110-ENERGY
1100-ELECTRIC
OPERATING
0001-
PROFESSIONAL City of Austin 7830 78300011 2
N
Strain or
Injury By, NOC Strain or Tear Knee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WC2012 40817 41182 1 City of Austin
0011 - AUSTIN
ENERGY 1110-ENERGY
1100-ELECTRIC
OPERATING
0001-
PROFESSIONAL City of Austin 7830 78300011 2
N Twisting Strain or Tear Knee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WC2016 42278 42643 1 City of Austin
0011 - AUSTIN
ENERGY 1110-ENERGY
1100-ELECTRIC
OPERATING
0001-
PROFESSIONAL City of Austin 7830 78300011 2
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