RFP26-0265_Exhibit_3_-_Claim_Review_Form.pdf
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- Solicitation number
- RFP26-0265
- Issued by
- Orange County, Orlando City, Florida
About this file
This is an exhibit form from a Request for Proposals issued by the City of Orlando's Procurement and Contracts Division for Third-Party Administration of Firefighters' Worker Compensation Claims Services in Florida. The Claim Review Form (Exhibit 3) serves as a standardized template that proposers and administrators must use to document and track individual firefighter worker compensation claims throughout their lifecycle. The form captures essential claim information including policy details, loss dates, claimant demographics, accident descriptions, legal representation, and financial data related to medical and indemnity payments and reserves.
The form requires comprehensive documentation of claim status, recommended actions, third-party recovery sources, and projected closing dates. Administrators must track amounts paid to date and current reserves separately for medical, indemnity, and expense categories, providing the City of Orlando with detailed claim-by-claim visibility. The form also includes space for noting additional information needed from the City and authority-related documentation, establishing a structured mechanism for ongoing communication and claim management between the third-party administrator and the municipality throughout the administration of firefighter compensation claims.
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Text version
Third Party Administration of Firefighter’s Worker Compensation Claims
RFP26-0265
Exhibit “3”
EXHIBIT “THREE”
CLAIM REVIEW FORM
Third Party Administration of Firefighter’s Worker Compensation Claims
RFP26-0265
Exhibit “3”
EXHIBIT “THREE” - CLAIM REVIEW FORM
Coverage: WC Policy Dates:
Policy Number: Loss Run valued as of:
Claim Number: Date of Loss:
Claimant: D.O.B./Age:
Description of Accident/Injuries:
Claimant Attorney:
Defense Attorney:
Amounts Paid to Date:
Medical Indemnity
Expense Total Paid
Current Reserves (INCLUDING AMOUNTS PAID):
Medical Indemnity
Expense Total Reserves
Current Status:
Recommended Action:
Third Party Sources of Recovery:
Authority/Additional Information Needed from City of Orlando:
Projected Closing Date:
File details come from the government source that posted it. Updated .