Sedgwick Claims Management Services, Inc.treasury.tn.gov/risk/LossControlReports/LossAn-DeptDiv.pdfSedgwick Claims Management Services, Inc. TABLE OF CONTENTS PREPARED: 06/30/2012

Sedgwick Claims Management Services, Inc.

Loss Analysis I

Sedgwick Claims Management Services Inc.

CMS UNIT: 810

Requestor: Debra Banks

a971376.00001 (@ 23:26:16 06/30/2012)

Client: 1376 STATE OF TENNESSEE Account: ALL Unit: ALL Blanks: Skip Blank Accnts & Units Plan: ALL Line: ALL Coverage: ALL State: ALL Examiner: ALL Vendor: ALL ICD Group: ALL Include: CLAIMS,INCIDENTS Claim Status: OPEN,CLOSED Major Classification: WC-ALL Subtypes: ALL Include Historical Pmnts: YES Incurred Range: ALL Incurred-Exclude Zero?: NO Paid To Dt Range: ALL Paid To Dt-Exclude Zero?: NO Date Option: LOSS Claims: 04/01/2012-06/30/2012 As Of: 06/30/2012 Break Level: Client,Account,Unit Display Grand Total: YES Cause Category/Codes: ALL Result/Nature Category/Codes: ALL Target/Part Category/Codes: ALL


TABLE OF CONTENTS PREPARED: 06/30/2012 LOSS ANALYSIS I PAGE: 1 CMS UNIT: 810

LABEL/DESCRIPTION PAGE NUMBER CLIENT 1376 STATE OF TENNESSEE 1 ACCOUNT 41000000 DEPT. OF REVENUE - 34700 1 UNIT 34700 REVENUE 1 UNIT 34701 ADMINISTRATION 2 UNIT 34716 PROCESSING 3 ACCOUNT 41000002 HIGHER EDUCATION DEPARTMENT 5 UNIT 33206 ACADEMIC SCHOLARSHIPS 5 ACCOUNT 41000065 TENNCARE 7 UNIT 31866 Tenncare Services 7 ACCOUNT 41000069 TENNESSEE STATE VETERANS HOME 9 UNIT 88530 TN VETERAN'S HOME-MURFREESBORO 9 UNIT 88531 TN VETERAN'S HOME-HUMBOLDT 10 UNIT 88532 TN VETERAN'S HOME-KNOXVILLE 11 ACCOUNT 41001120 COMMUNITY HEALTH AGENCIES 13 UNIT 88054 MID WEST REGION COMM HLTH AGNCY 13 ACCOUNT 41007548 COURT SYSTEM - 30200 15 UNIT 30205 SUPREME COURT BUILDINGS 15 UNIT 30227 ADMINISTRATIVE OFFICE OF THE COURTS 16 ACCOUNT 41007549 ATTORNEY GENERAL 18 UNIT 30300 ATTORNEY GENERAL (AGO) 18 UNIT 30301 ATTORNEY GENERAL AND REPORTER 19 ACCOUNT 41007553 DISTRICT OF PUPLIC DEFENDERS - 30600 21 UNIT 30601 DISTRICT PUBLIC DEFENDERS 21 ACCOUNT 41007554 COMPTROLLER - 30700 23 UNIT 30704 STATE AUDIT 23 ACCOUNT 41007555 TREASURY - 30900 25 UNIT 30900 TREASURY 25 ACCOUNT 41007564 FINANCE & ADMINISTRATION - 31700 27 UNIT 31701 ADMINISTRATION 27 UNIT 31703 OFFICE OF INFORMATION RESOURCES 28 ACCOUNT 41007566 GENERAL SERVICES - 32100 30 UNIT 32100 GENERAL SERVICES 30 UNIT 32102 POSTAL SERVICES 31 UNIT 32107 PROPERTY MANAGEMENT 32 UNIT 32115 INFORMATION SYSTEMS 33 ACCOUNT 41007568 AGRICULTURE DEPT. - 32500 35 UNIT 32500 AGRICULTURE 35 UNIT 32501 ADMINISTRATION & GRANTS 36 UNIT 32510 FORESTRY 37 ACCOUNT 41007569 DEPT. OF TOURISM DEVELOPEMENT - 32600 39 UNIT 32600 TOURISM (TOURIST DEVELOPMENT) 39 ACCOUNT 41007572 ENVIRONMENT & CONSERVATION - 32700 41 UNIT 32700 ENVIRONMENT & CONSERVATION (E&C) 41 UNIT 32701 ADMINISTRATION 42 UNIT 32712 STATE PARKS 43 ACCOUNT 41007573 TN WILDLIFE RESOURCES AGENCY - 32800 45 UNIT 32800 TN WILDLIFE RESOURCES AGENCY (TWRA) 45 UNIT 32801 WILDLIFE 46 UNIT 32802 BOATING 47 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 49 UNIT 32900 CORRECTIONS (TDOC} 49 UNIT 32901 ADMINISTRATION 50 UNIT 32906 TENNESSEE CORRECTION ACADEMY 51



LABEL/DESCRIPTION PAGE NUMBER UNIT 32910 TENNESSEE STATE PRISON 52 UNIT 32911 BRUSHY MOUNTAIN PENITENTIARY 53 UNIT 32913 PRISON FOR WOMEN (TPW) 54 UNIT 32914 TURNEY CENTER 55 UNIT 32916 MARK LUTTRELL CORRECTIONAL FAC. (MLRC) 56 UNIT 32917 MIDDLE TN CORRECTIONAL COMPLEX (MTCX) 57 UNIT 32919 MORGAN CNTY REGIONAL CORRECTION FACILITY 58 UNIT 32932 MAJOR MAINTENANCE 59 UNIT 32941 WEST TENNESSEE STATE PENITENIARY (WTSP) 60 UNIT 32942 RIVERBEND MAXIMUM SECURITY FAC. (RMSI) 61 UNIT 32945 NORTHWEST CORRECTIONAL CENTER (NWCC) 62 UNIT 32946 LOIS DEBERRY SPECIAL NEEDS FACILITY 63 UNIT 32947 MORGAN COUNTY CORRECTIONAL COMPLEX 64 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 66 UNIT 33101 ADMINISTRATION 66 UNIT 33106 CURRICULUM & INSTRUCTION 67 UNIT 33136 SPECIAL EDUCATION 68 UNIT 33190 ALVIN YORK INSTITUTE 69 UNIT 33192 TENNESSEE SCHOOL FOR THE DEAF 70 ACCOUNT 41007577 BOARD OF REGENTS (TBR) 72 UNIT 33254 NASHVILLE STATE COMMUNITY COLLEGE 72 UNIT 33255 PELLISSIPPI STATE COMMUNITY COLLEGE 73 UNIT 33260 TENNESSEE BOARD OF REGENTS (TBR) 74 UNIT 33270 AUSTIN PEAY STATE UNIVERSITY 75 UNIT 33272 EAST TENNESSEE STATE UNIVERSITY 76 UNIT 33274 The University of Memphis 77 UNIT 33275 MIDDLE TENNESSEE STATE UNIVERSITY 78 UNIT 33277 TENNESSEE STATE UNIVERSITY 79 UNIT 33278 TENNESSEE TECHNOLOGICAL UNIVERSITY 80 UNIT 33280 CHATANOOGA STATE COMMUNITY COLLEGE 81 UNIT 33281 CLEVELAND STATE COMMUNITY COLLEGE 82 UNIT 33282 COLUMBIA STATE COMMUNITY COLLEGE 83 UNIT 33284 DYERSBURG STATE COMMUNITY COLLEGE 84 UNIT 33286 JACKSON STATE COMMUNITY COLLEGE 85 UNIT 33288 MOTLOW STATE COMMUNITY COLLEGE 86 UNIT 33294 VOLUNTEER STATE COMMUNITY COLLEGE 87 UNIT 33296 WALTERS STATE COMMUNITY COLLEGE 88 ACCOUNT 41007579 COMMERCE AND INSURANCE DEPARTMENT 90 UNIT 33503 FIRE PREVENTION 90 UNIT 33510 REGULATORY BOARDS 91 UNIT 33511 TN LAW ENFORCEMENT TRAINING 92 ACCOUNT 41007581 LABOR AND WORK FORCE 94 UNIT 33700 LABOR & WORKFORCE (DEPT OF LABOR, DLWFD) 94 UNIT 33710 EMPLOYMENT SECURITY 95 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-33900 97 UNIT 33900 MENTAL HEALTH (MH) 97 UNIT 33905 MENTAL HEALTH SERVICES 98 UNIT 33908 COMMUNITY MENTAL HEALTH SERVICES 99 UNIT 33910 LAKESHORE MENTAL HEALTH INSTITUTE (LMHI) 100 UNIT 33911 MIDDLE TENNESS MENTAL HEALTH (MTMHI) 101 UNIT 33912 WESTERN MENTAL HEALTH INSTITUTE (WMHI) 102 UNIT 33916 MOCCASIN BEND MENTAL HEALTH (MBMHI) 103 UNIT 33917 MEMPHIS MENTAL HEALTH INSTITUTE (MMHI) 104



LABEL/DESCRIPTION PAGE NUMBER UNIT 33929 HAROLD W. JORDON REHAB CENTER 105 ACCOUNT 41007584 MILITARY 107 UNIT 34104 TN EMERGENCY MANAGEMENT AGENCY (TEMA) 107 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 109 UNIT 34300 HEALTH 109 UNIT 34301 ADMINISTRATION 110 UNIT 34310 HEALTH RELATED BOARDS 111 UNIT 34339 GENERAL ENVIRONMENTAL HEALTH 112 UNIT 34345 HEALTH SERVICES ADMINISTRATION 113 UNIT 34350 HEALTH DEPT-HSA MEDICAL PROGRAM 114 UNIT 34360 LOCAL HEALTH SERVICES 115 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 117 UNIT 34500 HUMAN SERVICES (DHS) 117 UNIT 34501 ADMINSTRATION 118 UNIT 34513 CHILD SUPPORT 119 UNIT 34516 FIELD OPERATIONS 120 UNIT 34530 FAMILY ASSISTANCE SERVICES 121 UNIT 34540 SOCIAL SERVICES 122 UNIT 34549 COMMUNITY SERVICES 123 UNIT 34570 VOCATIONAL REHABILITATION CENTERS 124 ACCOUNT 41007587 TENNESSEE BUREAU OF INVESTIGATION (TBI) 126 UNIT 34800 TENNESSEE BUREAU OF INVESTIGATION (TBI) 126 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 128 UNIT 34900 SAFETY 128 UNIT 34901 ADMINSTRATION 129 UNIT 34903 HIGHWAY PATROL 130 UNIT 34907 EQUIPMENT 131 UNIT 34915 OFFICE OF HOMELAND SECURITY 132 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 134 UNIT 35900 CHILDREN'S SERVICES (DCS) 134 UNIT 35904 CHILDREN SERV-CHILDR IN TN CUST-EDUC7/98 135 UNIT 35905 CHILDREN SERV-CHILDR IN TN CUST-HUMA7/98 136 UNIT 35906 CHILD SERV-CHILDR IN TN CUST-YOUTH-7/98 137 UNIT 35907 CHILDREN SERV-CHILDR IN TN CUST-MHMR7/98 138 UNIT 35910 ADMINISTRATION 139 UNIT 35940 ADOPTION SERVICES 140 UNIT 35950 CHILD & FAMILY MANAGEMENT 141 UNIT 35960 WILDER DEVELOPMENT CENTER 142 UNIT 35962 WOODLAND HILLS DEVELOPMENT CENTER 143 UNIT 35963 MOUNTAIN VIEW DEVELOPMENT CENTER 144 UNIT 35965 CHILD SERVICES (DCS) GROUP HOME 145 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 147 UNIT 40000 TRANSPORTATION (TDOT, DOT) 147 UNIT 40100 ADMINISTRATION/HEADQUARTERS 148 UNIT 41200 TDOT ENGINEERING 149 UNIT 41900 FIELD MAINTENANCE 150 UNIT 43000 EQUIPMENT PURCHASES & OPERATIONS 151 UNIT 45100 TDOT HIGHWAY MAINTENANCE 152 UNIT 47100 STATE CONSTRUCTION 153 UNIT 48000 HIGHWAY CONSTRUCTION 154 UNIT 48200 OTHER CONSTRUCTION 155 UNIT 48700 METROPOLITAN-URBAN 156 UNIT 48800 BRIDGE REPLACEMENT 157



LABEL/DESCRIPTION PAGE NUMBER ACCOUNT 41007591 UNIVERSITY OF TENNESSEE 159 UNIT 01000 UT KNOXVILLE (UTK) 159 UNIT 02000 SPACE INSTITUTE (UTSI) 160 UNIT 04000 UT CHATTANOOGA (UTC) 161 UNIT 05000 UT MARTIN (UTM) 162 UNIT 07000 HEALTH SCIENCE CENTER (UTHSC) 163 UNIT 08000 GRADUATE SCHOOL OF MEDICINE 164 UNIT 11000 INSTITUTE OF AGRICULTURE 165 UNIT 12000 AGRICULTURE EXTENSION (UT EXTENSION SVC) 166 UNIT 18000 COLLEGE OF VETERINARY SERVICE 167 UNIT 22000 CHATTANOOGA CLINICAL EDUCATION 168 ACCOUNT 41007596 TN CORRECTIONS INSTITUTE 170 UNIT 31609 TN CORRECTIONS INSTITUTE 170 ACCOUNT 41137603 BOARD PROBATION & PAROLES - 32400 172 UNIT 32402 PROBATION & PAROLE 172 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 174 UNIT 34400 MENTAL RETARDATION 174 UNIT 34401 ADMINISTRATION 175 UNIT 34410 ARLINGTON DEVELOPMENTAL CENTER 176 UNIT 34411 CLOVER BOTTOM DEVELOPMENTAL CENTER 177 UNIT 34412 GREENE VALLEY DEVELOPMENTAL CENTER 178 UNIT 34420 WEST TENNESSEE REGIONAL OFFICE 179 UNIT 34421 MIDDLE TENNESSEE REGIONAL OFFICE 180 UNIT 34422 East TN Regional Office 181 UNIT 34440 WEST TENNESSEE COMMUNITY HOME 182 UNIT 34442 East TN Homes 183 TOTAL FOR REPORT 186


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000000 DEPT. OF REVENUE - 34700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 1 UNIT 34700 REVENUE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 7.90 26,650.56 2900 Fall On the Same Level 1 7.90 26,650.56

ALL OTHER CODES 0.00 0.00 ALL OTHER CODES 0.00 0.00 TOTAL OF CODES 1 7.90 26,650.56 TOTAL OF CODES 1 7.90 26,650.56

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 7.90 26,650.56 5200 Strain 1 7.90 26,650.56


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 1 7.90 26,650.56 3800 Shoulder(s) 1 7.90 26,650.56



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000000 DEPT. OF REVENUE - 34700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 2 UNIT 34701 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9700 Repetitive Motion (reported af 1 7.90 15,639.36 9700 Repetitive Motion (reported af 1 7.90 15,639.36 1901 Bitten 1 0.00 0.00 5700 Pushing or Pulling 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 1901 Bitten 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 7.90 15,639.36 9000 Multiple Physical Injuries Onl 1 7.90 15,639.36 3700 Inflammation 1 0.00 0.00 5200 Strain 1 0.00 525.00 5200 Strain 1 0.00 525.00 3700 Inflammation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3000 Multiple Upper Extremities 1 7.90 15,639.36 3000 Multiple Upper Extremities 1 7.90 15,639.36 5600 Foot 1 0.00 0.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 5600 Foot 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000000 DEPT. OF REVENUE - 34700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 3 UNIT 34716 PROCESSING CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8100 Struck or Injured By, NOC 1 781.97 781.97 8100 Struck or Injured By, NOC 1 781.97 781.97

ALL OTHER CODES 0.00 0.00 ALL OTHER CODES 0.00 0.00 TOTAL OF CODES 1 781.97 781.97 TOTAL OF CODES 1 781.97 781.97

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4000 Laceration 1 781.97 781.97 4000 Laceration 1 781.97 781.97


----- PART/TARGET ----- ----- PART/TARGET ----- 3600 Finger(s) 1 781.97 781.97 3600 Finger(s) 1 781.97 781.97



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000000 DEPT. OF REVENUE - 34700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 4 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 7.90 26,650.56 2900 Fall On the Same Level 1 7.90 26,650.56 9700 Repetitive Motion (reported af 1 7.90 15,639.36 9700 Repetitive Motion (reported af 1 7.90 15,639.36 1901 Bitten 1 0.00 0.00 8100 Struck or Injured By, NOC 1 781.97 781.97 5700 Pushing or Pulling 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 8100 Struck or Injured By, NOC 1 781.97 781.97 1901 Bitten 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 7.90 27,175.56 5200 Strain 2 7.90 27,175.56 9000 Multiple Physical Injuries Onl 1 7.90 15,639.36 9000 Multiple Physical Injuries Onl 1 7.90 15,639.36 3700 Inflammation 1 0.00 0.00 4000 Laceration 1 781.97 781.97 4000 Laceration 1 781.97 781.97 3700 Inflammation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 1 7.90 26,650.56 3800 Shoulder(s) 1 7.90 26,650.56 3000 Multiple Upper Extremities 1 7.90 15,639.36 3000 Multiple Upper Extremities 1 7.90 15,639.36 5600 Foot 1 0.00 0.00 3600 Finger(s) 1 781.97 781.97 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 3600 Finger(s) 1 781.97 781.97 5600 Foot 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000002 HIGHER EDUCATION DEPARTMENT LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 5 UNIT 33206 ACADEMIC SCHOLARSHIPS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 1 0.00 525.00 4900 Sprain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5500 Ankle 1 0.00 525.00 5500 Ankle 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000002 HIGHER EDUCATION DEPARTMENT LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 6 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000065 TENNCARE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 7 UNIT 31866 Tenncare Services CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8700 Foreign Matter (Body) in Eye(s 1 816.08 816.08 8700 Foreign Matter (Body) in Eye(s 1 816.08 816.08


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5800 Vision Loss 1 816.08 816.08 5800 Vision Loss 1 816.08 816.08


----- PART/TARGET ----- ----- PART/TARGET ----- 1400 Eye(s) 1 816.08 816.08 1400 Eye(s) 1 816.08 816.08



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000065 TENNCARE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 8 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8700 Foreign Matter (Body) in Eye(s 1 816.08 816.08 8700 Foreign Matter (Body) in Eye(s 1 816.08 816.08


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5800 Vision Loss 1 816.08 816.08 5800 Vision Loss 1 816.08 816.08





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000069 TENNESSEE STATE VETERANS HOME LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 9 UNIT 88530 TN VETERAN'S HOME-MURFREESBORO CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 3 1,166.57 1,691.57 3100 Fall, Slip or Trip, NOC 1 0.00 7,559.34 8100 Struck or Injured By, NOC 1 302.22 302.22 7400 Fellow Worker, Patient 3 1,166.57 1,691.57 2900 Fall On the Same Level 1 0.00 525.00 6800 Stationary Object 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 7,559.34 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00 6800 Stationary Object 1 0.00 525.00 8100 Struck or Injured By, NOC 1 302.22 302.22

ALL OTHER CODES 0.00 0.00 ALL OTHER CODES 0.00 0.00 TOTAL OF CODES 8 1,468.79 11,128.13 TOTAL OF CODES 8 1,468.79 11,128.13

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 914.54 1,439.54 5200 Strain 2 302.22 7,861.56 5200 Strain 2 302.22 7,861.56 1000 Contusion (Bruise, Skin Surfac 2 914.54 1,439.54 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 5900 All Other Injuries, NOC 2 252.03 777.03 5900 All Other Injuries, NOC 2 252.03 777.03


----- PART/TARGET ----- ----- PART/TARGET ----- 1300 Ear(s) 1 914.54 914.54 5300 Knee 1 0.00 7,559.34 4101 Back (All Other) 1 302.22 302.22 1300 Ear(s) 1 914.54 914.54 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 6500 Insufficient Info to Identify; 1 0.00 525.00 6500 Insufficient Info to Identify; 1 0.00 525.00 4600 Pelvis 1 0.00 525.00 5300 Knee 1 0.00 7,559.34 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 1001 Head NEC 1 252.03 252.03 3400 Wrist 1 0.00 525.00 4600 Pelvis 1 0.00 525.00 4101 Back (All Other) 1 302.22 302.22 3400 Wrist 1 0.00 525.00 1001 Head NEC 1 252.03 252.03



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000069 TENNESSEE STATE VETERANS HOME LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 10 UNIT 88531 TN VETERAN'S HOME-HUMBOLDT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 0.00 0.00 5800 Reaching 1 0.00 525.00 5800 Reaching 1 0.00 525.00 5600 Lifting 1 0.00 525.00 5600 Lifting 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 0.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 1 0.00 0.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 3400 Wrist 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000069 TENNESSEE STATE VETERANS HOME LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 11 UNIT 88532 TN VETERAN'S HOME-KNOXVILLE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 2 0.00 1,050.00 5600 Lifting 2 0.00 1,050.00 1800 Powered Hand Tool, Appliance 1 0.00 0.00 8000 Object Handled By Others 1 0.00 525.00 5300 Twisting 1 321.92 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 5300 Twisting 1 321.92 525.00 8000 Object Handled By Others 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 1800 Powered Hand Tool, Appliance 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 5200 Strain 2 0.00 1,050.00 5200 Strain 2 0.00 1,050.00 4000 Laceration 1 0.00 0.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 4900 Sprain 1 321.92 525.00 4900 Sprain 1 321.92 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3600 Finger(s) 1 0.00 0.00 9000 Multiple Body Parts 1 0.00 525.00 3400 Wrist 1 321.92 525.00 6300 Lumbar and/or Sacral Vertebrae 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5600 Foot 1 0.00 525.00 6300 Lumbar and/or Sacral Vertebrae 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 1001 Head NEC 1 0.00 525.00 3400 Wrist 1 321.92 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 1001 Head NEC 1 0.00 525.00 5600 Foot 1 0.00 525.00 3600 Finger(s) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41000069 TENNESSEE STATE VETERANS HOME LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 12 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 4 1,166.57 1,691.57 3100 Fall, Slip or Trip, NOC 1 0.00 7,559.34 5600 Lifting 3 0.00 1,575.00 7400 Fellow Worker, Patient 4 1,166.57 1,691.57 8100 Struck or Injured By, NOC 1 302.22 302.22 5600 Lifting 3 0.00 1,575.00 2900 Fall On the Same Level 1 0.00 525.00 8000 Object Handled By Others 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00 6800 Stationary Object 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 7,559.34 6000 Strain or Injury By, NOC 1 0.00 525.00 6800 Stationary Object 1 0.00 525.00 5800 Reaching 1 0.00 525.00 5800 Reaching 1 0.00 525.00 5300 Twisting 1 321.92 525.00 1800 Powered Hand Tool, Appliance 1 0.00 0.00 2900 Fall On the Same Level 1 0.00 525.00 5300 Twisting 1 321.92 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 8000 Object Handled By Others 1 0.00 525.00 8100 Struck or Injured By, NOC 1 302.22 302.22 1300 Caught In, Under or Between, N 1 0.00 525.00 1800 Powered Hand Tool, Appliance 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 7 302.22 9,961.56 5200 Strain 7 302.22 9,961.56 5999 Unclassified, Insufficient Dat 3 0.00 1,575.00 5999 Unclassified, Insufficient Dat 3 0.00 1,575.00 1000 Contusion (Bruise, Skin Surfac 2 914.54 1,439.54 1000 Contusion (Bruise, Skin Surfac 2 914.54 1,439.54 5900 All Other Injuries, NOC 2 252.03 777.03 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 5900 All Other Injuries, NOC 2 252.03 777.03 4000 Laceration 1 0.00 0.00 4900 Sprain 1 321.92 525.00 4900 Sprain 1 321.92 525.00 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 3 321.92 1,050.00 5300 Knee 1 0.00 7,559.34 4200 Low Back Area (Incl. Lumbar & 2 0.00 1,050.00 4200 Low Back Area (Incl. Lumbar & 2 0.00 1,050.00 1001 Head NEC 2 252.03 777.03 3400 Wrist 3 321.92 1,050.00 1300 Ear(s) 1 914.54 914.54 1300 Ear(s) 1 914.54 914.54 4101 Back (All Other) 1 302.22 302.22 1001 Head NEC 2 252.03 777.03 6500 Insufficient Info to Identify; 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5300 Knee 1 0.00 7,559.34 6500 Insufficient Info to Identify; 1 0.00 525.00 4600 Pelvis 1 0.00 525.00 6300 Lumbar and/or Sacral Vertebrae 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 5600 Foot 1 0.00 525.00 3600 Finger(s) 1 0.00 0.00 4600 Pelvis 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 6300 Lumbar and/or Sacral Vertebrae 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 4101 Back (All Other) 1 302.22 302.22 5600 Foot 1 0.00 525.00 3600 Finger(s) 1 0.00 0.00 ALL OTHER CODES 0.00 0.00 ALL OTHER CODES 0.00 0.00 TOTAL OF CODES 18 1,790.71 15,328.13 TOTAL OF CODES 18 1,790.71 15,328.13


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41001120 COMMUNITY HEALTH AGENCIES LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 13 UNIT 88054 MID WEST REGION COMM HLTH AGNCY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6003 Overexertion 1 0.00 0.00 4600 Collision with a Fixed Object 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00 4600 Collision with a Fixed Object 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 6003 Overexertion 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 2 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 0.00 0.00 9000 Multiple Body Parts 1 0.00 525.00 2100 Vertebrae 1 0.00 525.00 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 2100 Vertebrae 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41001120 COMMUNITY HEALTH AGENCIES LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 14 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6003 Overexertion 1 0.00 0.00 4600 Collision with a Fixed Object 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00 4600 Collision with a Fixed Object 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 6003 Overexertion 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 2 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 0.00 0.00 9000 Multiple Body Parts 1 0.00 525.00 2100 Vertebrae 1 0.00 525.00 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 2100 Vertebrae 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007548 COURT SYSTEM - 30200 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 15 UNIT 30205 SUPREME COURT BUILDINGS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9804 Repetitive Motion (reported be 1 287.02 1,600.00 9804 Repetitive Motion (reported be 1 287.02 1,600.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3200 Elbow 1 287.02 1,600.00 3200 Elbow 1 287.02 1,600.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007548 COURT SYSTEM - 30200 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 16 UNIT 30227 ADMINISTRATIVE OFFICE OF THE COURTS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7502 Scrap, Debris, Waste 1 0.00 525.00 7502 Scrap, Debris, Waste 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2500 Foreign Body (Eye) 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007548 COURT SYSTEM - 30200 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 17 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9804 Repetitive Motion (reported be 1 287.02 1,600.00 9804 Repetitive Motion (reported be 1 287.02 1,600.00 7502 Scrap, Debris, Waste 1 0.00 525.00 7502 Scrap, Debris, Waste 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 287.02 1,600.00 5200 Strain 1 287.02 1,600.00 2500 Foreign Body (Eye) 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3200 Elbow 1 287.02 1,600.00 3200 Elbow 1 287.02 1,600.00 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007549 ATTORNEY GENERAL LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 18 UNIT 30300 ATTORNEY GENERAL (AGO) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3101 Trip 1 0.00 0.00 3101 Trip 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5600 Foot 1 0.00 0.00 5600 Foot 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007549 ATTORNEY GENERAL LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 19 UNIT 30301 ATTORNEY GENERAL AND REPORTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 1,263.41 6,250.00 2900 Fall On the Same Level 1 1,263.41 6,250.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 1,263.41 6,250.00 2800 Fracture 1 1,263.41 6,250.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 1 1,263.41 6,250.00 3800 Shoulder(s) 1 1,263.41 6,250.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007549 ATTORNEY GENERAL LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 20 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3101 Trip 1 0.00 0.00 2900 Fall On the Same Level 1 1,263.41 6,250.00 2900 Fall On the Same Level 1 1,263.41 6,250.00 3101 Trip 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 0.00 2800 Fracture 1 1,263.41 6,250.00 2800 Fracture 1 1,263.41 6,250.00 9000 Multiple Physical Injuries Onl 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5600 Foot 1 0.00 0.00 3800 Shoulder(s) 1 1,263.41 6,250.00 3800 Shoulder(s) 1 1,263.41 6,250.00 5600 Foot 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007553 DISTRICT OF PUPLIC DEFENDERS - 30 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 21 UNIT 30601 DISTRICT PUBLIC DEFENDERS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 187.10 3,450.00 6000 Strain or Injury By, NOC 1 187.10 3,450.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007553 DISTRICT OF PUPLIC DEFENDERS - 30 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 22 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 187.10 3,450.00 6000 Strain or Injury By, NOC 1 187.10 3,450.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007554 COMPTROLLER - 30700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 23 UNIT 30704 STATE AUDIT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1200 Object Handled 1 494.42 494.42 1200 Object Handled 1 494.42 494.42


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 494.42 494.42 1000 Contusion (Bruise, Skin Surfac 1 494.42 494.42


----- PART/TARGET ----- ----- PART/TARGET ----- 3700 Thumb 1 494.42 494.42 3700 Thumb 1 494.42 494.42



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007554 COMPTROLLER - 30700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 24 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1200 Object Handled 1 494.42 494.42 1200 Object Handled 1 494.42 494.42




----- PART/TARGET ----- ----- PART/TARGET ----- 3700 Thumb 1 494.42 494.42 3700 Thumb 1 494.42 494.42



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007555 TREASURY - 30900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 25 UNIT 30900 TREASURY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007555 TREASURY - 30900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 26 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007564 FINANCE & ADMINISTRATION - 31700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 27 UNIT 31701 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7800 Carpal Tunnel Syndrome 1 0.00 525.00 7800 Carpal Tunnel Syndrome 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3900 Wrist(s) and Hand(s) 1 0.00 525.00 3900 Wrist(s) and Hand(s) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007564 FINANCE & ADMINISTRATION - 31700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 28 UNIT 31703 OFFICE OF INFORMATION RESOURCES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 1 236.42 236.42 8500 Animal or Insect 1 236.42 236.42


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 3700 Inflammation 1 236.42 236.42 3700 Inflammation 1 236.42 236.42





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007564 FINANCE & ADMINISTRATION - 31700 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 29 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 1 236.42 236.42 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 8500 Animal or Insect 1 236.42 236.42


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7800 Carpal Tunnel Syndrome 1 0.00 525.00 7800 Carpal Tunnel Syndrome 1 0.00 525.00 3700 Inflammation 1 236.42 236.42 3700 Inflammation 1 236.42 236.42


----- PART/TARGET ----- ----- PART/TARGET ----- 3900 Wrist(s) and Hand(s) 1 0.00 525.00 3900 Wrist(s) and Hand(s) 1 0.00 525.00 5500 Ankle 1 236.42 236.42 5500 Ankle 1 236.42 236.42



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007566 GENERAL SERVICES - 32100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 30 UNIT 32100 GENERAL SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 0400 Fire or Flame 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 0400 Fire or Flame 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 0401 Burn or Scald (Heat) 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 0401 Burn or Scald (Heat) 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3500 Hand 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 3500 Hand 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007566 GENERAL SERVICES - 32100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 31 UNIT 32102 POSTAL SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5300 Twisting 1 2,009.75 9,861.04 5300 Twisting 1 2,009.75 9,861.04


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 1 2,009.75 9,861.04 4900 Sprain 1 2,009.75 9,861.04


----- PART/TARGET ----- ----- PART/TARGET ----- 3500 Hand 1 2,009.75 9,861.04 3500 Hand 1 2,009.75 9,861.04



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007566 GENERAL SERVICES - 32100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 32 UNIT 32107 PROPERTY MANAGEMENT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 1 4,941.61 13,045.88 5600 Lifting 1 4,941.61 13,045.88


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 4,941.61 13,045.88 5200 Strain 1 4,941.61 13,045.88


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 4,941.61 13,045.88 4200 Low Back Area (Incl. Lumbar & 1 4,941.61 13,045.88



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007566 GENERAL SERVICES - 32100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 33 UNIT 32115 INFORMATION SYSTEMS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1300 Caught In, Under or Between, N 1 126.96 126.96 1300 Caught In, Under or Between, N 1 126.96 126.96




----- PART/TARGET ----- ----- PART/TARGET ----- 5800 Great Toe 1 126.96 126.96 5800 Great Toe 1 126.96 126.96



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007566 GENERAL SERVICES - 32100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 34 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 0400 Fire or Flame 1 0.00 525.00 5600 Lifting 1 4,941.61 13,045.88 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 5300 Twisting 1 2,009.75 9,861.04 5300 Twisting 1 2,009.75 9,861.04 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 5600 Lifting 1 4,941.61 13,045.88 0400 Fire or Flame 1 0.00 525.00 1300 Caught In, Under or Between, N 1 126.96 126.96 1300 Caught In, Under or Between, N 1 126.96 126.96


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 0401 Burn or Scald (Heat) 1 0.00 525.00 5200 Strain 1 4,941.61 13,045.88 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4900 Sprain 1 2,009.75 9,861.04 4900 Sprain 1 2,009.75 9,861.04 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 4,941.61 13,045.88 0401 Burn or Scald (Heat) 1 0.00 525.00 4000 Laceration 1 126.96 126.96 4000 Laceration 1 126.96 126.96


----- PART/TARGET ----- ----- PART/TARGET ----- 3500 Hand 2 2,009.75 10,386.04 4200 Low Back Area (Incl. Lumbar & 1 4,941.61 13,045.88 9000 Multiple Body Parts 1 0.00 525.00 3500 Hand 2 2,009.75 10,386.04 4200 Low Back Area (Incl. Lumbar & 1 4,941.61 13,045.88 9000 Multiple Body Parts 1 0.00 525.00 5800 Great Toe 1 126.96 126.96 5800 Great Toe 1 126.96 126.96



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007568 AGRICULTURE DEPT. - 32500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 35 UNIT 32500 AGRICULTURE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 0.00 525.00 2800 Fall/Slip into Openings 1 1,056.38 1,090.49 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 2800 Fall/Slip into Openings 1 1,056.38 1,090.49 6000 Strain or Injury By, NOC 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 1,056.38 1,090.49 7800 Carpal Tunnel Syndrome 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 1,056.38 1,090.49 7800 Carpal Tunnel Syndrome 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 2 1,056.38 1,615.49 9000 Multiple Body Parts 2 1,056.38 1,615.49 3000 Multiple Upper Extremities 1 0.00 525.00 3000 Multiple Upper Extremities 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007568 AGRICULTURE DEPT. - 32500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 36 UNIT 32501 ADMINISTRATION & GRANTS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 1 35.91 35.91 7907 Plant 1 0.00 525.00 7907 Plant 1 0.00 525.00 8500 Animal or Insect 1 35.91 35.91


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5900 All Other Injuries, NOC 1 35.91 35.91 4000 Laceration 1 0.00 525.00 4000 Laceration 1 0.00 525.00 5900 All Other Injuries, NOC 1 35.91 35.91


----- PART/TARGET ----- ----- PART/TARGET ----- 1300 Ear(s) 1 35.91 35.91 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 1300 Ear(s) 1 35.91 35.91



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007568 AGRICULTURE DEPT. - 32500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 37 UNIT 32510 FORESTRY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 554.21 2,300.00 2800 Fall/Slip into Openings 1 3,298.21 17,396.06 2800 Fall/Slip into Openings 1 3,298.21 17,396.06 6000 Strain or Injury By, NOC 1 554.21 2,300.00 7900 Object Being Lifted or Handled 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 525.00 4800 Vehicle Upset 1 0.00 525.00 5500 Holding or Carrying 1 158.50 525.00 5500 Holding or Carrying 1 158.50 525.00 4800 Vehicle Upset 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 712.71 2,825.00 4900 Sprain 1 3,298.21 17,396.06 4900 Sprain 1 3,298.21 17,396.06 5200 Strain 2 712.71 2,825.00 5908 Chipped / Broken Tooth 1 0.00 525.00 5908 Chipped / Broken Tooth 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 1 554.21 2,300.00 5300 Knee 1 3,298.21 17,396.06 5300 Knee 1 3,298.21 17,396.06 3800 Shoulder(s) 1 554.21 2,300.00 1600 Teeth 1 0.00 525.00 6100 Abdomen Including Groin 1 158.50 525.00 3302 Arm, Multiple 1 0.00 525.00 3302 Arm, Multiple 1 0.00 525.00 6100 Abdomen Including Groin 1 158.50 525.00 1600 Teeth 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007568 AGRICULTURE DEPT. - 32500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 38 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 2 554.21 2,825.00 2800 Fall/Slip into Openings 2 4,354.59 18,486.55 2800 Fall/Slip into Openings 2 4,354.59 18,486.55 6000 Strain or Injury By, NOC 2 554.21 2,825.00 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 8500 Animal or Insect 1 35.91 35.91 7907 Plant 1 0.00 525.00 7907 Plant 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 525.00 5500 Holding or Carrying 1 158.50 525.00 4800 Vehicle Upset 1 0.00 525.00 4800 Vehicle Upset 1 0.00 525.00 5500 Holding or Carrying 1 158.50 525.00 8500 Animal or Insect 1 35.91 35.91


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 1,056.38 1,615.49 4900 Sprain 1 3,298.21 17,396.06 5200 Strain 2 712.71 2,825.00 5200 Strain 2 712.71 2,825.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 2 1,056.38 1,615.49 7800 Carpal Tunnel Syndrome 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5900 All Other Injuries, NOC 1 35.91 35.91 7800 Carpal Tunnel Syndrome 1 0.00 525.00 4000 Laceration 1 0.00 525.00 5908 Chipped / Broken Tooth 1 0.00 525.00 4900 Sprain 1 3,298.21 17,396.06 4000 Laceration 1 0.00 525.00 5908 Chipped / Broken Tooth 1 0.00 525.00 5900 All Other Injuries, NOC 1 35.91 35.91


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 2 1,056.38 1,615.49 5300 Knee 1 3,298.21 17,396.06 3000 Multiple Upper Extremities 1 0.00 525.00 3800 Shoulder(s) 1 554.21 2,300.00 1300 Ear(s) 1 35.91 35.91 9000 Multiple Body Parts 2 1,056.38 1,615.49 1400 Eye(s) 1 0.00 525.00 6100 Abdomen Including Groin 1 158.50 525.00 3800 Shoulder(s) 1 554.21 2,300.00 3302 Arm, Multiple 1 0.00 525.00 5300 Knee 1 3,298.21 17,396.06 3000 Multiple Upper Extremities 1 0.00 525.00 1600 Teeth 1 0.00 525.00 1600 Teeth 1 0.00 525.00 3302 Arm, Multiple 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 6100 Abdomen Including Groin 1 158.50 525.00 1300 Ear(s) 1 35.91 35.91



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007569 DEPT. OF TOURISM DEVELOPEMENT - 3 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 39 UNIT 32600 TOURISM (TOURIST DEVELOPMENT) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8200 Absorption, Ingestion, or Inha 1 0.00 0.00 8200 Absorption, Ingestion, or Inha 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 6502 Inhalation 1 0.00 0.00 6502 Inhalation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1001 Head NEC 1 0.00 0.00 1001 Head NEC 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007569 DEPT. OF TOURISM DEVELOPEMENT - 3 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 40 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8200 Absorption, Ingestion, or Inha 1 0.00 0.00 8200 Absorption, Ingestion, or Inha 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 6502 Inhalation 1 0.00 0.00 6502 Inhalation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1001 Head NEC 1 0.00 0.00 1001 Head NEC 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007572 ENVIRONMENT & CONSERVATION - 3270 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 41 UNIT 32700 ENVIRONMENT & CONSERVATION (E&C) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8100 Struck or Injured By, NOC 1 0.00 0.00 9700 Repetitive Motion (reported af 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 8100 Struck or Injured By, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 4000 Laceration 1 0.00 525.00 4000 Laceration 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1001 Head NEC 1 0.00 0.00 3500 Hand 1 0.00 525.00 1700 Mouth 1 0.00 525.00 1700 Mouth 1 0.00 525.00 3500 Hand 1 0.00 525.00 1001 Head NEC 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007572 ENVIRONMENT & CONSERVATION - 3270 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 42 UNIT 32701 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7907 Plant 1 0.00 525.00 7907 Plant 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5900 All Other Injuries, NOC 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3000 Multiple Upper Extremities 1 0.00 525.00 3000 Multiple Upper Extremities 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007572 ENVIRONMENT & CONSERVATION - 3270 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 43 UNIT 32712 STATE PARKS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 3 0.00 1,575.00 3100 Fall, Slip or Trip, NOC 1 0.00 2,300.00 8500 Animal or Insect 3 0.00 1,050.00 5600 Lifting 3 0.00 1,575.00 1900 Cut, Punctured, Scraped, NOC 2 670.01 670.01 8500 Animal or Insect 3 0.00 1,050.00 7900 Object Being Lifted or Handled 2 242.26 767.26 7500 Falling or Flying Object 2 0.00 1,050.00 2900 Fall On the Same Level 2 0.00 1,050.00 2900 Fall On the Same Level 2 0.00 1,050.00 6800 Stationary Object 2 0.00 525.00 7900 Object Being Lifted or Handled 2 242.26 767.26 7500 Falling or Flying Object 2 0.00 1,050.00 1900 Cut, Punctured, Scraped, NOC 2 670.01 670.01 6002 Bending 1 279.41 279.41 7907 Plant 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 7903 Metal Item, NOC 1 0.00 525.00 5800 Reaching 1 0.00 525.00 7000 Striking Against/Stepping On, 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 2,300.00 6800 Stationary Object 2 0.00 525.00 2600 Fall/Slip From Ladder/Scaffold 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 7907 Plant 1 0.00 525.00 5800 Reaching 1 0.00 525.00 5300 Twisting 1 0.00 525.00 5300 Twisting 1 0.00 525.00 ALL OTHER CODES 2 0.00 1,050.00 ALL OTHER CODES 2 279.41 804.41 TOTAL OF CODES 25 1,191.68 12,941.68 TOTAL OF CODES 25 1,191.68 12,941.68

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 7 279.41 3,429.41 5200 Strain 7 279.41 3,429.41 4000 Laceration 3 912.27 912.27 5999 Unclassified, Insufficient Dat 1 0.00 2,300.00 9000 Multiple Physical Injuries Onl 3 0.00 1,575.00 9000 Multiple Physical Injuries Onl 3 0.00 1,575.00 4300 Puncture 3 0.00 1,050.00 4300 Puncture 3 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 3 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 3 0.00 1,050.00 5999 Unclassified, Insufficient Dat 1 0.00 2,300.00 4000 Laceration 3 912.27 912.27 5900 All Other Injuries, NOC 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 4900 Sprain 1 0.00 525.00 4900 Sprain 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 0402 Chemical Burn 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 0402 Chemical Burn 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 5 0.00 2,100.00 5100 Hip 1 0.00 2,300.00 3600 Finger(s) 2 670.01 670.01 9000 Multiple Body Parts 5 0.00 2,100.00 4200 Low Back Area (Incl. Lumbar & 2 279.41 804.41 3500 Hand 2 0.00 1,050.00 3500 Hand 2 0.00 1,050.00 3400 Wrist 2 0.00 1,050.00 3400 Wrist 2 0.00 1,050.00 4200 Low Back Area (Incl. Lumbar & 2 279.41 804.41 1001 Head NEC 1 242.26 242.26 3600 Finger(s) 2 670.01 670.01 3800 Shoulder(s) 1 0.00 525.00 5500 Ankle 1 0.00 525.00 5100 Hip 1 0.00 2,300.00 5400 Lower Leg 1 0.00 525.00 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 1700 Mouth 1 0.00 525.00 3200 Elbow 1 0.00 525.00 1101 Scalp 1 0.00 525.00 1700 Mouth 1 0.00 525.00 5500 Ankle 1 0.00 525.00 1500 Nose 1 0.00 525.00 3200 Elbow 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 ALL OTHER CODES 3 0.00 1,050.00 ALL OTHER CODES 3 242.26 767.26 TOTAL OF CODES 25 1,191.68 12,941.68 TOTAL OF CODES 25 1,191.68 12,941.68


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007572 ENVIRONMENT & CONSERVATION - 3270 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 44 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 3 0.00 1,575.00 3100 Fall, Slip or Trip, NOC 2 0.00 2,825.00 8500 Animal or Insect 3 0.00 1,050.00 5600 Lifting 3 0.00 1,575.00 3100 Fall, Slip or Trip, NOC 2 0.00 2,825.00 8500 Animal or Insect 3 0.00 1,050.00 7907 Plant 2 0.00 1,050.00 7907 Plant 2 0.00 1,050.00 1900 Cut, Punctured, Scraped, NOC 2 670.01 670.01 7500 Falling or Flying Object 2 0.00 1,050.00 7900 Object Being Lifted or Handled 2 242.26 767.26 2900 Fall On the Same Level 2 0.00 1,050.00 2900 Fall On the Same Level 2 0.00 1,050.00 7900 Object Being Lifted or Handled 2 242.26 767.26 6800 Stationary Object 2 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 2 670.01 670.01 7500 Falling or Flying Object 2 0.00 1,050.00 9700 Repetitive Motion (reported af 1 0.00 525.00 8100 Struck or Injured By, NOC 1 0.00 0.00 7903 Metal Item, NOC 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 7000 Striking Against/Stepping On, 1 0.00 525.00 6002 Bending 1 279.41 279.41 6800 Stationary Object 2 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 5800 Reaching 1 0.00 525.00 5800 Reaching 1 0.00 525.00 ALL OTHER CODES 4 0.00 2,100.00 ALL OTHER CODES 4 279.41 1,329.41 TOTAL OF CODES 29 1,191.68 14,516.68 TOTAL OF CODES 29 1,191.68 14,516.68

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 7 279.41 3,429.41 5200 Strain 7 279.41 3,429.41 1000 Contusion (Bruise, Skin Surfac 4 0.00 1,050.00 5999 Unclassified, Insufficient Dat 2 0.00 2,825.00 4000 Laceration 4 912.27 1,437.27 9000 Multiple Physical Injuries Onl 3 0.00 1,575.00 9000 Multiple Physical Injuries Onl 3 0.00 1,575.00 4000 Laceration 4 912.27 1,437.27 4300 Puncture 3 0.00 1,050.00 5900 All Other Injuries, NOC 2 0.00 1,050.00 5999 Unclassified, Insufficient Dat 2 0.00 2,825.00 4300 Puncture 3 0.00 1,050.00 5900 All Other Injuries, NOC 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 4 0.00 1,050.00 4900 Sprain 1 0.00 525.00 4900 Sprain 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 0402 Chemical Burn 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 0402 Chemical Burn 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 5 0.00 2,100.00 5100 Hip 1 0.00 2,300.00 3500 Hand 3 0.00 1,575.00 9000 Multiple Body Parts 5 0.00 2,100.00 1001 Head NEC 2 242.26 242.26 3500 Hand 3 0.00 1,575.00 1700 Mouth 2 0.00 1,050.00 3400 Wrist 2 0.00 1,050.00 3600 Finger(s) 2 670.01 670.01 1700 Mouth 2 0.00 1,050.00 4200 Low Back Area (Incl. Lumbar & 2 279.41 804.41 4200 Low Back Area (Incl. Lumbar & 2 279.41 804.41 3400 Wrist 2 0.00 1,050.00 3600 Finger(s) 2 670.01 670.01 3000 Multiple Upper Extremities 1 0.00 525.00 5500 Ankle 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 5400 Lower Leg 1 0.00 525.00 5100 Hip 1 0.00 2,300.00 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 3200 Elbow 1 0.00 525.00 1101 Scalp 1 0.00 525.00 3000 Multiple Upper Extremities 1 0.00 525.00 5500 Ankle 1 0.00 525.00 1500 Nose 1 0.00 525.00 ALL OTHER CODES 4 0.00 1,575.00 ALL OTHER CODES 5 242.26 1,292.26 TOTAL OF CODES 29 1,191.68 14,516.68 TOTAL OF CODES 29 1,191.68 14,516.68


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007573 TN WILDLIFE RESOURCES AGENCY - 32 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 45 UNIT 32800 TN WILDLIFE RESOURCES AGENCY (TWRA) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9902 Contact with Infectious Diseas 1 505.08 505.08 8500 Animal or Insect 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 8500 Animal or Insect 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 9902 Contact with Infectious Diseas 1 505.08 505.08


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 0100 No Physical Injury 1 505.08 505.08 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4000 Laceration 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 4000 Laceration 1 0.00 525.00 0100 No Physical Injury 1 505.08 505.08


----- PART/TARGET ----- ----- PART/TARGET ----- 6600 No Physical Injury 1 505.08 505.08 5600 Foot 1 0.00 525.00 5600 Foot 1 0.00 525.00 3500 Hand 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 3500 Hand 1 0.00 525.00 6600 No Physical Injury 1 505.08 505.08



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007573 TN WILDLIFE RESOURCES AGENCY - 32 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 46 UNIT 32801 WILDLIFE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9902 Contact with Infectious Diseas 7 3,535.56 3,535.56 9902 Contact with Infectious Diseas 7 3,535.56 3,535.56 3100 Fall, Slip or Trip, NOC 1 1,187.37 1,700.00 3100 Fall, Slip or Trip, NOC 1 1,187.37 1,700.00 4500 Collision with Another Vehicle 1 0.00 525.00 8500 Animal or Insect 1 934.97 934.97 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 4600 Collision with a Fixed Object 1 0.00 0.00 4500 Collision with Another Vehicle 1 0.00 525.00 8500 Animal or Insect 1 934.97 934.97 1901 Bitten 1 0.00 525.00 1901 Bitten 1 0.00 525.00 4600 Collision with a Fixed Object 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7300 Contagious Disease 7 3,535.56 3,535.56 7300 Contagious Disease 7 3,535.56 3,535.56 5200 Strain 3 1,187.37 2,750.00 5200 Strain 3 1,187.37 2,750.00 9000 Multiple Physical Injuries Onl 2 0.00 525.00 7120 All Other Occupational Disease 1 934.97 934.97 5900 All Other Injuries, NOC 1 0.00 525.00 9000 Multiple Physical Injuries Onl 2 0.00 525.00 4300 Puncture 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 7120 All Other Occupational Disease 1 934.97 934.97 4300 Puncture 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9100 Body Systems & Multiple Body S 8 4,470.53 4,470.53 9100 Body Systems & Multiple Body S 8 4,470.53 4,470.53 9000 Multiple Body Parts 3 0.00 1,050.00 3800 Shoulder(s) 2 1,187.37 2,225.00 3800 Shoulder(s) 2 1,187.37 2,225.00 9000 Multiple Body Parts 3 0.00 1,050.00 3301 ForeArm 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 3301 ForeArm 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007573 TN WILDLIFE RESOURCES AGENCY - 32 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 47 UNIT 32802 BOATING CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7602 Hoisting Apparatus 1 0.00 525.00 7602 Hoisting Apparatus 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 0.00 525.00 5200 Strain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 1 0.00 525.00 3400 Wrist 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007573 TN WILDLIFE RESOURCES AGENCY - 32 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 48 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9902 Contact with Infectious Diseas 8 4,040.64 4,040.64 9902 Contact with Infectious Diseas 8 4,040.64 4,040.64 8500 Animal or Insect 2 934.97 1,459.97 3100 Fall, Slip or Trip, NOC 1 1,187.37 1,700.00 3100 Fall, Slip or Trip, NOC 1 1,187.37 1,700.00 8500 Animal or Insect 2 934.97 1,459.97 4500 Collision with Another Vehicle 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 7602 Hoisting Apparatus 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 7602 Hoisting Apparatus 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 1901 Bitten 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 4600 Collision with a Fixed Object 1 0.00 0.00 1300 Caught In, Under or Between, N 1 0.00 525.00 1901 Bitten 1 0.00 525.00 4600 Collision with a Fixed Object 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7300 Contagious Disease 7 3,535.56 3,535.56 7300 Contagious Disease 7 3,535.56 3,535.56 5200 Strain 4 1,187.37 3,275.00 5200 Strain 4 1,187.37 3,275.00 9000 Multiple Physical Injuries Onl 3 0.00 1,050.00 9000 Multiple Physical Injuries Onl 3 0.00 1,050.00 5900 All Other Injuries, NOC 1 0.00 525.00 7120 All Other Occupational Disease 1 934.97 934.97 4300 Puncture 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 0100 No Physical Injury 1 505.08 505.08 4300 Puncture 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 4000 Laceration 1 0.00 525.00 4000 Laceration 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 7120 All Other Occupational Disease 1 934.97 934.97 0100 No Physical Injury 1 505.08 505.08


----- PART/TARGET ----- ----- PART/TARGET ----- 9100 Body Systems & Multiple Body S 8 4,470.53 4,470.53 9100 Body Systems & Multiple Body S 8 4,470.53 4,470.53 9000 Multiple Body Parts 3 0.00 1,050.00 3800 Shoulder(s) 2 1,187.37 2,225.00 3800 Shoulder(s) 2 1,187.37 2,225.00 9000 Multiple Body Parts 3 0.00 1,050.00 3301 ForeArm 1 0.00 525.00 5600 Foot 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 3400 Wrist 1 0.00 525.00 3500 Hand 1 0.00 525.00 6600 No Physical Injury 1 505.08 505.08 3400 Wrist 1 0.00 525.00 5600 Foot 1 0.00 525.00 3301 ForeArm 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 3500 Hand 1 0.00 525.00 6600 No Physical Injury 1 505.08 505.08



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 49 UNIT 32900 CORRECTIONS (TDOC} CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 4 1,957.90 32,509.44 5700 Pushing or Pulling 3 343.49 39,337.78 5300 Twisting 3 484.90 10,232.64 7400 Fellow Worker, Patient 4 1,957.90 32,509.44 1900 Cut, Punctured, Scraped, NOC 3 288.94 12,872.56 2700 Fall/Slip From Liquid/Grease S 1 5,373.95 21,061.46 5700 Pushing or Pulling 3 343.49 39,337.78 2900 Fall On the Same Level 2 4,510.00 15,064.40 1200 Object Handled 2 1,404.97 1,929.97 1900 Cut, Punctured, Scraped, NOC 3 288.94 12,872.56 2900 Fall On the Same Level 2 4,510.00 15,064.40 6000 Strain or Injury By, NOC 1 826.98 10,733.56 6002 Bending 2 1,248.06 3,948.06 5300 Twisting 3 484.90 10,232.64 9902 Contact with Infectious Diseas 2 0.00 1,050.00 9803 Stress 1 7.90 8,985.72 8500 Animal or Insect 1 582.24 582.24 6002 Bending 2 1,248.06 3,948.06 2700 Fall/Slip From Liquid/Grease S 1 5,373.95 21,061.46 1200 Object Handled 2 1,404.97 1,929.97 7900 Object Being Lifted or Handled 1 910.64 910.64 8100 Struck or Injured By, NOC 1 0.00 1,400.00 8107 Bodily Fluid, Blood, Saliva, E 1 128.63 128.63 9902 Contact with Infectious Diseas 2 0.00 1,050.00 6000 Strain or Injury By, NOC 1 826.98 10,733.56 7900 Object Being Lifted or Handled 1 910.64 910.64 9803 Stress 1 7.90 8,985.72 8500 Animal or Insect 1 582.24 582.24 ALL OTHER CODES 6 0.00 3,500.00 ALL OTHER CODES 6 128.63 2,228.63 TOTAL OF CODES 33 18,068.60 162,847.10 TOTAL OF CODES 33 18,068.60 162,847.10

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 14 7,518.80 86,586.20 5200 Strain 14 7,518.80 86,586.20 4000 Laceration 6 2,212.85 29,377.72 4000 Laceration 6 2,212.85 29,377.72 1000 Contusion (Bruise, Skin Surfac 3 5,373.95 21,586.46 1000 Contusion (Bruise, Skin Surfac 3 5,373.95 21,586.46 4900 Sprain 2 510.86 12,291.76 4900 Sprain 2 510.86 12,291.76 9000 Multiple Physical Injuries Onl 2 910.64 910.64 7700 Mental Stress 1 7.90 8,985.72 1300 Crushing 1 1,404.97 1,404.97 1300 Crushing 1 1,404.97 1,404.97 0100 No Physical Injury 1 128.63 128.63 9000 Multiple Physical Injuries Onl 2 910.64 910.64 7300 Contagious Disease 1 0.00 525.00 7300 Contagious Disease 1 0.00 525.00 7700 Mental Stress 1 7.90 8,985.72 5999 Unclassified, Insufficient Dat 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 0100 No Physical Injury 1 128.63 128.63


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 6 10,794.59 37,036.50 9000 Multiple Body Parts 6 10,794.59 37,036.50 3800 Shoulder(s) 4 440.96 35,088.32 3800 Shoulder(s) 4 440.96 35,088.32 3600 Finger(s) 3 1,404.97 2,454.97 1002 Face, Multiple Parts 1 1,341.67 15,397.92 4200 Low Back Area (Incl. Lumbar & 3 876.33 1,926.33 5300 Knee 3 856.63 13,654.37 5300 Knee 3 856.63 13,654.37 1000 Multiple Head Injury 1 288.94 11,822.56 3500 Hand 2 0.00 1,050.00 4100 Upper Back Area (Thoracic Area 1 7.90 11,788.80 3300 Lower Arm 2 0.00 1,050.00 5200 Upper Leg 1 826.98 10,733.56 5400 Lower Leg 1 582.24 582.24 3900 Wrist(s) and Hand(s) 1 7.90 10,119.22 3200 Elbow 1 502.96 502.96 9001 Stress 1 7.90 8,985.72 9100 Body Systems & Multiple Body S 1 128.63 128.63 3600 Finger(s) 3 1,404.97 2,454.97 1000 Multiple Head Injury 1 288.94 11,822.56 4200 Low Back Area (Incl. Lumbar & 3 876.33 1,926.33 1002 Face, Multiple Parts 1 1,341.67 15,397.92 3500 Hand 2 0.00 1,050.00 5200 Upper Leg 1 826.98 10,733.56 3300 Lower Arm 2 0.00 1,050.00 9001 Stress 1 7.90 8,985.72 5400 Lower Leg 1 582.24 582.24 ALL OTHER CODES 3 15.80 22,433.02 ALL OTHER CODES 3 631.59 1,156.59 TOTAL OF CODES 33 18,068.60 162,847.10 TOTAL OF CODES 33 18,068.60 162,847.10


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 50 UNIT 32901 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 3 7.90 8,599.92 7400 Fellow Worker, Patient 3 7.90 8,599.92 3300 Fall/Slip On Stairs 1 1,029.65 1,029.65 3300 Fall/Slip On Stairs 1 1,029.65 1,029.65 1300 Caught In, Under or Between, N 1 0.00 0.00 8200 Absorption, Ingestion, or Inha 1 0.00 525.00 0901 Liquids, NOC 1 0.00 525.00 8107 Bodily Fluid, Blood, Saliva, E 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 0.00 5600 Lifting 1 378.00 525.00 5600 Lifting 1 378.00 525.00 5300 Twisting 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 227.70 525.00 3100 Fall, Slip or Trip, NOC 1 227.70 525.00 8200 Absorption, Ingestion, or Inha 1 0.00 525.00 0901 Liquids, NOC 1 0.00 525.00 8107 Bodily Fluid, Blood, Saliva, E 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 0.00 5300 Twisting 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 3 1,407.65 1,554.65 4900 Sprain 2 7.90 8,074.92 1000 Contusion (Bruise, Skin Surfac 2 227.70 1,050.00 5200 Strain 3 1,407.65 1,554.65 4900 Sprain 2 7.90 8,074.92 1000 Contusion (Bruise, Skin Surfac 2 227.70 1,050.00 4000 Laceration 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 0400 Burn 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 3701 Conjunctivitis 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 0400 Burn 1 0.00 525.00 3701 Conjunctivitis 1 0.00 525.00 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 3 0.00 1,575.00 4200 Low Back Area (Incl. Lumbar & 1 7.90 7,549.92 5500 Ankle 1 1,029.65 1,029.65 9000 Multiple Body Parts 3 0.00 1,575.00 3600 Finger(s) 1 0.00 0.00 5500 Ankle 1 1,029.65 1,029.65 5200 Upper Leg 1 0.00 525.00 5200 Upper Leg 1 0.00 525.00 5600 Foot 1 0.00 0.00 4101 Back (All Other) 1 378.00 525.00 4101 Back (All Other) 1 378.00 525.00 3302 Arm, Multiple 1 0.00 525.00 1101 Scalp 1 227.70 525.00 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 1101 Scalp 1 227.70 525.00 3302 Arm, Multiple 1 0.00 525.00 5600 Foot 1 0.00 0.00 4200 Low Back Area (Incl. Lumbar & 1 7.90 7,549.92 3600 Finger(s) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 51 UNIT 32906 TENNESSEE CORRECTION ACADEMY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 139.78 139.78 3100 Fall, Slip or Trip, NOC 1 139.78 139.78


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 139.78 139.78 2800 Fracture 1 139.78 139.78


----- PART/TARGET ----- ----- PART/TARGET ----- 1500 Nose 1 139.78 139.78 1500 Nose 1 139.78 139.78



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 52 UNIT 32910 TENNESSEE STATE PRISON CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 7.90 7.90 3100 Fall, Slip or Trip, NOC 1 7.90 7.90







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 53 UNIT 32911 BRUSHY MOUNTAIN PENITENTIARY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 168.08 168.08 7400 Fellow Worker, Patient 1 168.08 168.08




----- PART/TARGET ----- ----- PART/TARGET ----- 4400 Chest (Incl. Ribs, Sternum & S 1 168.08 168.08 4400 Chest (Incl. Ribs, Sternum & S 1 168.08 168.08



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 54 UNIT 32913 PRISON FOR WOMEN (TPW) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 3 572.58 50,268.22 7400 Fellow Worker, Patient 3 572.58 50,268.22 3300 Fall/Slip On Stairs 2 6,545.10 29,100.61 3300 Fall/Slip On Stairs 2 6,545.10 29,100.61 8200 Absorption, Ingestion, or Inha 1 0.00 1,193.00 8200 Absorption, Ingestion, or Inha 1 0.00 1,193.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 0.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 3 564.68 35,597.38 5200 Strain 3 564.68 35,597.38 4900 Sprain 2 2,043.05 17,230.99 2800 Fracture 1 4,509.95 27,065.46 2800 Fracture 1 4,509.95 27,065.46 4900 Sprain 2 2,043.05 17,230.99 9000 Multiple Physical Injuries Onl 1 0.00 1,193.00 9000 Multiple Physical Injuries Onl 1 0.00 1,193.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 1300 Crushing 1 0.00 0.00 1300 Crushing 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 2 15.80 36,599.26 3800 Shoulder(s) 2 15.80 36,599.26 5600 Foot 1 4,509.95 27,065.46 5600 Foot 1 4,509.95 27,065.46 9100 Body Systems & Multiple Body S 1 0.00 1,193.00 2102 Cervical 1 556.78 13,668.96 5300 Knee 1 2,035.15 2,035.15 5300 Knee 1 2,035.15 2,035.15 5000 Multiple Lower Extremities 1 0.00 525.00 9100 Body Systems & Multiple Body S 1 0.00 1,193.00 2102 Cervical 1 556.78 13,668.96 9000 Multiple Body Parts 1 0.00 525.00 3600 Finger(s) 1 0.00 0.00 5000 Multiple Lower Extremities 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 3600 Finger(s) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 55 UNIT 32914 TURNEY CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8100 Struck or Injured By, NOC 1 0.00 525.00 9803 Stress 1 7.90 8,199.84 9803 Stress 1 7.90 8,199.84 3300 Fall/Slip On Stairs 1 1,487.68 1,487.68 3300 Fall/Slip On Stairs 1 1,487.68 1,487.68 8100 Struck or Injured By, NOC 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 0100 No Physical Injury 1 7.90 8,199.84 0100 No Physical Injury 1 7.90 8,199.84 5200 Strain 1 1,487.68 1,487.68 5200 Strain 1 1,487.68 1,487.68 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1400 Eye(s) 1 0.00 525.00 6600 No Physical Injury 1 7.90 8,199.84 6600 No Physical Injury 1 7.90 8,199.84 9000 Multiple Body Parts 1 1,487.68 1,487.68 9000 Multiple Body Parts 1 1,487.68 1,487.68 1400 Eye(s) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 56 UNIT 32916 MARK LUTTRELL CORRECTIONAL FAC. (MLRC) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 57 UNIT 32917 MIDDLE TN CORRECTIONAL COMPLEX (MTCX) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 2 1,053.09 3,220.81 3100 Fall, Slip or Trip, NOC 1 3,296.79 12,820.56 3100 Fall, Slip or Trip, NOC 1 3,296.79 12,820.56 6800 Stationary Object 2 1,053.09 3,220.81


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 3 4,349.88 16,041.37 1000 Contusion (Bruise, Skin Surfac 3 4,349.88 16,041.37


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 3,296.79 12,820.56 4200 Low Back Area (Incl. Lumbar & 1 3,296.79 12,820.56 5600 Foot 1 1,053.09 2,695.81 5600 Foot 1 1,053.09 2,695.81 5400 Lower Leg 1 0.00 525.00 5400 Lower Leg 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 58 UNIT 32919 MORGAN CNTY REGIONAL CORRECTION FACILIT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6001 Bodily Reaction 1 1,343.14 9,673.34 6001 Bodily Reaction 1 1,343.14 9,673.34


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 1,343.14 9,673.34 5200 Strain 1 1,343.14 9,673.34


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 1,343.14 9,673.34 5300 Knee 1 1,343.14 9,673.34



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 59 UNIT 32932 MAJOR MAINTENANCE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7900 Object Being Lifted or Handled 1 7.90 19,161.97 7900 Object Being Lifted or Handled 1 7.90 19,161.97 9900 Other Miscellaneous, NOC 1 0.00 0.00 9900 Other Miscellaneous, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 7.90 19,161.97 2800 Fracture 1 7.90 19,161.97 5999 Unclassified, Insufficient Dat 1 0.00 0.00 5999 Unclassified, Insufficient Dat 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3500 Hand 2 7.90 19,161.97 3500 Hand 2 7.90 19,161.97



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 60 UNIT 32941 WEST TENNESSEE STATE PENITENIARY (WTSP) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8107 Bodily Fluid, Blood, Saliva, E 2 791.08 791.08 7903 Metal Item, NOC 1 116.38 20,806.00 1902 Needle Stick 1 0.00 525.00 8107 Bodily Fluid, Blood, Saliva, E 2 791.08 791.08 7903 Metal Item, NOC 1 116.38 20,806.00 1902 Needle Stick 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 8000 All Other Cumulative Injuries, 1 791.08 791.08 4900 Sprain 1 116.38 20,806.00 0100 No Physical Injury 1 0.00 0.00 8000 All Other Cumulative Injuries, 1 791.08 791.08 4300 Puncture 1 0.00 525.00 4300 Puncture 1 0.00 525.00 4900 Sprain 1 116.38 20,806.00 0100 No Physical Injury 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1002 Face, Multiple Parts 2 791.08 791.08 3600 Finger(s) 1 116.38 20,806.00 3500 Hand 1 0.00 525.00 1002 Face, Multiple Parts 2 791.08 791.08 3600 Finger(s) 1 116.38 20,806.00 3500 Hand 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 61 UNIT 32942 RIVERBEND MAXIMUM SECURITY FAC. (RMSI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8107 Bodily Fluid, Blood, Saliva, E 6 7.90 13,623.58 8107 Bodily Fluid, Blood, Saliva, E 6 7.90 13,623.58 0901 Liquids, NOC 2 0.00 1,050.00 6000 Strain or Injury By, NOC 1 1,664.48 9,663.54 7400 Fellow Worker, Patient 2 0.00 1,050.00 7400 Fellow Worker, Patient 2 0.00 1,050.00 2900 Fall On the Same Level 1 0.00 0.00 0901 Liquids, NOC 2 0.00 1,050.00 6000 Strain or Injury By, NOC 1 1,664.48 9,663.54 6002 Bending 1 0.00 525.00 8700 Foreign Matter (Body) in Eye(s 1 183.10 183.10 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 8700 Foreign Matter (Body) in Eye(s 1 183.10 183.10 6001 Bodily Reaction 1 0.00 0.00 6001 Bodily Reaction 1 0.00 0.00 6002 Bending 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 0100 No Physical Injury 3 0.00 525.00 5200 Strain 2 1,664.48 9,663.54 1000 Contusion (Bruise, Skin Surfac 2 0.00 525.00 5999 Unclassified, Insufficient Dat 2 7.90 9,218.58 5999 Unclassified, Insufficient Dat 2 7.90 9,218.58 3600 Infection 1 0.00 2,650.00 5900 All Other Injuries, NOC 2 0.00 2,280.00 5900 All Other Injuries, NOC 2 0.00 2,280.00 5200 Strain 2 1,664.48 9,663.54 4000 Laceration 2 0.00 1,050.00 4000 Laceration 2 0.00 1,050.00 7300 Contagious Disease 1 0.00 525.00 3600 Infection 1 0.00 2,650.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 525.00 2500 Foreign Body (Eye) 1 183.10 183.10 0100 No Physical Injury 3 0.00 525.00 7300 Contagious Disease 1 0.00 525.00 2500 Foreign Body (Eye) 1 183.10 183.10


----- PART/TARGET ----- ----- PART/TARGET ----- 1002 Face, Multiple Parts 4 7.90 9,743.58 1002 Face, Multiple Parts 4 7.90 9,743.58 9000 Multiple Body Parts 3 0.00 2,280.00 5300 Knee 1 1,664.48 9,663.54 3301 ForeArm 2 0.00 1,050.00 9100 Body Systems & Multiple Body S 1 0.00 2,650.00 3500 Hand 1 0.00 0.00 9000 Multiple Body Parts 3 0.00 2,280.00 5300 Knee 1 1,664.48 9,663.54 3301 ForeArm 2 0.00 1,050.00 9100 Body Systems & Multiple Body S 1 0.00 2,650.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 1400 Eye(s) 1 183.10 183.10 3600 Finger(s) 1 0.00 525.00 4101 Back (All Other) 1 0.00 0.00 1400 Eye(s) 1 183.10 183.10 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4101 Back (All Other) 1 0.00 0.00 3600 Finger(s) 1 0.00 525.00 3500 Hand 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 62 UNIT 32945 NORTHWEST CORRECTIONAL CENTER (NWCC) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6004 Running and Training 1 526.34 11,446.44 6004 Running and Training 1 526.34 11,446.44 7900 Object Being Lifted or Handled 1 258.56 258.56 2900 Fall On the Same Level 1 1,217.92 1,217.92 2900 Fall On the Same Level 1 1,217.92 1,217.92 2500 Fall/Slip From a Different Lev 1 0.00 525.00 7400 Fellow Worker, Patient 1 128.63 128.63 7900 Object Being Lifted or Handled 1 258.56 258.56 2500 Fall/Slip From a Different Lev 1 0.00 525.00 7400 Fellow Worker, Patient 1 128.63 128.63


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 1,476.48 1,476.48 5200 Strain 1 526.34 11,446.44 5200 Strain 1 526.34 11,446.44 1000 Contusion (Bruise, Skin Surfac 2 1,476.48 1,476.48 4000 Laceration 1 128.63 128.63 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4000 Laceration 1 128.63 128.63


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 2 526.34 11,971.44 5300 Knee 2 526.34 11,971.44 3600 Finger(s) 1 258.56 258.56 3200 Elbow 1 1,217.92 1,217.92 3200 Elbow 1 1,217.92 1,217.92 3600 Finger(s) 1 258.56 258.56 1400 Eye(s) 1 128.63 128.63 1400 Eye(s) 1 128.63 128.63



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 63 UNIT 32946 LOIS DEBERRY SPECIAL NEEDS FACILITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 2 3,196.79 12,671.88 3000 Slipped, Did Not Fall 1 9,264.92 41,386.50 6000 Strain or Injury By, NOC 2 2,950.08 8,062.34 3101 Trip 1 6,599.88 16,645.66 2700 Fall/Slip From Liquid/Grease S 2 7.90 5,000.00 2900 Fall On the Same Level 1 5,527.17 14,304.84 8107 Bodily Fluid, Blood, Saliva, E 1 317.82 317.82 7400 Fellow Worker, Patient 2 3,196.79 12,671.88 3000 Slipped, Did Not Fall 1 9,264.92 41,386.50 6000 Strain or Injury By, NOC 2 2,950.08 8,062.34 0900 Contact With, NOC 1 0.00 0.00 2700 Fall/Slip From Liquid/Grease S 2 7.90 5,000.00 3101 Trip 1 6,599.88 16,645.66 5300 Twisting 1 0.00 2,300.00 2900 Fall On the Same Level 1 5,527.17 14,304.84 6004 Running and Training 1 0.00 525.00 9807 Heart Attack/Condition 1 7.90 7.90 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 8107 Bodily Fluid, Blood, Saliva, E 1 317.82 317.82 6004 Running and Training 1 0.00 525.00 8100 Struck or Injured By, NOC 1 227.28 227.28 8100 Struck or Injured By, NOC 1 227.28 227.28 9807 Heart Attack/Condition 1 7.90 7.90 5300 Twisting 1 0.00 2,300.00 0900 Contact With, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 3 6,599.88 17,170.66 4901 Meniscus Tear 1 9,264.92 41,386.50 1000 Contusion (Bruise, Skin Surfac 3 3,431.97 17,374.16 1000 Contusion (Bruise, Skin Surfac 3 3,431.97 17,374.16 5900 All Other Injuries, NOC 2 317.82 317.82 4900 Sprain 3 6,599.88 17,170.66 5200 Strain 2 2,950.08 10,362.34 2800 Fracture 1 5,527.17 14,304.84 4901 Meniscus Tear 1 9,264.92 41,386.50 5200 Strain 2 2,950.08 10,362.34 6800 Dermatitis 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 2800 Fracture 1 5,527.17 14,304.84 0700 Concussion (Brain, Cerebral) 1 0.00 525.00 7700 Mental Stress 1 7.90 7.90 5900 All Other Injuries, NOC 2 317.82 317.82 0700 Concussion (Brain, Cerebral) 1 0.00 525.00 7700 Mental Stress 1 7.90 7.90 9000 Multiple Physical Injuries Onl 1 0.00 525.00 6800 Dermatitis 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 4 9,272.82 48,686.50 5300 Knee 4 9,272.82 48,686.50 4400 Chest (Incl. Ribs, Sternum & S 2 7.90 7.90 5500 Ankle 2 9,549.96 24,708.00 5500 Ankle 2 9,549.96 24,708.00 5600 Foot 1 5,527.17 14,304.84 1002 Face, Multiple Parts 1 317.82 317.82 3200 Elbow 1 3,196.79 12,146.88 5600 Foot 1 5,527.17 14,304.84 9000 Multiple Body Parts 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 3200 Elbow 1 3,196.79 12,146.88 1001 Head NEC 1 0.00 525.00 3400 Wrist 1 0.00 0.00 1002 Face, Multiple Parts 1 317.82 317.82 1001 Head NEC 1 0.00 525.00 3600 Finger(s) 1 227.28 227.28 3600 Finger(s) 1 227.28 227.28 4400 Chest (Incl. Ribs, Sternum & S 2 7.90 7.90 9000 Multiple Body Parts 1 0.00 525.00 3400 Wrist 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 64 UNIT 32947 MORGAN COUNTY CORRECTIONAL COMPLEX CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 262.58 9,391.94 3100 Fall, Slip or Trip, NOC 1 262.58 9,391.94


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 262.58 9,391.94 1000 Contusion (Bruise, Skin Surfac 1 262.58 9,391.94


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 262.58 9,391.94 5300 Knee 1 262.58 9,391.94



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007574 DEPARTMENT OF CORRECTION - 32900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 65 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 16 6,031.88 105,396.17 7400 Fellow Worker, Patient 16 6,031.88 105,396.17 8107 Bodily Fluid, Blood, Saliva, E 11 1,245.43 15,386.11 3000 Slipped, Did Not Fall 1 9,264.92 41,386.50 2900 Fall On the Same Level 7 11,255.09 31,637.16 5700 Pushing or Pulling 3 343.49 39,337.78 3100 Fall, Slip or Trip, NOC 7 3,934.75 23,935.18 2900 Fall On the Same Level 7 11,255.09 31,637.16 5300 Twisting 5 484.90 13,057.64 3300 Fall/Slip On Stairs 4 9,062.43 31,617.94 6000 Strain or Injury By, NOC 5 5,441.54 28,459.44 6000 Strain or Injury By, NOC 5 5,441.54 28,459.44 3300 Fall/Slip On Stairs 4 9,062.43 31,617.94 2700 Fall/Slip From Liquid/Grease S 3 5,381.85 26,061.46 2700 Fall/Slip From Liquid/Grease S 3 5,381.85 26,061.46 3100 Fall, Slip or Trip, NOC 7 3,934.75 23,935.18 6002 Bending 3 1,248.06 4,473.06 7903 Metal Item, NOC 1 116.38 20,806.00 7900 Object Being Lifted or Handled 3 1,177.10 20,331.17 7900 Object Being Lifted or Handled 3 1,177.10 20,331.17 1900 Cut, Punctured, Scraped, NOC 3 288.94 12,872.56 9803 Stress 2 15.80 17,185.56 5700 Pushing or Pulling 3 343.49 39,337.78 3101 Trip 1 6,599.88 16,645.66 6800 Stationary Object 3 1,053.09 3,745.81 8107 Bodily Fluid, Blood, Saliva, E 11 1,245.43 15,386.11 8100 Struck or Injured By, NOC 3 227.28 2,152.28 5300 Twisting 5 484.90 13,057.64 ALL OTHER CODES 33 20,422.67 128,389.71 ALL OTHER CODES 40 7,243.06 55,609.70 TOTAL OF CODES 109 67,598.50 486,853.47 TOTAL OF CODES 109 67,598.50 486,853.47

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 27 17,462.85 166,371.57 5200 Strain 27 17,462.85 166,371.57 1000 Contusion (Bruise, Skin Surfac 19 15,290.64 68,663.49 4900 Sprain 10 9,278.07 75,574.33 4000 Laceration 10 2,341.48 30,556.35 1000 Contusion (Bruise, Skin Surfac 19 15,290.64 68,663.49 4900 Sprain 10 9,278.07 75,574.33 2800 Fracture 4 10,184.80 60,672.05 9000 Multiple Physical Injuries Onl 8 918.54 4,211.54 4901 Meniscus Tear 1 9,264.92 41,386.50 0100 No Physical Injury 6 136.53 8,853.47 4000 Laceration 10 2,341.48 30,556.35 5900 All Other Injuries, NOC 6 317.82 3,647.82 5999 Unclassified, Insufficient Dat 4 7.90 9,743.58 5999 Unclassified, Insufficient Dat 4 7.90 9,743.58 7700 Mental Stress 2 15.80 8,993.62 2800 Fracture 4 10,184.80 60,672.05 0100 No Physical Injury 6 136.53 8,853.47 1300 Crushing 2 1,404.97 1,404.97 9000 Multiple Physical Injuries Onl 8 918.54 4,211.54 7300 Contagious Disease 2 0.00 1,050.00 5900 All Other Injuries, NOC 6 317.82 3,647.82 7700 Mental Stress 2 15.80 8,993.62 3600 Infection 1 0.00 2,650.00 0400 Burn 1 0.00 525.00 1300 Crushing 2 1,404.97 1,404.97 3701 Conjunctivitis 1 0.00 525.00 7300 Contagious Disease 2 0.00 1,050.00 ALL OTHER CODES 7 10,239.10 46,060.68 ALL OTHER CODES 7 974.18 3,074.18 TOTAL OF CODES 109 67,598.50 486,853.47 TOTAL OF CODES 109 67,598.50 486,853.47

----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 17 12,290.17 43,962.08 5300 Knee 13 15,961.14 105,076.28 5300 Knee 13 15,961.14 105,076.28 3800 Shoulder(s) 6 456.76 71,687.58 3600 Finger(s) 9 2,007.19 24,271.81 5600 Foot 4 11,090.21 44,066.11 1002 Face, Multiple Parts 8 2,458.47 26,250.40 9000 Multiple Body Parts 17 12,290.17 43,962.08 4200 Low Back Area (Incl. Lumbar & 6 4,181.02 22,821.81 1002 Face, Multiple Parts 8 2,458.47 26,250.40 3500 Hand 6 7.90 20,736.97 5500 Ankle 3 10,579.61 25,737.65 3800 Shoulder(s) 6 456.76 71,687.58 3600 Finger(s) 9 2,007.19 24,271.81 1400 Eye(s) 5 311.73 1,886.73 4200 Low Back Area (Incl. Lumbar & 6 4,181.02 22,821.81 5600 Foot 4 11,090.21 44,066.11 3500 Hand 6 7.90 20,736.97 3200 Elbow 3 4,917.67 13,867.76 3200 Elbow 3 4,917.67 13,867.76 9100 Body Systems & Multiple Body S 3 128.63 3,971.63 2102 Cervical 1 556.78 13,668.96 5500 Ankle 3 10,579.61 25,737.65 1000 Multiple Head Injury 1 288.94 11,822.56 4400 Chest (Incl. Ribs, Sternum & S 3 175.98 175.98 4100 Upper Back Area (Thoracic Area 1 7.90 11,788.80 5400 Lower Leg 2 582.24 1,107.24 5200 Upper Leg 2 826.98 11,258.56 ALL OTHER CODES 21 2,449.78 81,233.44 ALL OTHER CODES 29 1,967.76 39,836.14 TOTAL OF CODES 109 67,598.50 486,853.47 TOTAL OF CODES 109 67,598.50 486,853.47


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 66 UNIT 33101 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 5200 Upper Leg 1 0.00 525.00 5200 Upper Leg 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 67 UNIT 33106 CURRICULUM & INSTRUCTION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 68 UNIT 33136 SPECIAL EDUCATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 35,769.22 2900 Fall On the Same Level 1 0.00 35,769.22


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 1 0.00 35,769.22 4900 Sprain 1 0.00 35,769.22


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 1 0.00 35,769.22 9000 Multiple Body Parts 1 0.00 35,769.22



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 69 UNIT 33190 ALVIN YORK INSTITUTE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 70 UNIT 33192 TENNESSEE SCHOOL FOR THE DEAF CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1600 Hand Tool, Utensil; Not Powere 1 508.59 508.59 1600 Hand Tool, Utensil; Not Powere 1 508.59 508.59




----- PART/TARGET ----- ----- PART/TARGET ----- 3500 Hand 1 508.59 508.59 3500 Hand 1 508.59 508.59



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007576 EDUCATION DEPARTMENT - 33100 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 71 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 2 0.00 36,294.22 2900 Fall On the Same Level 2 0.00 36,294.22 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 508.59 508.59 1600 Hand Tool, Utensil; Not Powere 1 508.59 508.59


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 2 0.00 36,294.22 4900 Sprain 2 0.00 36,294.22 3700 Inflammation 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 4000 Laceration 1 508.59 508.59 4000 Laceration 1 508.59 508.59


----- PART/TARGET ----- ----- PART/TARGET ----- 5200 Upper Leg 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 35,769.22 5600 Foot 1 0.00 525.00 5600 Foot 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 35,769.22 5500 Ankle 1 0.00 525.00 5500 Ankle 1 0.00 525.00 5200 Upper Leg 1 0.00 525.00 3500 Hand 1 508.59 508.59 3500 Hand 1 508.59 508.59



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 72 UNIT 33254 NASHVILLE STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 1 0.00 525.00 5600 Lifting 1 334.91 11,312.16 7500 Falling or Flying Object 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00 5600 Lifting 1 334.91 11,312.16 6800 Stationary Object 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 5200 Strain 1 334.91 11,312.16 4000 Laceration 1 0.00 525.00 4000 Laceration 1 0.00 525.00 5200 Strain 1 334.91 11,312.16 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1001 Head NEC 1 0.00 525.00 6300 Lumbar and/or Sacral Vertebrae 1 334.91 11,312.16 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 6300 Lumbar and/or Sacral Vertebrae 1 334.91 11,312.16 1001 Head NEC 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 73 UNIT 33255 PELLISSIPPI STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00 5500 Holding or Carrying 1 0.00 525.00 5500 Holding or Carrying 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4101 Back (All Other) 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 74 UNIT 33260 TENNESSEE BOARD OF REGENTS (TBR) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9700 Repetitive Motion (reported af 1 7.90 37,283.20 9700 Repetitive Motion (reported af 1 7.90 37,283.20


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7800 Carpal Tunnel Syndrome 1 7.90 37,283.20 7800 Carpal Tunnel Syndrome 1 7.90 37,283.20


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 1 7.90 37,283.20 3400 Wrist 1 7.90 37,283.20



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 75 UNIT 33270 AUSTIN PEAY STATE UNIVERSITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 2,255.90 29,969.36 6000 Strain or Injury By, NOC 1 2,255.90 29,969.36 2700 Fall/Slip From Liquid/Grease S 1 0.00 525.00 5700 Pushing or Pulling 1 567.28 2,250.00 5700 Pushing or Pulling 1 567.28 2,250.00 2700 Fall/Slip From Liquid/Grease S 1 0.00 525.00 1800 Powered Hand Tool, Appliance 1 0.00 525.00 1800 Powered Hand Tool, Appliance 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 1 2,255.90 29,969.36 4900 Sprain 1 2,255.90 29,969.36 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 567.28 2,250.00 5200 Strain 1 567.28 2,250.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4000 Laceration 1 0.00 525.00 4000 Laceration 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 2,255.90 29,969.36 5300 Knee 1 2,255.90 29,969.36 9000 Multiple Body Parts 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 567.28 2,250.00 4200 Low Back Area (Incl. Lumbar & 1 567.28 2,250.00 9000 Multiple Body Parts 1 0.00 525.00 5400 Lower Leg 1 0.00 525.00 5400 Lower Leg 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 76 UNIT 33272 EAST TENNESSEE STATE UNIVERSITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 2 7.90 5,525.00 6800 Stationary Object 2 7.90 5,525.00 2900 Fall On the Same Level 2 15.70 2,875.40 2900 Fall On the Same Level 2 15.70 2,875.40 7500 Falling or Flying Object 2 0.00 1,050.00 1902 Needle Stick 1 2,326.47 2,326.47 1900 Cut, Punctured, Scraped, NOC 1 7.90 7.90 7500 Falling or Flying Object 2 0.00 1,050.00 1300 Caught In, Under or Between, N 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 1200 Object Handled 1 39.20 525.00 5300 Twisting 1 317.16 525.00 1902 Needle Stick 1 2,326.47 2,326.47 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 1300 Caught In, Under or Between, N 1 0.00 525.00 5300 Twisting 1 317.16 525.00 1200 Object Handled 1 39.20 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 7.90 7.90


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4000 Laceration 5 62.80 3,933.30 4901 Meniscus Tear 1 7.90 5,000.00 5200 Strain 2 317.16 1,050.00 4000 Laceration 5 62.80 3,933.30 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 4300 Puncture 1 2,326.47 2,326.47 4300 Puncture 1 2,326.47 2,326.47 5200 Strain 2 317.16 1,050.00 4901 Meniscus Tear 1 7.90 5,000.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 0400 Burn 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 0400 Burn 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3600 Finger(s) 3 2,365.67 3,376.47 5300 Knee 2 7.90 5,525.00 5300 Knee 2 7.90 5,525.00 3600 Finger(s) 3 2,365.67 3,376.47 5400 Lower Leg 1 7.90 7.90 1900 Facial Bones 1 15.70 2,350.40 4100 Upper Back Area (Thoracic Area 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5500 Ankle 1 317.16 525.00 5500 Ankle 1 317.16 525.00 1001 Head NEC 1 0.00 525.00 4100 Upper Back Area (Thoracic Area 1 0.00 525.00 1900 Facial Bones 1 15.70 2,350.40 1400 Eye(s) 1 0.00 525.00 1101 Scalp 1 0.00 525.00 1101 Scalp 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 1001 Head NEC 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5400 Lower Leg 1 7.90 7.90



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 77 UNIT 33274 The University of Memphis CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 5 2,869.06 11,929.68 3100 Fall, Slip or Trip, NOC 5 2,869.06 11,929.68 8200 Absorption, Ingestion, or Inha 3 0.00 1,575.00 8200 Absorption, Ingestion, or Inha 3 0.00 1,575.00 8100 Struck or Injured By, NOC 2 0.00 1,050.00 8100 Struck or Injured By, NOC 2 0.00 1,050.00 1300 Caught In, Under or Between, N 1 283.44 283.44 7911 Wood Item, NOC 1 638.00 638.00 3000 Slipped, Did Not Fall 1 375.19 375.19 3101 Trip 1 0.00 525.00 7911 Wood Item, NOC 1 638.00 638.00 0200 Hot Object or Substances 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 0.00 3000 Slipped, Did Not Fall 1 375.19 375.19 0200 Hot Object or Substances 1 0.00 525.00 1300 Caught In, Under or Between, N 1 283.44 283.44 3101 Trip 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 3 283.44 1,333.44 4900 Sprain 3 2,334.85 10,870.47 4900 Sprain 3 2,334.85 10,870.47 6502 Inhalation 3 0.00 1,575.00 6502 Inhalation 3 0.00 1,575.00 1000 Contusion (Bruise, Skin Surfac 3 283.44 1,333.44 9000 Multiple Physical Injuries Onl 2 431.92 956.92 9000 Multiple Physical Injuries Onl 2 431.92 956.92 2800 Fracture 1 0.00 525.00 2500 Foreign Body (Eye) 1 638.00 638.00 2500 Foreign Body (Eye) 1 638.00 638.00 2800 Fracture 1 0.00 525.00 3700 Inflammation 1 0.00 0.00 0401 Burn or Scald (Heat) 1 0.00 525.00 5200 Strain 1 477.48 477.48 5200 Strain 1 477.48 477.48 0401 Burn or Scald (Heat) 1 0.00 525.00 3700 Inflammation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1400 Eye(s) 3 638.00 1,688.00 5300 Knee 2 606.82 9,142.44 9000 Multiple Body Parts 3 431.92 1,481.92 1400 Eye(s) 3 638.00 1,688.00 6600 No Physical Injury 3 0.00 1,575.00 6600 No Physical Injury 3 0.00 1,575.00 5300 Knee 2 606.82 9,142.44 9000 Multiple Body Parts 3 431.92 1,481.92 3600 Finger(s) 1 283.44 283.44 3400 Wrist 1 1,352.84 1,352.84 5500 Ankle 1 375.19 375.19 5600 Foot 1 0.00 525.00 5001 Leg, Multiple 1 477.48 477.48 5001 Leg, Multiple 1 477.48 477.48 3400 Wrist 1 1,352.84 1,352.84 5500 Ankle 1 375.19 375.19 5600 Foot 1 0.00 525.00 3600 Finger(s) 1 283.44 283.44



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 78 UNIT 33275 MIDDLE TENNESSEE STATE UNIVERSITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 3 1,265.44 3,327.31 3101 Trip 1 12.82 41,755.44 3100 Fall, Slip or Trip, NOC 2 555.08 2,105.00 2600 Fall/Slip From Ladder/Scaffold 1 8,994.60 37,808.29 2900 Fall On the Same Level 2 0.00 1,050.00 6000 Strain or Injury By, NOC 3 1,265.44 3,327.31 2600 Fall/Slip From Ladder/Scaffold 1 8,994.60 37,808.29 3100 Fall, Slip or Trip, NOC 2 555.08 2,105.00 5700 Pushing or Pulling 1 0.00 525.00 2900 Fall On the Same Level 2 0.00 1,050.00 3101 Trip 1 12.82 41,755.44 5700 Pushing or Pulling 1 0.00 525.00 8500 Animal or Insect 1 0.00 0.00 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 8500 Animal or Insect 1 0.00 0.00 7500 Falling or Flying Object 1 0.00 0.00 7500 Falling or Flying Object 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 5 1,820.52 5,432.31 2800 Fracture 2 9,007.42 79,563.73 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 5200 Strain 5 1,820.52 5,432.31 2800 Fracture 2 9,007.42 79,563.73 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4300 Puncture 1 0.00 0.00 3700 Inflammation 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 4300 Puncture 1 0.00 0.00 4000 Laceration 1 0.00 0.00 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 2 1,218.21 3,780.00 3600 Finger(s) 1 12.82 41,755.44 9000 Multiple Body Parts 2 0.00 1,050.00 5600 Foot 2 8,994.60 38,333.29 5600 Foot 2 8,994.60 38,333.29 4200 Low Back Area (Incl. Lumbar & 2 1,218.21 3,780.00 5300 Knee 2 0.00 1,050.00 9000 Multiple Body Parts 2 0.00 1,050.00 3900 Wrist(s) and Hand(s) 1 602.31 602.31 5300 Knee 2 0.00 1,050.00 3800 Shoulder(s) 1 0.00 525.00 3900 Wrist(s) and Hand(s) 1 602.31 602.31 3600 Finger(s) 1 12.82 41,755.44 3800 Shoulder(s) 1 0.00 525.00 5200 Upper Leg 1 0.00 0.00 5200 Upper Leg 1 0.00 0.00 1001 Head NEC 1 0.00 0.00 1001 Head NEC 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 79 UNIT 33277 TENNESSEE STATE UNIVERSITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 573.19 2,631.09 8100 Struck or Injured By, NOC 1 2,531.01 42,114.24 2900 Fall On the Same Level 1 1,091.26 1,091.26 3100 Fall, Slip or Trip, NOC 1 573.19 2,631.09 8100 Struck or Injured By, NOC 1 2,531.01 42,114.24 8901 Altercation 1 29.08 1,336.00 8901 Altercation 1 29.08 1,336.00 2900 Fall On the Same Level 1 1,091.26 1,091.26 1902 Needle Stick 1 0.00 0.00 1902 Needle Stick 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 1,091.26 1,091.26 9100 Multiple Injuries Including Bo 1 2,531.01 42,114.24 9000 Multiple Physical Injuries Onl 1 573.19 2,631.09 9000 Multiple Physical Injuries Onl 1 573.19 2,631.09 9100 Multiple Injuries Including Bo 1 2,531.01 42,114.24 1000 Contusion (Bruise, Skin Surfac 1 29.08 1,336.00 1000 Contusion (Bruise, Skin Surfac 1 29.08 1,336.00 5200 Strain 1 1,091.26 1,091.26 4300 Puncture 1 0.00 0.00 4300 Puncture 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 1 573.19 2,631.09 1002 Face, Multiple Parts 1 2,531.01 42,114.24 4200 Low Back Area (Incl. Lumbar & 1 1,091.26 1,091.26 9000 Multiple Body Parts 1 573.19 2,631.09 1002 Face, Multiple Parts 1 2,531.01 42,114.24 5300 Knee 1 29.08 1,336.00 5300 Knee 1 29.08 1,336.00 4200 Low Back Area (Incl. Lumbar & 1 1,091.26 1,091.26 3600 Finger(s) 1 0.00 0.00 3600 Finger(s) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 80 UNIT 33278 TENNESSEE TECHNOLOGICAL UNIVERSITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 1,269.06 1,269.06 6000 Strain or Injury By, NOC 1 1,269.06 1,269.06 7500 Falling or Flying Object 1 434.00 434.00 6003 Overexertion 1 0.00 525.00 6003 Overexertion 1 0.00 525.00 3101 Trip 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 3101 Trip 1 0.00 525.00 7500 Falling or Flying Object 1 434.00 434.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 1,269.06 1,794.06 5200 Strain 2 1,269.06 1,794.06 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 2800 Fracture 1 434.00 434.00 2800 Fracture 1 434.00 434.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5100 Hip 1 1,269.06 1,269.06 5100 Hip 1 1,269.06 1,269.06 5700 Toe(s) 1 434.00 434.00 9000 Multiple Body Parts 1 0.00 525.00 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 5000 Multiple Lower Extremities 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5700 Toe(s) 1 434.00 434.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 81 UNIT 33280 CHATANOOGA STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7900 Object Being Lifted or Handled 1 341.54 341.54 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 7900 Object Being Lifted or Handled 1 341.54 341.54


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 341.54 341.54 5999 Unclassified, Insufficient Dat 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 341.54 341.54


----- PART/TARGET ----- ----- PART/TARGET ----- 3600 Finger(s) 1 341.54 341.54 3200 Elbow 1 0.00 525.00 3200 Elbow 1 0.00 525.00 3600 Finger(s) 1 341.54 341.54



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 82 UNIT 33281 CLEVELAND STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 0.00 3300 Fall/Slip On Stairs 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 0.00 0.00 2800 Fracture 1 0.00 0.00





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 83 UNIT 33282 COLUMBIA STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 415.87 415.87 3100 Fall, Slip or Trip, NOC 1 415.87 415.87 5300 Twisting 1 87.77 87.77 5300 Twisting 1 87.77 87.77


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 415.87 415.87 1000 Contusion (Bruise, Skin Surfac 1 415.87 415.87 5200 Strain 1 87.77 87.77 5200 Strain 1 87.77 87.77


----- PART/TARGET ----- ----- PART/TARGET ----- 1002 Face, Multiple Parts 1 415.87 415.87 1002 Face, Multiple Parts 1 415.87 415.87 6300 Lumbar and/or Sacral Vertebrae 1 87.77 87.77 6300 Lumbar and/or Sacral Vertebrae 1 87.77 87.77



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 84 UNIT 33284 DYERSBURG STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 1 144.50 144.50 6800 Stationary Object 1 144.50 144.50 3100 Fall, Slip or Trip, NOC 1 0.00 0.00 6001 Bodily Reaction 1 0.00 0.00 6001 Bodily Reaction 1 0.00 0.00 3100 Fall, Slip or Trip, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5900 All Other Injuries, NOC 2 144.50 144.50 5900 All Other Injuries, NOC 2 144.50 144.50 9000 Multiple Physical Injuries Onl 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 1800 Other facial soft tissue 1 144.50 144.50 1800 Other facial soft tissue 1 144.50 144.50 9000 Multiple Body Parts 1 0.00 0.00 9100 Body Systems & Multiple Body S 1 0.00 0.00 9100 Body Systems & Multiple Body S 1 0.00 0.00 9000 Multiple Body Parts 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 85 UNIT 33286 JACKSON STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 314.19 7,161.90 2900 Fall On the Same Level 1 1,160.53 9,404.12 3000 Slipped, Did Not Fall 1 0.00 1,650.00 3300 Fall/Slip On Stairs 1 314.19 7,161.90 2900 Fall On the Same Level 1 1,160.53 9,404.12 3000 Slipped, Did Not Fall 1 0.00 1,650.00 5600 Lifting 1 0.00 0.00 5600 Lifting 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 1,474.72 16,566.02 1000 Contusion (Bruise, Skin Surfac 2 1,474.72 16,566.02 3700 Inflammation 1 0.00 1,650.00 3700 Inflammation 1 0.00 1,650.00 4600 Rupture 1 0.00 0.00 4600 Rupture 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 3 1,474.72 18,216.02 5300 Knee 3 1,474.72 18,216.02 3700 Thumb 1 0.00 0.00 3700 Thumb 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 86 UNIT 33288 MOTLOW STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 87 UNIT 33294 VOLUNTEER STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3200 Elbow 1 0.00 525.00 3200 Elbow 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 88 UNIT 33296 WALTERS STATE COMMUNITY COLLEGE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2700 Fall/Slip From Liquid/Grease S 1 78.88 78.88 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 2700 Fall/Slip From Liquid/Grease S 1 78.88 78.88


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 78.88 78.88 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 2800 Fracture 1 78.88 78.88


----- PART/TARGET ----- ----- PART/TARGET ----- 5600 Foot 1 78.88 78.88 9000 Multiple Body Parts 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5600 Foot 1 78.88 78.88



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007577 BOARD OF REGENTS (TBR) LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 89 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 11 4,413.20 17,606.64 8100 Struck or Injured By, NOC 3 2,531.01 43,164.24 2900 Fall On the Same Level 9 2,267.49 15,470.78 3101 Trip 3 12.82 42,805.44 6000 Strain or Injury By, NOC 6 4,790.40 35,090.73 2600 Fall/Slip From Ladder/Scaffold 1 8,994.60 37,808.29 7500 Falling or Flying Object 5 434.00 2,009.00 9700 Repetitive Motion (reported af 1 7.90 37,283.20 6800 Stationary Object 4 152.40 6,194.50 6000 Strain or Injury By, NOC 6 4,790.40 35,090.73 5700 Pushing or Pulling 3 567.28 3,300.00 3100 Fall, Slip or Trip, NOC 11 4,413.20 17,606.64 1900 Cut, Punctured, Scraped, NOC 3 7.90 1,057.90 2900 Fall On the Same Level 9 2,267.49 15,470.78 8100 Struck or Injured By, NOC 3 2,531.01 43,164.24 5600 Lifting 2 334.91 11,312.16 8200 Absorption, Ingestion, or Inha 3 0.00 1,575.00 3300 Fall/Slip On Stairs 3 314.19 7,686.90 3101 Trip 3 12.82 42,805.44 6800 Stationary Object 4 152.40 6,194.50 3300 Fall/Slip On Stairs 3 314.19 7,686.90 5700 Pushing or Pulling 3 567.28 3,300.00 5600 Lifting 2 334.91 11,312.16 1902 Needle Stick 2 2,326.47 2,326.47 2700 Fall/Slip From Liquid/Grease S 2 78.88 603.88 3000 Slipped, Did Not Fall 2 375.19 2,025.19 1300 Caught In, Under or Between, N 2 283.44 808.44 7500 Falling or Flying Object 5 434.00 2,009.00 ALL OTHER CODES 19 13,156.91 85,521.46 ALL OTHER CODES 23 1,822.97 10,123.53 TOTAL OF CODES 78 29,344.83 274,207.07 TOTAL OF CODES 78 29,344.83 274,207.07

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 16 5,965.44 24,545.04 2800 Fracture 6 9,520.30 80,601.61 1000 Contusion (Bruise, Skin Surfac 12 2,544.65 22,092.87 9100 Multiple Injuries Including Bo 1 2,531.01 42,114.24 4000 Laceration 10 62.80 6,033.30 4900 Sprain 4 4,590.75 40,839.83 9000 Multiple Physical Injuries Onl 7 1,005.11 5,163.01 7800 Carpal Tunnel Syndrome 1 7.90 37,283.20 2800 Fracture 6 9,520.30 80,601.61 5200 Strain 16 5,965.44 24,545.04 4900 Sprain 4 4,590.75 40,839.83 1000 Contusion (Bruise, Skin Surfac 12 2,544.65 22,092.87 5999 Unclassified, Insufficient Dat 4 0.00 2,100.00 4000 Laceration 10 62.80 6,033.30 4300 Puncture 3 2,326.47 2,326.47 9000 Multiple Physical Injuries Onl 7 1,005.11 5,163.01 3700 Inflammation 3 0.00 2,175.00 4901 Meniscus Tear 1 7.90 5,000.00 6502 Inhalation 3 0.00 1,575.00 4300 Puncture 3 2,326.47 2,326.47 2500 Foreign Body (Eye) 2 638.00 1,163.00 3700 Inflammation 3 0.00 2,175.00 5900 All Other Injuries, NOC 2 144.50 144.50 5999 Unclassified, Insufficient Dat 4 0.00 2,100.00 7800 Carpal Tunnel Syndrome 1 7.90 37,283.20 6502 Inhalation 3 0.00 1,575.00 4901 Meniscus Tear 1 7.90 5,000.00 2500 Foreign Body (Eye) 2 638.00 1,163.00 ALL OTHER CODES 4 2,531.01 43,164.24 ALL OTHER CODES 5 144.50 1,194.50 TOTAL OF CODES 78 29,344.83 274,207.07 TOTAL OF CODES 78 29,344.83 274,207.07

----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 12 4,374.42 65,763.82 5300 Knee 12 4,374.42 65,763.82 9000 Multiple Body Parts 11 1,005.11 7,263.01 3600 Finger(s) 9 3,003.47 46,281.89 3600 Finger(s) 9 3,003.47 46,281.89 1002 Face, Multiple Parts 2 2,946.88 42,530.11 1400 Eye(s) 5 638.00 2,738.00 5600 Foot 4 9,073.48 38,937.17 4200 Low Back Area (Incl. Lumbar & 5 2,876.75 7,646.26 3400 Wrist 2 1,360.74 38,636.04 5600 Foot 4 9,073.48 38,937.17 6300 Lumbar and/or Sacral Vertebrae 2 422.68 11,399.93 1001 Head NEC 3 0.00 1,050.00 4200 Low Back Area (Incl. Lumbar & 5 2,876.75 7,646.26 6600 No Physical Injury 3 0.00 1,575.00 9000 Multiple Body Parts 11 1,005.11 7,263.01 6300 Lumbar and/or Sacral Vertebrae 2 422.68 11,399.93 1400 Eye(s) 5 638.00 2,738.00 3400 Wrist 2 1,360.74 38,636.04 1900 Facial Bones 1 15.70 2,350.40 5400 Lower Leg 2 7.90 532.90 6600 No Physical Injury 3 0.00 1,575.00 5500 Ankle 2 692.35 900.19 5100 Hip 1 1,269.06 1,269.06 1002 Face, Multiple Parts 2 2,946.88 42,530.11 3200 Elbow 2 0.00 1,050.00 3200 Elbow 2 0.00 1,050.00 1001 Head NEC 3 0.00 1,050.00 ALL OTHER CODES 14 2,943.05 7,902.75 ALL OTHER CODES 16 2,358.54 5,716.38 TOTAL OF CODES 78 29,344.83 274,207.07 TOTAL OF CODES 78 29,344.83 274,207.07


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007579 COMMERCE AND INSURANCE DEPARTMENT LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 90 UNIT 33503 FIRE PREVENTION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 60.90 60.90 3100 Fall, Slip or Trip, NOC 1 367.86 3,550.00 3100 Fall, Slip or Trip, NOC 1 367.86 3,550.00 2900 Fall On the Same Level 1 60.90 60.90


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 2 428.76 3,610.90 4900 Sprain 2 428.76 3,610.90


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 1 60.90 60.90 3800 Shoulder(s) 1 367.86 3,550.00 3800 Shoulder(s) 1 367.86 3,550.00 3400 Wrist 1 60.90 60.90



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007579 COMMERCE AND INSURANCE DEPARTMENT LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 91 UNIT 33510 REGULATORY BOARDS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4101 Back (All Other) 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007579 COMMERCE AND INSURANCE DEPARTMENT LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 92 UNIT 33511 TN LAW ENFORCEMENT TRAINING CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6004 Running and Training 1 2,350.65 2,650.65 6004 Running and Training 1 2,350.65 2,650.65


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 1 2,350.65 2,650.65 4900 Sprain 1 2,350.65 2,650.65


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 2,350.65 2,650.65 5300 Knee 1 2,350.65 2,650.65



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007579 COMMERCE AND INSURANCE DEPARTMENT LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 93 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 2 367.86 4,075.00 3100 Fall, Slip or Trip, NOC 2 367.86 4,075.00 2900 Fall On the Same Level 1 60.90 60.90 6004 Running and Training 1 2,350.65 2,650.65 6004 Running and Training 1 2,350.65 2,650.65 2900 Fall On the Same Level 1 60.90 60.90


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4900 Sprain 3 2,779.41 6,261.55 4900 Sprain 3 2,779.41 6,261.55 5200 Strain 1 0.00 525.00 5200 Strain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 1 60.90 60.90 3800 Shoulder(s) 1 367.86 3,550.00 3800 Shoulder(s) 1 367.86 3,550.00 5300 Knee 1 2,350.65 2,650.65 4101 Back (All Other) 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00 5300 Knee 1 2,350.65 2,650.65 3400 Wrist 1 60.90 60.90



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007581 LABOR AND WORK FORCE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 94 UNIT 33700 LABOR & WORKFORCE (DEPT OF LABOR, DLWFD CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9700 Repetitive Motion (reported af 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 3,052.27 13,087.38 1900 Cut, Punctured, Scraped, NOC 1 0.00 0.00 3101 Trip 1 608.83 2,450.00 3100 Fall, Slip or Trip, NOC 1 3,052.27 13,087.38 9700 Repetitive Motion (reported af 1 0.00 525.00 3101 Trip 1 608.83 2,450.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 3,052.27 13,087.38 4000 Laceration 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 608.83 2,450.00 9000 Multiple Physical Injuries Onl 1 3,052.27 13,087.38 5200 Strain 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 608.83 2,450.00 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3000 Multiple Upper Extremities 1 0.00 525.00 9000 Multiple Body Parts 1 3,052.27 13,087.38 3300 Lower Arm 1 0.00 0.00 3302 Arm, Multiple 1 608.83 2,450.00 9000 Multiple Body Parts 1 3,052.27 13,087.38 3000 Multiple Upper Extremities 1 0.00 525.00 3302 Arm, Multiple 1 608.83 2,450.00 3300 Lower Arm 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007581 LABOR AND WORK FORCE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 95 UNIT 33710 EMPLOYMENT SECURITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9900 Other Miscellaneous, NOC 1 0.00 525.00 9900 Other Miscellaneous, NOC 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 0.00 525.00 5200 Strain 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3200 Elbow 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00 3200 Elbow 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007581 LABOR AND WORK FORCE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 96 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9700 Repetitive Motion (reported af 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 3,052.27 13,087.38 1900 Cut, Punctured, Scraped, NOC 1 0.00 0.00 3101 Trip 1 608.83 2,450.00 3100 Fall, Slip or Trip, NOC 1 3,052.27 13,087.38 9900 Other Miscellaneous, NOC 1 0.00 525.00 3101 Trip 1 608.83 2,450.00 9700 Repetitive Motion (reported af 1 0.00 525.00 9900 Other Miscellaneous, NOC 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 1 3,052.27 13,087.38 1000 Contusion (Bruise, Skin Surfac 2 608.83 2,975.00 1000 Contusion (Bruise, Skin Surfac 2 608.83 2,975.00 4000 Laceration 1 0.00 0.00 5200 Strain 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 1 3,052.27 13,087.38 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3000 Multiple Upper Extremities 1 0.00 525.00 9000 Multiple Body Parts 1 3,052.27 13,087.38 3300 Lower Arm 1 0.00 0.00 3302 Arm, Multiple 1 608.83 2,450.00 9000 Multiple Body Parts 1 3,052.27 13,087.38 4101 Back (All Other) 1 0.00 525.00 3302 Arm, Multiple 1 608.83 2,450.00 3200 Elbow 1 0.00 525.00 3200 Elbow 1 0.00 525.00 3000 Multiple Upper Extremities 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00 3300 Lower Arm 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 97 UNIT 33900 MENTAL HEALTH (MH) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 2 0.00 1,425.00 7400 Fellow Worker, Patient 2 0.00 1,425.00 7500 Falling or Flying Object 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,425.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,425.00 5200 Strain 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 1 0.00 525.00 1002 Face, Multiple Parts 1 0.00 900.00 1002 Face, Multiple Parts 1 0.00 900.00 5300 Knee 1 0.00 525.00 1001 Head NEC 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 5300 Knee 1 0.00 525.00 1001 Head NEC 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 98 UNIT 33905 MENTAL HEALTH SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 1000 Multiple Head Injury 1 0.00 525.00 1000 Multiple Head Injury 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 99 UNIT 33908 COMMUNITY MENTAL HEALTH SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 6300 Lumbar and/or Sacral Vertebrae 1 0.00 525.00 6300 Lumbar and/or Sacral Vertebrae 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 100 UNIT 33910 LAKESHORE MENTAL HEALTH INSTITUTE (LMHI CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 0.00 525.00 5200 Strain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9100 Body Systems & Multiple Body S 1 0.00 525.00 9100 Body Systems & Multiple Body S 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 101 UNIT 33911 MIDDLE TENNESS MENTAL HEALTH (MTMHI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 19 16,189.38 96,398.60 5600 Lifting 4 20,728.39 131,370.89 8100 Struck or Injured By, NOC 6 1,145.63 48,492.92 7400 Fellow Worker, Patient 19 16,189.38 96,398.60 5600 Lifting 4 20,728.39 131,370.89 8100 Struck or Injured By, NOC 6 1,145.63 48,492.92 8500 Animal or Insect 3 0.00 1,050.00 6003 Overexertion 1 7.90 13,588.16 6000 Strain or Injury By, NOC 3 423.95 11,201.25 5300 Twisting 1 1,082.78 12,878.08 5700 Pushing or Pulling 3 0.00 2,950.00 6001 Bodily Reaction 1 622.45 11,220.96 2900 Fall On the Same Level 2 677.97 11,083.44 6000 Strain or Injury By, NOC 3 423.95 11,201.25 7900 Object Being Lifted or Handled 1 262.09 262.09 2900 Fall On the Same Level 2 677.97 11,083.44 5300 Twisting 1 1,082.78 12,878.08 5700 Pushing or Pulling 3 0.00 2,950.00 1300 Caught In, Under or Between, N 1 0.00 525.00 8500 Animal or Insect 3 0.00 1,050.00 6001 Bodily Reaction 1 622.45 11,220.96 8700 Foreign Matter (Body) in Eye(s 1 0.00 525.00 9902 Contact with Infectious Diseas 1 0.00 0.00 3300 Fall/Slip On Stairs 1 0.00 525.00 6003 Overexertion 1 7.90 13,588.16 1300 Caught In, Under or Between, N 1 0.00 525.00 8700 Foreign Matter (Body) in Eye(s 1 0.00 525.00 7900 Object Being Lifted or Handled 1 262.09 262.09 ALL OTHER CODES 1 0.00 525.00 ALL OTHER CODES 1 0.00 0.00 TOTAL OF CODES 48 41,140.54 342,071.39 TOTAL OF CODES 48 41,140.54 342,071.39

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 13 6,052.82 68,713.07 1601 Herniated Disc 1 17,048.45 106,536.20 9000 Multiple Physical Injuries Onl 12 4,154.37 41,681.76 5200 Strain 9 9,066.48 94,636.49 5200 Strain 9 9,066.48 94,636.49 1000 Contusion (Bruise, Skin Surfac 13 6,052.82 68,713.07 4900 Sprain 6 1,657.10 25,242.55 9000 Multiple Physical Injuries Onl 12 4,154.37 41,681.76 5900 All Other Injuries, NOC 2 0.00 525.00 4900 Sprain 6 1,657.10 25,242.55 4300 Puncture 2 0.00 1,050.00 2800 Fracture 1 3,161.32 3,161.32 1601 Herniated Disc 1 17,048.45 106,536.20 4300 Puncture 2 0.00 1,050.00 2800 Fracture 1 3,161.32 3,161.32 5900 All Other Injuries, NOC 2 0.00 525.00 3700 Inflammation 1 0.00 0.00 3701 Conjunctivitis 1 0.00 525.00 3701 Conjunctivitis 1 0.00 525.00 3700 Inflammation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 10 3,748.39 60,988.35 6300 Lumbar and/or Sacral Vertebrae 1 17,048.45 106,536.20 4200 Low Back Area (Incl. Lumbar & 5 2,462.12 37,070.18 9000 Multiple Body Parts 10 3,748.39 60,988.35 1002 Face, Multiple Parts 4 2,242.46 2,767.46 4200 Low Back Area (Incl. Lumbar & 5 2,462.12 37,070.18 2102 Cervical 3 4,540.06 35,482.54 2102 Cervical 3 4,540.06 35,482.54 5500 Ankle 2 416.05 416.05 4400 Chest (Incl. Ribs, Sternum & S 1 507.55 21,804.00 3100 Upper Arm (Incl. Clavicle & Sc 2 262.09 262.09 3800 Shoulder(s) 2 7.90 15,488.16 1001 Head NEC 2 0.00 1,050.00 5300 Knee 1 7.90 13,431.64 3302 Arm, Multiple 2 0.00 1,050.00 4101 Back (All Other) 1 2,990.38 11,123.43 3800 Shoulder(s) 2 7.90 15,488.16 5100 Hip 1 677.97 11,083.44 4400 Chest (Incl. Ribs, Sternum & S 1 507.55 21,804.00 5700 Toe(s) 1 1,165.33 8,520.90 4100 Upper Back Area (Thoracic Area 1 548.26 548.26 3500 Hand 1 1,354.31 7,612.37 5700 Toe(s) 1 1,165.33 8,520.90 1500 Nose 1 3,161.32 3,161.32 6300 Lumbar and/or Sacral Vertebrae 1 17,048.45 106,536.20 1002 Face, Multiple Parts 4 2,242.46 2,767.46 1500 Nose 1 3,161.32 3,161.32 3302 Arm, Multiple 2 0.00 1,050.00 ALL OTHER CODES 11 5,030.56 46,925.88 ALL OTHER CODES 14 1,226.40 5,951.40 TOTAL OF CODES 48 41,140.54 342,071.39 TOTAL OF CODES 48 41,140.54 342,071.39


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 102 UNIT 33912 WESTERN MENTAL HEALTH INSTITUTE (WMHI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 6 0.00 13,823.52 7400 Fellow Worker, Patient 6 0.00 13,823.52 6000 Strain or Injury By, NOC 2 0.00 1,050.00 5500 Holding or Carrying 1 7.90 13,590.72 5500 Holding or Carrying 1 7.90 13,590.72 8100 Struck or Injured By, NOC 1 2,200.90 12,895.20 2700 Fall/Slip From Liquid/Grease S 1 1,678.87 2,900.00 2700 Fall/Slip From Liquid/Grease S 1 1,678.87 2,900.00 8100 Struck or Injured By, NOC 1 2,200.90 12,895.20 6000 Strain or Injury By, NOC 2 0.00 1,050.00 1902 Needle Stick 1 1,014.69 1,014.69 1902 Needle Stick 1 1,014.69 1,014.69 2900 Fall On the Same Level 1 352.30 352.30 5600 Lifting 1 435.91 435.91 5600 Lifting 1 435.91 435.91 2900 Fall On the Same Level 1 352.30 352.30


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 4 4,232.07 27,871.02 1000 Contusion (Bruise, Skin Surfac 4 4,232.07 27,871.02 5200 Strain 4 443.81 15,076.63 5200 Strain 4 443.81 15,076.63 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 4300 Puncture 2 1,014.69 1,539.69 4300 Puncture 2 1,014.69 1,539.69 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 3700 Inflammation 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 1600 Dislocation 1 0.00 0.00 1600 Dislocation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 4 3,879.77 16,845.20 9000 Multiple Body Parts 4 3,879.77 16,845.20 4200 Low Back Area (Incl. Lumbar & 3 435.91 1,485.91 3800 Shoulder(s) 2 360.20 13,943.02 3600 Finger(s) 2 1,014.69 1,014.69 1400 Eye(s) 1 0.00 11,723.52 3800 Shoulder(s) 2 360.20 13,943.02 4200 Low Back Area (Incl. Lumbar & 3 435.91 1,485.91 3000 Multiple Upper Extremities 1 0.00 525.00 3600 Finger(s) 2 1,014.69 1,014.69 1400 Eye(s) 1 0.00 11,723.52 3400 Wrist 1 0.00 525.00 3400 Wrist 1 0.00 525.00 3000 Multiple Upper Extremities 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 103 UNIT 33916 MOCCASIN BEND MENTAL HEALTH (MBMHI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 7 5,221.83 27,876.93 5600 Lifting 3 3,580.11 69,069.71 5600 Lifting 3 3,580.11 69,069.71 7400 Fellow Worker, Patient 7 5,221.83 27,876.93 1900 Cut, Punctured, Scraped, NOC 1 73.09 525.00 6003 Overexertion 1 0.00 26,731.76 7900 Object Being Lifted or Handled 1 0.00 0.00 5800 Reaching 1 471.32 11,400.00 6000 Strain or Injury By, NOC 1 363.57 363.57 8000 Object Handled By Others 1 282.19 8,740.50 8100 Struck or Injured By, NOC 1 1,435.85 7,684.60 8100 Struck or Injured By, NOC 1 1,435.85 7,684.60 5300 Twisting 1 419.89 419.89 8500 Animal or Insect 1 0.00 525.00 8000 Object Handled By Others 1 282.19 8,740.50 1900 Cut, Punctured, Scraped, NOC 1 73.09 525.00 5800 Reaching 1 471.32 11,400.00 1202 Furniture 1 0.00 525.00 6003 Overexertion 1 0.00 26,731.76 5300 Twisting 1 419.89 419.89 1202 Furniture 1 0.00 525.00 6000 Strain or Injury By, NOC 1 363.57 363.57 8500 Animal or Insect 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 8 4,515.98 75,926.04 5200 Strain 8 4,515.98 75,926.04 1000 Contusion (Bruise, Skin Surfac 3 2,308.15 15,479.86 2800 Fracture 1 2,900.34 32,247.08 4000 Laceration 2 73.09 525.00 1000 Contusion (Bruise, Skin Surfac 3 2,308.15 15,479.86 5900 All Other Injuries, NOC 2 493.38 11,422.06 5900 All Other Injuries, NOC 2 493.38 11,422.06 4900 Sprain 1 1,435.85 7,684.60 4901 Meniscus Tear 1 121.06 9,527.32 4901 Meniscus Tear 1 121.06 9,527.32 4900 Sprain 1 1,435.85 7,684.60 2800 Fracture 1 2,900.34 32,247.08 4300 Puncture 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 4000 Laceration 2 73.09 525.00 4300 Puncture 1 0.00 525.00 3700 Inflammation 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 4 3,416.32 11,951.76 3800 Shoulder(s) 3 3,371.66 70,378.84 5300 Knee 3 781.83 11,474.95 4600 Pelvis 1 19.00 35,400.00 3800 Shoulder(s) 3 3,371.66 70,378.84 9000 Multiple Body Parts 4 3,416.32 11,951.76 5600 Foot 2 0.00 525.00 5300 Knee 3 781.83 11,474.95 5400 Lower Leg 2 22.06 547.06 3100 Upper Arm (Incl. Clavicle & Sc 1 282.19 8,740.50 3700 Thumb 1 73.09 525.00 5500 Ankle 1 1,435.85 7,684.60 4600 Pelvis 1 19.00 35,400.00 1400 Eye(s) 1 2,025.96 6,214.36 1400 Eye(s) 1 2,025.96 6,214.36 5400 Lower Leg 2 22.06 547.06 5500 Ankle 1 1,435.85 7,684.60 5600 Foot 2 0.00 525.00 3400 Wrist 1 419.89 419.89 3700 Thumb 1 73.09 525.00 3100 Upper Arm (Incl. Clavicle & Sc 1 282.19 8,740.50 3400 Wrist 1 419.89 419.89



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 104 UNIT 33917 MEMPHIS MENTAL HEALTH INSTITUTE (MMHI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 5 3,783.60 41,149.88 7400 Fellow Worker, Patient 5 3,783.60 41,149.88 1901 Bitten 2 457.04 457.04 6001 Bodily Reaction 1 119.91 30,744.64 8100 Struck or Injured By, NOC 1 699.13 19,768.96 8100 Struck or Injured By, NOC 1 699.13 19,768.96 2900 Fall On the Same Level 1 1,216.92 13,223.32 8901 Altercation 1 7.90 13,548.12 2500 Fall/Slip From a Different Lev 1 280.91 1,525.00 2900 Fall On the Same Level 1 1,216.92 13,223.32 5700 Pushing or Pulling 1 684.48 684.48 2500 Fall/Slip From a Different Lev 1 280.91 1,525.00 8901 Altercation 1 7.90 13,548.12 5700 Pushing or Pulling 1 684.48 684.48 2700 Fall/Slip From Liquid/Grease S 1 27.95 27.95 1901 Bitten 2 457.04 457.04 6001 Bodily Reaction 1 119.91 30,744.64 2700 Fall/Slip From Liquid/Grease S 1 27.95 27.95


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 6 1,789.05 29,406.43 5200 Strain 3 1,971.56 41,675.62 5200 Strain 3 1,971.56 41,675.62 9000 Multiple Physical Injuries Onl 2 1,368.09 40,269.04 9000 Multiple Physical Injuries Onl 2 1,368.09 40,269.04 1000 Contusion (Bruise, Skin Surfac 6 1,789.05 29,406.43 4900 Sprain 2 2,149.14 9,253.30 4900 Sprain 2 2,149.14 9,253.30 5900 All Other Injuries, NOC 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 3 1,396.04 40,296.99 9000 Multiple Body Parts 3 1,396.04 40,296.99 5300 Knee 2 2,384.09 23,469.82 3800 Shoulder(s) 1 119.91 30,744.64 3500 Hand 1 169.48 169.48 5300 Knee 2 2,384.09 23,469.82 5500 Ankle 1 280.91 1,525.00 2102 Cervical 1 7.90 13,548.12 3100 Upper Arm (Incl. Clavicle & Sc 1 287.56 287.56 3400 Wrist 1 1,868.23 7,728.30 3400 Wrist 1 1,868.23 7,728.30 3302 Arm, Multiple 1 79.24 2,150.00 3000 Multiple Upper Extremities 1 684.48 684.48 5500 Ankle 1 280.91 1,525.00 2102 Cervical 1 7.90 13,548.12 3000 Multiple Upper Extremities 1 684.48 684.48 3800 Shoulder(s) 1 119.91 30,744.64 1400 Eye(s) 1 0.00 525.00 3302 Arm, Multiple 1 79.24 2,150.00 3100 Upper Arm (Incl. Clavicle & Sc 1 287.56 287.56 1400 Eye(s) 1 0.00 525.00 3500 Hand 1 169.48 169.48



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 105 UNIT 33929 HAROLD W. JORDON REHAB CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6002 Bending 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 6002 Bending 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007582 MENTAL HEALTH/RETARDATION DPT-339 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 106 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 41 25,194.81 181,723.93 5600 Lifting 8 24,744.41 200,876.51 8100 Struck or Injured By, NOC 9 5,481.51 88,841.68 7400 Fellow Worker, Patient 41 25,194.81 181,723.93 5600 Lifting 8 24,744.41 200,876.51 8100 Struck or Injured By, NOC 9 5,481.51 88,841.68 6000 Strain or Injury By, NOC 6 787.52 12,614.82 6001 Bodily Reaction 2 742.36 41,965.60 3300 Fall/Slip On Stairs 4 0.00 2,100.00 6003 Overexertion 2 7.90 40,319.92 2900 Fall On the Same Level 4 2,247.19 24,659.06 2900 Fall On the Same Level 4 2,247.19 24,659.06 8500 Animal or Insect 4 0.00 1,575.00 5500 Holding or Carrying 1 7.90 13,590.72 5700 Pushing or Pulling 4 684.48 3,634.48 8901 Altercation 1 7.90 13,548.12 1901 Bitten 2 457.04 457.04 5300 Twisting 2 1,502.67 13,297.97 7900 Object Being Lifted or Handled 2 262.09 262.09 6000 Strain or Injury By, NOC 6 787.52 12,614.82 5300 Twisting 2 1,502.67 13,297.97 5800 Reaching 1 471.32 11,400.00 6001 Bodily Reaction 2 742.36 41,965.60 8000 Object Handled By Others 1 282.19 8,740.50 6003 Overexertion 2 7.90 40,319.92 5700 Pushing or Pulling 4 684.48 3,634.48 2700 Fall/Slip From Liquid/Grease S 2 1,706.82 2,927.95 2700 Fall/Slip From Liquid/Grease S 2 1,706.82 2,927.95 ALL OTHER CODES 14 2,138.00 53,494.03 ALL OTHER CODES 22 2,087.82 10,608.82 TOTAL OF CODES 106 65,956.80 668,750.08 TOTAL OF CODES 106 65,956.80 668,750.08

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 29 14,382.09 143,420.38 5200 Strain 28 15,997.83 229,414.78 5200 Strain 28 15,997.83 229,414.78 1000 Contusion (Bruise, Skin Surfac 29 14,382.09 143,420.38 9000 Multiple Physical Injuries Onl 19 5,522.46 84,575.80 1601 Herniated Disc 1 17,048.45 106,536.20 4900 Sprain 9 5,242.09 42,180.45 9000 Multiple Physical Injuries Onl 19 5,522.46 84,575.80 5900 All Other Injuries, NOC 5 493.38 12,472.06 4900 Sprain 9 5,242.09 42,180.45 4300 Puncture 5 1,014.69 3,114.69 2800 Fracture 2 6,061.66 35,408.40 3700 Inflammation 3 0.00 1,050.00 5900 All Other Injuries, NOC 5 493.38 12,472.06 4000 Laceration 2 73.09 525.00 4901 Meniscus Tear 1 121.06 9,527.32 2800 Fracture 2 6,061.66 35,408.40 4300 Puncture 5 1,014.69 3,114.69 1600 Dislocation 1 0.00 0.00 3700 Inflammation 3 0.00 1,050.00 4901 Meniscus Tear 1 121.06 9,527.32 4000 Laceration 2 73.09 525.00 1601 Herniated Disc 1 17,048.45 106,536.20 3701 Conjunctivitis 1 0.00 525.00 3701 Conjunctivitis 1 0.00 525.00 1600 Dislocation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 21 12,440.52 130,082.30 3800 Shoulder(s) 9 3,859.67 131,079.66 4200 Low Back Area (Incl. Lumbar & 10 2,898.03 39,606.09 9000 Multiple Body Parts 21 12,440.52 130,082.30 3800 Shoulder(s) 9 3,859.67 131,079.66 6300 Lumbar and/or Sacral Vertebrae 2 17,048.45 107,061.20 5300 Knee 7 3,173.82 48,901.41 2102 Cervical 4 4,547.96 49,030.66 1002 Face, Multiple Parts 5 2,242.46 3,667.46 5300 Knee 7 3,173.82 48,901.41 1400 Eye(s) 5 2,025.96 19,512.88 4200 Low Back Area (Incl. Lumbar & 10 2,898.03 39,606.09 2102 Cervical 4 4,547.96 49,030.66 4600 Pelvis 1 19.00 35,400.00 5500 Ankle 4 2,132.81 9,625.65 4400 Chest (Incl. Ribs, Sternum & S 1 507.55 21,804.00 3100 Upper Arm (Incl. Clavicle & Sc 4 831.84 9,290.15 1400 Eye(s) 5 2,025.96 19,512.88 3400 Wrist 4 2,288.12 9,198.19 4101 Back (All Other) 1 2,990.38 11,123.43 1001 Head NEC 3 0.00 1,575.00 5100 Hip 1 677.97 11,083.44 3600 Finger(s) 3 1,014.69 1,539.69 5500 Ankle 4 2,132.81 9,625.65 3302 Arm, Multiple 3 79.24 3,200.00 3100 Upper Arm (Incl. Clavicle & Sc 4 831.84 9,290.15 3000 Multiple Upper Extremities 3 684.48 1,734.48 3400 Wrist 4 2,288.12 9,198.19 ALL OTHER CODES 21 27,737.20 210,706.46 ALL OTHER CODES 32 10,514.72 35,951.02 TOTAL OF CODES 106 65,956.80 668,750.08 TOTAL OF CODES 106 65,956.80 668,750.08


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007584 MILITARY LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 107 UNIT 34104 TN EMERGENCY MANAGEMENT AGENCY (TEMA) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9806 Continuous Trauma 1 0.00 525.00 9806 Continuous Trauma 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 8000 All Other Cumulative Injuries, 1 0.00 525.00 8000 All Other Cumulative Injuries, 1 0.00 525.00





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007584 MILITARY LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 108 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9806 Continuous Trauma 1 0.00 525.00 9806 Continuous Trauma 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 8000 All Other Cumulative Injuries, 1 0.00 525.00 8000 All Other Cumulative Injuries, 1 0.00 525.00





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 109 UNIT 34300 HEALTH CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6001 Bodily Reaction 1 0.00 0.00 6001 Bodily Reaction 1 0.00 0.00 3300 Fall/Slip On Stairs 1 0.00 0.00 3300 Fall/Slip On Stairs 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5300 Syncope 1 0.00 0.00 5300 Syncope 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9100 Body Systems & Multiple Body S 1 0.00 0.00 9100 Body Systems & Multiple Body S 1 0.00 0.00 5300 Knee 1 0.00 0.00 5300 Knee 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 110 UNIT 34301 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7900 Object Being Lifted or Handled 1 0.00 0.00 2700 Fall/Slip From Liquid/Grease S 1 687.50 687.50 2700 Fall/Slip From Liquid/Grease S 1 687.50 687.50 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 0.00 1900 Cut, Punctured, Scraped, NOC 1 227.28 227.28 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 0.00 1900 Cut, Punctured, Scraped, NOC 1 227.28 227.28 7500 Falling or Flying Object 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4000 Laceration 2 227.28 227.28 5200 Strain 2 687.50 1,212.50 5200 Strain 2 687.50 1,212.50 4000 Laceration 2 227.28 227.28 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 2 687.50 1,212.50 4200 Low Back Area (Incl. Lumbar & 2 687.50 1,212.50 1400 Eye(s) 1 0.00 0.00 5600 Foot 1 227.28 227.28 5001 Leg, Multiple 1 0.00 0.00 5001 Leg, Multiple 1 0.00 0.00 5600 Foot 1 227.28 227.28 1400 Eye(s) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 111 UNIT 34310 HEALTH RELATED BOARDS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 1 248.92 2,525.00 3100 Fall, Slip or Trip, NOC 1 248.92 2,525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 112 UNIT 34339 GENERAL ENVIRONMENTAL HEALTH CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6002 Bending 1 213.50 1,200.00 6002 Bending 1 213.50 1,200.00




----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 213.50 1,200.00 5300 Knee 1 213.50 1,200.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 113 UNIT 34345 HEALTH SERVICES ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7500 Falling or Flying Object 1 0.00 525.00 7500 Falling or Flying Object 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 114 UNIT 34350 HEALTH DEPT-HSA MEDICAL PROGRAM CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5999 Unclassified, Insufficient Dat 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00





CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 115 UNIT 34360 LOCAL HEALTH SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2500 Fall/Slip From a Different Lev 1 0.00 0.00 1200 Object Handled 1 3,833.11 43,895.76 5600 Lifting 1 5,448.27 24,008.16 5600 Lifting 1 5,448.27 24,008.16 1200 Object Handled 1 3,833.11 43,895.76 3300 Fall/Slip On Stairs 1 0.00 0.00 3300 Fall/Slip On Stairs 1 0.00 0.00 2500 Fall/Slip From a Different Lev 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 5,448.27 24,008.16 2800 Fracture 1 3,833.11 43,895.76 4900 Sprain 1 0.00 0.00 5200 Strain 2 5,448.27 24,008.16 2800 Fracture 1 3,833.11 43,895.76 4900 Sprain 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5500 Ankle 2 0.00 0.00 3600 Finger(s) 1 3,833.11 43,895.76 4200 Low Back Area (Incl. Lumbar & 1 5,448.27 24,008.16 4200 Low Back Area (Incl. Lumbar & 1 5,448.27 24,008.16 3600 Finger(s) 1 3,833.11 43,895.76 5500 Ankle 2 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007585 HEALTH DEPARTMENT - 34300 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 116 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 3 0.00 525.00 1200 Object Handled 1 3,833.11 43,895.76 7500 Falling or Flying Object 2 0.00 525.00 5600 Lifting 1 5,448.27 24,008.16 3100 Fall, Slip or Trip, NOC 2 248.92 3,050.00 3100 Fall, Slip or Trip, NOC 2 248.92 3,050.00 6001 Bodily Reaction 1 0.00 0.00 6002 Bending 1 213.50 1,200.00 7900 Object Being Lifted or Handled 1 0.00 0.00 2700 Fall/Slip From Liquid/Grease S 1 687.50 687.50 2700 Fall/Slip From Liquid/Grease S 1 687.50 687.50 7500 Falling or Flying Object 2 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 227.28 227.28 3300 Fall/Slip On Stairs 3 0.00 525.00 6002 Bending 1 213.50 1,200.00 1900 Cut, Punctured, Scraped, NOC 1 227.28 227.28 2500 Fall/Slip From a Different Lev 1 0.00 0.00 7900 Object Being Lifted or Handled 1 0.00 0.00 5600 Lifting 1 5,448.27 24,008.16 6001 Bodily Reaction 1 0.00 0.00 1200 Object Handled 1 3,833.11 43,895.76 2500 Fall/Slip From a Different Lev 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 5 6,349.27 26,420.66 2800 Fracture 1 3,833.11 43,895.76 1000 Contusion (Bruise, Skin Surfac 4 248.92 3,050.00 5200 Strain 5 6,349.27 26,420.66 4000 Laceration 2 227.28 227.28 1000 Contusion (Bruise, Skin Surfac 4 248.92 3,050.00 5300 Syncope 1 0.00 0.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 4000 Laceration 2 227.28 227.28 4900 Sprain 1 0.00 0.00 5300 Syncope 1 0.00 0.00 2800 Fracture 1 3,833.11 43,895.76 4900 Sprain 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 3 6,135.77 25,220.66 3600 Finger(s) 1 3,833.11 43,895.76 5300 Knee 2 213.50 1,200.00 4200 Low Back Area (Incl. Lumbar & 3 6,135.77 25,220.66 5600 Foot 2 227.28 752.28 3800 Shoulder(s) 1 248.92 2,525.00 5500 Ankle 2 0.00 0.00 5300 Knee 2 213.50 1,200.00 9100 Body Systems & Multiple Body S 1 0.00 0.00 5600 Foot 2 227.28 752.28 1400 Eye(s) 1 0.00 0.00 9000 Multiple Body Parts 1 0.00 525.00 5001 Leg, Multiple 1 0.00 0.00 9100 Body Systems & Multiple Body S 1 0.00 0.00 3800 Shoulder(s) 1 248.92 2,525.00 5500 Ankle 2 0.00 0.00 9000 Multiple Body Parts 1 0.00 525.00 1400 Eye(s) 1 0.00 0.00 3600 Finger(s) 1 3,833.11 43,895.76 5001 Leg, Multiple 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 117 UNIT 34500 HUMAN SERVICES (DHS) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3100 Fall, Slip or Trip, NOC 2 143.01 143.01 4500 Collision with Another Vehicle 1 7.90 17,700.00 4500 Collision with Another Vehicle 1 7.90 17,700.00 8100 Struck or Injured By, NOC 1 7.90 17,017.60 9700 Repetitive Motion (reported af 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 5600 Lifting 1 0.00 525.00 6004 Running and Training 1 0.00 525.00 8100 Struck or Injured By, NOC 1 7.90 17,017.60 5600 Lifting 1 0.00 525.00 6004 Running and Training 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 2 143.01 143.01


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 2 7.90 17,700.00 9000 Multiple Physical Injuries Onl 2 7.90 17,700.00 1000 Contusion (Bruise, Skin Surfac 2 150.91 17,160.61 1000 Contusion (Bruise, Skin Surfac 2 150.91 17,160.61 5200 Strain 2 0.00 1,050.00 5200 Strain 2 0.00 1,050.00 7800 Carpal Tunnel Syndrome 1 0.00 525.00 7800 Carpal Tunnel Syndrome 1 0.00 525.00 2800 Fracture 1 0.00 525.00 2800 Fracture 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 2 7.90 17,700.00 9000 Multiple Body Parts 2 7.90 17,700.00 4400 Chest (Incl. Ribs, Sternum & S 1 143.01 143.01 1001 Head NEC 1 7.90 17,017.60 3900 Wrist(s) and Hand(s) 1 0.00 525.00 5500 Ankle 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 5300 Knee 1 0.00 525.00 1001 Head NEC 1 7.90 17,017.60 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 5300 Knee 1 0.00 525.00 3900 Wrist(s) and Hand(s) 1 0.00 525.00 5500 Ankle 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 143.01 143.01



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 118 UNIT 34501 ADMINSTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 1 442.93 442.93 3300 Fall/Slip On Stairs 1 0.00 525.00 6801 Working Surface 1 78.08 78.08 6800 Stationary Object 1 442.93 442.93 3300 Fall/Slip On Stairs 1 0.00 525.00 6801 Working Surface 1 78.08 78.08


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 78.08 603.08 1000 Contusion (Bruise, Skin Surfac 2 78.08 603.08 2800 Fracture 1 442.93 442.93 2800 Fracture 1 442.93 442.93


----- PART/TARGET ----- ----- PART/TARGET ----- 5700 Toe(s) 1 442.93 442.93 5300 Knee 1 0.00 525.00 5600 Foot 1 78.08 78.08 5700 Toe(s) 1 442.93 442.93 5300 Knee 1 0.00 525.00 5600 Foot 1 78.08 78.08



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 119 UNIT 34513 CHILD SUPPORT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 120 UNIT 34516 FIELD OPERATIONS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 121 UNIT 34530 FAMILY ASSISTANCE SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 0.00 0.00 6000 Strain or Injury By, NOC 1 0.00 0.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3302 Arm, Multiple 1 0.00 0.00 3302 Arm, Multiple 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 122 UNIT 34540 SOCIAL SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6003 Overexertion 1 0.00 525.00 4600 Collision with a Fixed Object 1 7.90 11,256.88 4600 Collision with a Fixed Object 1 7.90 11,256.88 6003 Overexertion 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 1 7.90 11,256.88 1000 Contusion (Bruise, Skin Surfac 1 7.90 11,256.88 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 2 7.90 11,781.88 9000 Multiple Body Parts 2 7.90 11,781.88 4000 Multiple Trunk 1 0.00 525.00 4000 Multiple Trunk 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 123 UNIT 34549 COMMUNITY SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5800 Reaching 1 0.00 525.00 5800 Reaching 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 525.00 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 124 UNIT 34570 VOCATIONAL REHABILITATION CENTERS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3000 Slipped, Did Not Fall 1 0.00 0.00 7000 Striking Against/Stepping On, 1 0.00 525.00 7000 Striking Against/Stepping On, 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 3000 Slipped, Did Not Fall 1 0.00 0.00




----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 2 0.00 525.00 5500 Ankle 1 0.00 525.00 5500 Ankle 1 0.00 525.00 5300 Knee 2 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007586 DEPT. OF HUMAN SERVICES - 34500 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 125 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 3 0.00 1,575.00 4500 Collision with Another Vehicle 2 7.90 18,225.00 3100 Fall, Slip or Trip, NOC 2 143.01 143.01 8100 Struck or Injured By, NOC 1 7.90 17,017.60 4500 Collision with Another Vehicle 2 7.90 18,225.00 4600 Collision with a Fixed Object 1 7.90 11,256.88 2900 Fall On the Same Level 2 0.00 1,050.00 3300 Fall/Slip On Stairs 3 0.00 1,575.00 9700 Repetitive Motion (reported af 1 0.00 525.00 2900 Fall On the Same Level 2 0.00 1,050.00 5600 Lifting 1 0.00 525.00 9700 Repetitive Motion (reported af 1 0.00 525.00 8100 Struck or Injured By, NOC 1 7.90 17,017.60 7000 Striking Against/Stepping On, 1 0.00 525.00 6004 Running and Training 1 0.00 525.00 6004 Running and Training 1 0.00 525.00 6800 Stationary Object 1 442.93 442.93 6003 Overexertion 1 0.00 525.00 6801 Working Surface 1 78.08 78.08 5800 Reaching 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 0.00 5600 Lifting 1 0.00 525.00 6003 Overexertion 1 0.00 525.00 6800 Stationary Object 1 442.93 442.93 4600 Collision with a Fixed Object 1 7.90 11,256.88 3100 Fall, Slip or Trip, NOC 2 143.01 143.01 5800 Reaching 1 0.00 525.00 6801 Working Surface 1 78.08 78.08 ALL OTHER CODES 2 0.00 525.00 ALL OTHER CODES 2 0.00 0.00 TOTAL OF CODES 21 687.72 52,938.50 TOTAL OF CODES 21 687.72 52,938.50

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 6 0.00 2,625.00 1000 Contusion (Bruise, Skin Surfac 5 236.89 29,020.57 9000 Multiple Physical Injuries Onl 5 7.90 19,275.00 9000 Multiple Physical Injuries Onl 5 7.90 19,275.00 1000 Contusion (Bruise, Skin Surfac 5 236.89 29,020.57 5200 Strain 6 0.00 2,625.00 2800 Fracture 2 442.93 967.93 2800 Fracture 2 442.93 967.93 7800 Carpal Tunnel Syndrome 1 0.00 525.00 7800 Carpal Tunnel Syndrome 1 0.00 525.00 4900 Sprain 1 0.00 0.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 4900 Sprain 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 5 15.80 30,006.88 9000 Multiple Body Parts 5 15.80 30,006.88 5300 Knee 5 0.00 2,100.00 1001 Head NEC 1 7.90 17,017.60 5500 Ankle 2 0.00 1,050.00 5300 Knee 5 0.00 2,100.00 4400 Chest (Incl. Ribs, Sternum & S 1 143.01 143.01 5500 Ankle 2 0.00 1,050.00 3900 Wrist(s) and Hand(s) 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4000 Multiple Trunk 1 0.00 525.00 1001 Head NEC 1 7.90 17,017.60 3900 Wrist(s) and Hand(s) 1 0.00 525.00 5700 Toe(s) 1 442.93 442.93 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 525.00 5600 Foot 1 78.08 78.08 5700 Toe(s) 1 442.93 442.93 3302 Arm, Multiple 1 0.00 0.00 4400 Chest (Incl. Ribs, Sternum & S 1 143.01 143.01 4000 Multiple Trunk 1 0.00 525.00 5600 Foot 1 78.08 78.08 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 525.00 3302 Arm, Multiple 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007587 TENNESSEE BUREAU OF INVESTIGATION LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 126 UNIT 34800 TENNESSEE BUREAU OF INVESTIGATION (TBI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9902 Contact with Infectious Diseas 2 0.00 1,050.00 9902 Contact with Infectious Diseas 2 0.00 1,050.00 2900 Fall On the Same Level 1 0.00 0.00 2900 Fall On the Same Level 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7301 Tuberculosis 2 0.00 1,050.00 7301 Tuberculosis 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 6500 Insufficient Info to Identify; 2 0.00 1,050.00 6500 Insufficient Info to Identify; 2 0.00 1,050.00 5300 Knee 1 0.00 0.00 5300 Knee 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007587 TENNESSEE BUREAU OF INVESTIGATION LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 127 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9902 Contact with Infectious Diseas 2 0.00 1,050.00 9902 Contact with Infectious Diseas 2 0.00 1,050.00 2900 Fall On the Same Level 1 0.00 0.00 2900 Fall On the Same Level 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 7301 Tuberculosis 2 0.00 1,050.00 7301 Tuberculosis 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 6500 Insufficient Info to Identify; 2 0.00 1,050.00 6500 Insufficient Info to Identify; 2 0.00 1,050.00 5300 Knee 1 0.00 0.00 5300 Knee 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 128 UNIT 34900 SAFETY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6004 Running and Training 1 0.00 525.00 6004 Running and Training 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 0.00 525.00 5300 Knee 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 129 UNIT 34901 ADMINSTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 2 0.00 3,075.00 6800 Stationary Object 2 0.00 3,075.00 2900 Fall On the Same Level 1 0.00 525.00 7500 Falling or Flying Object 1 322.12 525.00 7500 Falling or Flying Object 1 322.12 525.00 2900 Fall On the Same Level 1 0.00 525.00 0900 Contact With, NOC 1 21.25 426.00 0900 Contact With, NOC 1 21.25 426.00 8500 Animal or Insect 1 0.00 0.00 8500 Animal or Insect 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 322.12 1,050.00 4000 Laceration 1 0.00 2,550.00 3700 Inflammation 2 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 2 322.12 1,050.00 6601 Poisoning, Systemic 1 21.25 426.00 3700 Inflammation 2 0.00 525.00 4000 Laceration 1 0.00 2,550.00 6601 Poisoning, Systemic 1 21.25 426.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5600 Foot 1 322.12 525.00 3200 Elbow 1 0.00 2,550.00 3301 ForeArm 1 0.00 525.00 5600 Foot 1 322.12 525.00 9000 Multiple Body Parts 1 21.25 426.00 5001 Leg, Multiple 1 0.00 525.00 5001 Leg, Multiple 1 0.00 525.00 3301 ForeArm 1 0.00 525.00 5400 Lower Leg 1 0.00 0.00 9000 Multiple Body Parts 1 21.25 426.00 3200 Elbow 1 0.00 2,550.00 5400 Lower Leg 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 130 UNIT 34903 HIGHWAY PATROL CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7700 Motor Vehicle 2 0.00 1,050.00 3100 Fall, Slip or Trip, NOC 1 9,880.51 56,092.00 6003 Overexertion 1 1,040.00 1,040.00 5000 Motor Vehicle, NOC 1 7.90 32,906.48 5500 Holding or Carrying 1 1,047.62 21,106.56 5500 Holding or Carrying 1 1,047.62 21,106.56 3100 Fall, Slip or Trip, NOC 1 9,880.51 56,092.00 7700 Motor Vehicle 2 0.00 1,050.00 5000 Motor Vehicle, NOC 1 7.90 32,906.48 6003 Overexertion 1 1,040.00 1,040.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 2 9,888.41 88,998.48 2800 Fracture 2 9,888.41 88,998.48 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 5200 Strain 1 1,047.62 21,106.56 5908 Chipped / Broken Tooth 1 1,040.00 1,040.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 5200 Strain 1 1,047.62 21,106.56 5908 Chipped / Broken Tooth 1 1,040.00 1,040.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 2 0.00 1,050.00 3800 Shoulder(s) 1 9,880.51 56,092.00 1600 Teeth 1 1,040.00 1,040.00 4400 Chest (Incl. Ribs, Sternum & S 1 7.90 32,906.48 4101 Back (All Other) 1 1,047.62 21,106.56 4101 Back (All Other) 1 1,047.62 21,106.56 3800 Shoulder(s) 1 9,880.51 56,092.00 9000 Multiple Body Parts 2 0.00 1,050.00 4400 Chest (Incl. Ribs, Sternum & S 1 7.90 32,906.48 1600 Teeth 1 1,040.00 1,040.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 131 UNIT 34907 EQUIPMENT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 4500 Collision with Another Vehicle 1 7,299.11 30,864.72 4500 Collision with Another Vehicle 1 7,299.11 30,864.72


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 7,299.11 30,864.72 2800 Fracture 1 7,299.11 30,864.72


----- PART/TARGET ----- ----- PART/TARGET ----- 3600 Finger(s) 1 7,299.11 30,864.72 3600 Finger(s) 1 7,299.11 30,864.72



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 132 UNIT 34915 OFFICE OF HOMELAND SECURITY CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5300 Twisting 1 431.07 820.86 5300 Twisting 1 431.07 820.86







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007588 DEPT. OF SAFETY - 34900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 133 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 2 0.00 3,075.00 3100 Fall, Slip or Trip, NOC 1 9,880.51 56,092.00 7700 Motor Vehicle 2 0.00 1,050.00 5000 Motor Vehicle, NOC 1 7.90 32,906.48 7500 Falling or Flying Object 1 322.12 525.00 4500 Collision with Another Vehicle 1 7,299.11 30,864.72 6004 Running and Training 1 0.00 525.00 5500 Holding or Carrying 1 1,047.62 21,106.56 0900 Contact With, NOC 1 21.25 426.00 6800 Stationary Object 2 0.00 3,075.00 2900 Fall On the Same Level 1 0.00 525.00 7700 Motor Vehicle 2 0.00 1,050.00 8500 Animal or Insect 1 0.00 0.00 6003 Overexertion 1 1,040.00 1,040.00 6003 Overexertion 1 1,040.00 1,040.00 5300 Twisting 1 431.07 820.86 5500 Holding or Carrying 1 1,047.62 21,106.56 7500 Falling or Flying Object 1 322.12 525.00 3100 Fall, Slip or Trip, NOC 1 9,880.51 56,092.00 6004 Running and Training 1 0.00 525.00 5000 Motor Vehicle, NOC 1 7.90 32,906.48 2900 Fall On the Same Level 1 0.00 525.00 4500 Collision with Another Vehicle 1 7,299.11 30,864.72 0900 Contact With, NOC 1 21.25 426.00 5300 Twisting 1 431.07 820.86 8500 Animal or Insect 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 3 1,478.69 22,452.42 2800 Fracture 3 17,187.52 119,863.20 2800 Fracture 3 17,187.52 119,863.20 5200 Strain 3 1,478.69 22,452.42 1000 Contusion (Bruise, Skin Surfac 2 322.12 1,050.00 4000 Laceration 1 0.00 2,550.00 3700 Inflammation 2 0.00 525.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 2 322.12 1,050.00 6601 Poisoning, Systemic 1 21.25 426.00 5908 Chipped / Broken Tooth 1 1,040.00 1,040.00 4000 Laceration 1 0.00 2,550.00 3700 Inflammation 2 0.00 525.00 5908 Chipped / Broken Tooth 1 1,040.00 1,040.00 6601 Poisoning, Systemic 1 21.25 426.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 3 21.25 1,476.00 3800 Shoulder(s) 1 9,880.51 56,092.00 5600 Foot 1 322.12 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 7.90 32,906.48 5300 Knee 1 0.00 525.00 3600 Finger(s) 1 7,299.11 30,864.72 3301 ForeArm 1 0.00 525.00 4101 Back (All Other) 1 1,047.62 21,106.56 5001 Leg, Multiple 1 0.00 525.00 3200 Elbow 1 0.00 2,550.00 5400 Lower Leg 1 0.00 0.00 9000 Multiple Body Parts 3 21.25 1,476.00 3200 Elbow 1 0.00 2,550.00 1600 Teeth 1 1,040.00 1,040.00 1600 Teeth 1 1,040.00 1,040.00 5500 Ankle 1 431.07 820.86 4101 Back (All Other) 1 1,047.62 21,106.56 5600 Foot 1 322.12 525.00 3800 Shoulder(s) 1 9,880.51 56,092.00 5300 Knee 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 7.90 32,906.48 5001 Leg, Multiple 1 0.00 525.00 3600 Finger(s) 1 7,299.11 30,864.72 3301 ForeArm 1 0.00 525.00 5500 Ankle 1 431.07 820.86 5400 Lower Leg 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 134 UNIT 35900 CHILDREN'S SERVICES (DCS) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 4 1,895.68 2,420.68 8100 Struck or Injured By, NOC 2 8,209.92 64,935.75 8100 Struck or Injured By, NOC 2 8,209.92 64,935.75 5700 Pushing or Pulling 1 7.90 15,878.40 8500 Animal or Insect 2 0.00 1,050.00 3300 Fall/Slip On Stairs 1 4,989.67 15,284.77 4500 Collision with Another Vehicle 2 15.80 12,717.24 4500 Collision with Another Vehicle 2 15.80 12,717.24 3300 Fall/Slip On Stairs 1 4,989.67 15,284.77 2900 Fall On the Same Level 4 1,895.68 2,420.68 5700 Pushing or Pulling 1 7.90 15,878.40 2700 Fall/Slip From Liquid/Grease S 1 584.33 1,740.00 5000 Motor Vehicle, NOC 1 0.00 0.00 8500 Animal or Insect 2 0.00 1,050.00 7700 Motor Vehicle 1 0.00 0.00 8200 Absorption, Ingestion, or Inha 1 0.00 525.00 2700 Fall/Slip From Liquid/Grease S 1 584.33 1,740.00 7700 Motor Vehicle 1 0.00 0.00 8200 Absorption, Ingestion, or Inha 1 0.00 525.00 5000 Motor Vehicle, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 4 23.70 28,595.64 2800 Fracture 1 7,883.33 64,609.16 9000 Multiple Physical Injuries Onl 4 910.92 3,116.59 5200 Strain 4 23.70 28,595.64 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 1 4,989.67 15,284.77 4000 Laceration 1 339.47 339.47 9000 Multiple Physical Injuries Onl 4 910.92 3,116.59 1000 Contusion (Bruise, Skin Surfac 1 4,989.67 15,284.77 4900 Sprain 1 1,556.21 1,556.21 4900 Sprain 1 1,556.21 1,556.21 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 2800 Fracture 1 7,883.33 64,609.16 4000 Laceration 1 339.47 339.47 5900 All Other Injuries, NOC 1 0.00 0.00 5900 All Other Injuries, NOC 1 0.00 0.00 0000 NO DESCRIPTION SET-UP 1 0.00 0.00 0000 NO DESCRIPTION SET-UP 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 6 600.13 15,507.24 1900 Facial Bones 1 7,883.33 64,609.16 3800 Shoulder(s) 2 7.90 15,878.40 3800 Shoulder(s) 2 7.90 15,878.40 3200 Elbow 1 339.47 339.47 9000 Multiple Body Parts 6 600.13 15,507.24 3400 Wrist 1 4,989.67 15,284.77 3400 Wrist 1 4,989.67 15,284.77 3600 Finger(s) 1 1,556.21 1,556.21 3600 Finger(s) 1 1,556.21 1,556.21 1800 Other facial soft tissue 1 326.59 326.59 6600 No Physical Injury 1 0.00 525.00 1900 Facial Bones 1 7,883.33 64,609.16 5001 Leg, Multiple 1 0.00 525.00 4101 Back (All Other) 1 0.00 0.00 3200 Elbow 1 339.47 339.47 6600 No Physical Injury 1 0.00 525.00 1800 Other facial soft tissue 1 326.59 326.59 5001 Leg, Multiple 1 0.00 525.00 4101 Back (All Other) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 135 UNIT 35904 CHILDREN SERV-CHILDR IN TN CUST-EDUC7/9 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8200 Absorption, Ingestion, or Inha 1 0.00 525.00 8200 Absorption, Ingestion, or Inha 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 6600 No Physical Injury 1 0.00 525.00 6600 No Physical Injury 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 136 UNIT 35905 CHILDREN SERV-CHILDR IN TN CUST-HUMA7/9 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 4500 Collision with Another Vehicle 1 7.90 7.90 4500 Collision with Another Vehicle 1 7.90 7.90




----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 1 7.90 7.90 3800 Shoulder(s) 1 7.90 7.90



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 137 UNIT 35906 CHILD SERV-CHILDR IN TN CUST-YOUTH-7/98 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 5300 Twisting 1 393.50 393.50 5300 Twisting 1 393.50 393.50


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 393.50 393.50 5200 Strain 1 393.50 393.50


----- PART/TARGET ----- ----- PART/TARGET ----- 5001 Leg, Multiple 1 393.50 393.50 9000 Multiple Body Parts 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5001 Leg, Multiple 1 393.50 393.50



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 138 UNIT 35907 CHILDREN SERV-CHILDR IN TN CUST-MHMR7/9 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 0.00 0.00 7400 Fellow Worker, Patient 1 0.00 0.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 139 UNIT 35910 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 4500 Collision with Another Vehicle 3 15.80 2,550.00 3100 Fall, Slip or Trip, NOC 1 0.00 24,205.40 5600 Lifting 2 871.57 12,615.76 6800 Stationary Object 1 1,154.69 13,553.68 2900 Fall On the Same Level 2 0.00 1,050.00 5600 Lifting 2 871.57 12,615.76 3100 Fall, Slip or Trip, NOC 1 0.00 24,205.40 4500 Collision with Another Vehicle 3 15.80 2,550.00 7500 Falling or Flying Object 1 162.28 162.28 2900 Fall On the Same Level 2 0.00 1,050.00 6800 Stationary Object 1 1,154.69 13,553.68 7500 Falling or Flying Object 1 162.28 162.28


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 3 1,316.97 15,215.96 2800 Fracture 1 0.00 24,205.40 4900 Sprain 2 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 3 1,316.97 15,215.96 9000 Multiple Physical Injuries Onl 2 15.80 1,050.00 3400 Hernia (Rupture) 1 871.57 12,090.76 2800 Fracture 1 0.00 24,205.40 9000 Multiple Physical Injuries Onl 2 15.80 1,050.00 3400 Hernia (Rupture) 1 871.57 12,090.76 4900 Sprain 2 0.00 1,050.00 5200 Strain 1 0.00 525.00 5200 Strain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 1 0.00 24,205.40 3400 Wrist 1 0.00 24,205.40 5600 Foot 1 162.28 162.28 1101 Scalp 1 1,154.69 13,553.68 6100 Abdomen Including Groin 1 871.57 12,090.76 6100 Abdomen Including Groin 1 871.57 12,090.76 5300 Knee 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 1,500.00 9000 Multiple Body Parts 1 7.90 525.00 9000 Multiple Body Parts 1 7.90 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 1,500.00 5500 Ankle 1 0.00 525.00 3000 Multiple Upper Extremities 1 7.90 525.00 5300 Knee 1 0.00 525.00 1101 Scalp 1 1,154.69 13,553.68 3301 ForeArm 1 0.00 525.00 5500 Ankle 1 0.00 525.00 3000 Multiple Upper Extremities 1 7.90 525.00 3301 ForeArm 1 0.00 525.00 5600 Foot 1 162.28 162.28



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 140 UNIT 35940 ADOPTION SERVICES CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3300 Fall/Slip On Stairs 1 17.05 7,332.00 3300 Fall/Slip On Stairs 1 17.05 7,332.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 17.05 7,332.00 4200 Low Back Area (Incl. Lumbar & 1 17.05 7,332.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 141 UNIT 35950 CHILD & FAMILY MANAGEMENT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 202.41 202.41 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 3300 Fall/Slip On Stairs 1 0.00 525.00 2900 Fall On the Same Level 1 202.41 202.41


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 202.41 202.41 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 5999 Unclassified, Insufficient Dat 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 202.41 202.41


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 202.41 202.41 9000 Multiple Body Parts 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5300 Knee 1 202.41 202.41



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 142 UNIT 35960 WILDER DEVELOPMENT CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 6 242.74 25,580.28 7400 Fellow Worker, Patient 6 242.74 25,580.28 8100 Struck or Injured By, NOC 3 1,974.31 3,171.89 8100 Struck or Injured By, NOC 3 1,974.31 3,171.89 6800 Stationary Object 1 0.00 525.00 6800 Stationary Object 1 0.00 525.00 5500 Holding or Carrying 1 0.00 525.00 5500 Holding or Carrying 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 2700 Fall/Slip From Liquid/Grease S 1 0.00 525.00 2700 Fall/Slip From Liquid/Grease S 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 5 1,937.26 18,667.84 1000 Contusion (Bruise, Skin Surfac 5 1,937.26 18,667.84 5200 Strain 3 271.89 1,321.89 2800 Fracture 1 7.90 8,762.44 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 5200 Strain 3 271.89 1,321.89 4900 Sprain 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 2800 Fracture 1 7.90 8,762.44 4900 Sprain 2 0.00 1,050.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 5 271.89 1,846.89 3500 Hand 1 234.84 14,717.84 4200 Low Back Area (Incl. Lumbar & 1 1,702.42 2,900.00 5700 Toe(s) 1 7.90 8,762.44 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 1,702.42 2,900.00 5700 Toe(s) 1 7.90 8,762.44 9000 Multiple Body Parts 5 271.89 1,846.89 3600 Finger(s) 1 0.00 525.00 5100 Hip 1 0.00 525.00 3302 Arm, Multiple 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 3500 Hand 1 234.84 14,717.84 3900 Wrist(s) and Hand(s) 1 0.00 525.00 5100 Hip 1 0.00 525.00 3600 Finger(s) 1 0.00 525.00 3900 Wrist(s) and Hand(s) 1 0.00 525.00 3302 Arm, Multiple 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 143 UNIT 35962 WOODLAND HILLS DEVELOPMENT CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 2 1,461.51 3,514.38 6003 Overexertion 1 7.90 16,397.48 5500 Holding or Carrying 2 459.79 984.79 5300 Twisting 1 2,514.28 15,425.20 7400 Fellow Worker, Patient 2 0.00 1,050.00 6004 Running and Training 2 1,691.72 9,506.72 6004 Running and Training 2 1,691.72 9,506.72 7000 Striking Against/Stepping On, 1 1,587.66 9,262.44 6800 Stationary Object 1 491.75 525.00 2900 Fall On the Same Level 2 1,461.51 3,514.38 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 5600 Lifting 1 0.00 1,900.00 7000 Striking Against/Stepping On, 1 1,587.66 9,262.44 7400 Fellow Worker, Patient 2 0.00 1,050.00 5300 Twisting 1 2,514.28 15,425.20 5500 Holding or Carrying 2 459.79 984.79 6003 Overexertion 1 7.90 16,397.48 6800 Stationary Object 1 491.75 525.00 6000 Strain or Injury By, NOC 1 0.00 0.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 5600 Lifting 1 0.00 1,900.00 6000 Strain or Injury By, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 6 3,465.82 17,984.99 4900 Sprain 5 4,740.89 23,133.54 4900 Sprain 5 4,740.89 23,133.54 1000 Contusion (Bruise, Skin Surfac 6 3,465.82 17,984.99 9000 Multiple Physical Injuries Onl 2 7.90 16,922.48 9000 Multiple Physical Injuries Onl 2 7.90 16,922.48 5200 Strain 2 0.00 1,050.00 5200 Strain 2 0.00 1,050.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3800 Shoulder(s) 3 1,921.30 3,974.17 5000 Multiple Lower Extremities 1 7.90 16,397.48 5300 Knee 3 1,587.66 10,312.44 5600 Foot 1 2,514.28 15,425.20 3200 Elbow 2 491.75 1,050.00 5300 Knee 3 1,587.66 10,312.44 1400 Eye(s) 1 0.00 525.00 5400 Lower Leg 1 1,691.72 8,981.72 9000 Multiple Body Parts 1 0.00 525.00 3800 Shoulder(s) 3 1,921.30 3,974.17 5600 Foot 1 2,514.28 15,425.20 3400 Wrist 1 0.00 1,900.00 5000 Multiple Lower Extremities 1 7.90 16,397.48 3200 Elbow 2 491.75 1,050.00 5400 Lower Leg 1 1,691.72 8,981.72 9000 Multiple Body Parts 1 0.00 525.00 3500 Hand 1 0.00 0.00 1400 Eye(s) 1 0.00 525.00 3400 Wrist 1 0.00 1,900.00 3500 Hand 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 144 UNIT 35963 MOUNTAIN VIEW DEVELOPMENT CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6002 Bending 1 2,121.88 12,584.44 6002 Bending 1 2,121.88 12,584.44 6003 Overexertion 1 0.00 525.00 6003 Overexertion 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 2,121.88 12,584.44 5200 Strain 1 2,121.88 12,584.44 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 2,121.88 12,584.44 4200 Low Back Area (Incl. Lumbar & 1 2,121.88 12,584.44 5500 Ankle 1 0.00 525.00 5500 Ankle 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 145 UNIT 35965 CHILD SERVICES (DCS) GROUP HOME CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007589 CHILDREN'S SERVICES PLAN - 35900 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 146 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 11 3,559.60 8,237.47 8100 Struck or Injured By, NOC 5 10,184.23 68,107.64 7400 Fellow Worker, Patient 11 242.74 27,680.28 7400 Fellow Worker, Patient 11 242.74 27,680.28 4500 Collision with Another Vehicle 6 39.50 15,275.14 3100 Fall, Slip or Trip, NOC 2 0.00 24,730.40 8100 Struck or Injured By, NOC 5 10,184.23 68,107.64 3300 Fall/Slip On Stairs 3 5,006.72 23,141.77 3300 Fall/Slip On Stairs 3 5,006.72 23,141.77 6003 Overexertion 2 7.90 16,922.48 5600 Lifting 3 871.57 14,515.76 5700 Pushing or Pulling 1 7.90 15,878.40 6800 Stationary Object 3 1,646.44 14,603.68 5300 Twisting 2 2,907.78 15,818.70 5500 Holding or Carrying 3 459.79 1,509.79 4500 Collision with Another Vehicle 6 39.50 15,275.14 2700 Fall/Slip From Liquid/Grease S 2 584.33 2,265.00 6800 Stationary Object 3 1,646.44 14,603.68 8200 Absorption, Ingestion, or Inha 2 0.00 1,050.00 5600 Lifting 3 871.57 14,515.76 8500 Animal or Insect 2 0.00 1,050.00 6002 Bending 1 2,121.88 12,584.44 5300 Twisting 2 2,907.78 15,818.70 6004 Running and Training 2 1,691.72 9,506.72 3100 Fall, Slip or Trip, NOC 2 0.00 24,730.40 7000 Striking Against/Stepping On, 1 1,587.66 9,262.44 6003 Overexertion 2 7.90 16,922.48 2900 Fall On the Same Level 11 3,559.60 8,237.47 ALL OTHER CODES 9 5,571.44 47,394.28 ALL OTHER CODES 13 1,206.40 6,037.07 TOTAL OF CODES 66 31,082.04 282,302.39 TOTAL OF CODES 66 31,082.04 282,302.39

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 16 11,709.72 67,678.56 2800 Fracture 3 7,891.23 97,577.00 5200 Strain 15 3,038.33 52,012.78 1000 Contusion (Bruise, Skin Surfac 16 11,709.72 67,678.56 9000 Multiple Physical Injuries Onl 13 934.62 23,189.07 5200 Strain 15 3,038.33 52,012.78 4900 Sprain 10 6,297.10 26,789.75 4900 Sprain 10 6,297.10 26,789.75 5999 Unclassified, Insufficient Dat 5 0.00 2,625.00 9000 Multiple Physical Injuries Onl 13 934.62 23,189.07 2800 Fracture 3 7,891.23 97,577.00 3400 Hernia (Rupture) 1 871.57 12,090.76 4000 Laceration 1 339.47 339.47 5999 Unclassified, Insufficient Dat 5 0.00 2,625.00 5900 All Other Injuries, NOC 1 0.00 0.00 4000 Laceration 1 339.47 339.47 0000 NO DESCRIPTION SET-UP 1 0.00 0.00 5900 All Other Injuries, NOC 1 0.00 0.00 3400 Hernia (Rupture) 1 871.57 12,090.76 0000 NO DESCRIPTION SET-UP 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 16 879.92 19,454.13 1900 Facial Bones 1 7,883.33 64,609.16 3800 Shoulder(s) 6 1,937.10 19,860.47 3400 Wrist 3 4,989.67 41,390.17 5300 Knee 5 1,790.07 11,039.85 4200 Low Back Area (Incl. Lumbar & 4 3,841.35 23,341.44 4200 Low Back Area (Incl. Lumbar & 4 3,841.35 23,341.44 3800 Shoulder(s) 6 1,937.10 19,860.47 3200 Elbow 3 831.22 1,389.47 9000 Multiple Body Parts 16 879.92 19,454.13 3400 Wrist 3 4,989.67 41,390.17 5000 Multiple Lower Extremities 1 7.90 16,397.48 4400 Chest (Incl. Ribs, Sternum & S 3 0.00 2,550.00 5600 Foot 2 2,676.56 15,587.48 3600 Finger(s) 2 1,556.21 2,081.21 3500 Hand 2 234.84 14,717.84 6600 No Physical Injury 2 0.00 1,050.00 1101 Scalp 1 1,154.69 13,553.68 5001 Leg, Multiple 2 393.50 918.50 6100 Abdomen Including Groin 1 871.57 12,090.76 5600 Foot 2 2,676.56 15,587.48 5300 Knee 5 1,790.07 11,039.85 5500 Ankle 2 0.00 1,050.00 5400 Lower Leg 1 1,691.72 8,981.72 3500 Hand 2 234.84 14,717.84 5700 Toe(s) 1 7.90 8,762.44 1800 Other facial soft tissue 1 326.59 326.59 4400 Chest (Incl. Ribs, Sternum & S 3 0.00 2,550.00 ALL OTHER CODES 13 11,625.01 127,545.24 ALL OTHER CODES 19 3,115.42 9,965.77 TOTAL OF CODES 66 31,082.04 282,302.39 TOTAL OF CODES 66 31,082.04 282,302.39


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 147 UNIT 40000 TRANSPORTATION (TDOT, DOT) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 3 251.18 1,301.18 2700 Fall/Slip From Liquid/Grease S 1 1,007.67 29,661.78 5600 Lifting 2 882.61 3,430.28 5600 Lifting 2 882.61 3,430.28 7500 Falling or Flying Object 1 1,733.78 1,733.78 7500 Falling or Flying Object 1 1,733.78 1,733.78 2700 Fall/Slip From Liquid/Grease S 1 1,007.67 29,661.78 8500 Animal or Insect 3 251.18 1,301.18 2900 Fall On the Same Level 1 0.00 525.00 8400 Electric Current 1 0.00 525.00 8400 Electric Current 1 0.00 525.00 8100 Struck or Injured By, NOC 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 0.00 5700 Pushing or Pulling 1 0.00 525.00 7907 Plant 1 0.00 0.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 3100 Fall, Slip or Trip, NOC 1 0.00 525.00 7907 Plant 1 0.00 0.00 8100 Struck or Injured By, NOC 1 0.00 525.00 7900 Object Being Lifted or Handled 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 3 882.61 3,955.28 2800 Fracture 1 1,007.67 29,661.78 1000 Contusion (Bruise, Skin Surfac 3 0.00 1,050.00 5200 Strain 3 882.61 3,955.28 5900 All Other Injuries, NOC 2 0.00 525.00 4000 Laceration 1 1,733.78 1,733.78 4000 Laceration 1 1,733.78 1,733.78 1000 Contusion (Bruise, Skin Surfac 3 0.00 1,050.00 3700 Inflammation 1 251.18 251.18 9000 Multiple Physical Injuries Onl 1 0.00 525.00 2800 Fracture 1 1,007.67 29,661.78 5900 All Other Injuries, NOC 2 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4300 Puncture 1 0.00 525.00 0400 Burn 1 0.00 525.00 0400 Burn 1 0.00 525.00 4300 Puncture 1 0.00 525.00 3700 Inflammation 1 251.18 251.18


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 5 638.93 4,761.60 5300 Knee 1 1,007.67 29,661.78 3500 Hand 2 0.00 525.00 9000 Multiple Body Parts 5 638.93 4,761.60 4200 Low Back Area (Incl. Lumbar & 1 243.68 243.68 1500 Nose 1 1,733.78 1,733.78 1500 Nose 1 1,733.78 1,733.78 3800 Shoulder(s) 1 0.00 525.00 5100 Hip 1 251.18 251.18 3500 Hand 2 0.00 525.00 5300 Knee 1 1,007.67 29,661.78 3000 Multiple Upper Extremities 1 0.00 525.00 1002 Face, Multiple Parts 1 0.00 525.00 1002 Face, Multiple Parts 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 5100 Hip 1 251.18 251.18 3000 Multiple Upper Extremities 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 243.68 243.68



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 148 UNIT 40100 ADMINISTRATION/HEADQUARTERS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2500 Fall/Slip From a Different Lev 2 7,740.10 30,365.15 2500 Fall/Slip From a Different Lev 2 7,740.10 30,365.15 1900 Cut, Punctured, Scraped, NOC 2 0.00 1,050.00 1900 Cut, Punctured, Scraped, NOC 2 0.00 1,050.00 7900 Object Being Lifted or Handled 1 417.58 417.58 7500 Falling or Flying Object 1 0.00 525.00 8100 Struck or Injured By, NOC 1 0.00 0.00 7900 Object Being Lifted or Handled 1 417.58 417.58 7500 Falling or Flying Object 1 0.00 525.00 8100 Struck or Injured By, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4000 Laceration 3 1,035.39 2,085.39 5200 Strain 1 6,704.71 29,329.76 5200 Strain 1 6,704.71 29,329.76 4000 Laceration 3 1,035.39 2,085.39 1000 Contusion (Bruise, Skin Surfac 1 417.58 417.58 2500 Foreign Body (Eye) 1 0.00 525.00 2800 Fracture 1 0.00 0.00 1000 Contusion (Bruise, Skin Surfac 1 417.58 417.58 2500 Foreign Body (Eye) 1 0.00 525.00 2800 Fracture 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3400 Wrist 2 417.58 942.58 6300 Lumbar and/or Sacral Vertebrae 1 6,704.71 29,329.76 6300 Lumbar and/or Sacral Vertebrae 1 6,704.71 29,329.76 5400 Lower Leg 1 1,035.39 1,035.39 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 525.00 3400 Wrist 2 417.58 942.58 3600 Finger(s) 1 0.00 0.00 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 525.00 5400 Lower Leg 1 1,035.39 1,035.39 1400 Eye(s) 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 3600 Finger(s) 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 149 UNIT 41200 TDOT ENGINEERING CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6000 Strain or Injury By, NOC 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 14,761.92 4500 Collision with Another Vehicle 1 0.00 14,761.92 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00 6000 Strain or Injury By, NOC 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5200 Strain 1 0.00 14,761.92 5200 Strain 1 0.00 14,761.92 9000 Multiple Physical Injuries Onl 1 0.00 525.00 3700 Inflammation 1 0.00 525.00 3700 Inflammation 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 1 0.00 525.00 2102 Cervical 1 0.00 14,761.92 2102 Cervical 1 0.00 14,761.92 9000 Multiple Body Parts 1 0.00 525.00 6100 Abdomen Including Groin 1 0.00 525.00 6100 Abdomen Including Groin 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 150 UNIT 41900 FIELD MAINTENANCE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5300 Twisting 2 437.82 9,629.24 5000 Motor Vehicle, NOC 1 7.90 10,056.96 5000 Motor Vehicle, NOC 1 7.90 10,056.96 5300 Twisting 2 437.82 9,629.24


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5999 Unclassified, Insufficient Dat 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 7.90 10,056.96 4900 Sprain 1 437.82 9,104.24 4900 Sprain 1 437.82 9,104.24 9000 Multiple Physical Injuries Onl 1 7.90 10,056.96 5999 Unclassified, Insufficient Dat 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 6100 Abdomen Including Groin 1 0.00 525.00 9000 Multiple Body Parts 1 7.90 10,056.96 5300 Knee 1 437.82 9,104.24 5300 Knee 1 437.82 9,104.24 9000 Multiple Body Parts 1 7.90 10,056.96 6100 Abdomen Including Groin 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 151 UNIT 43000 EQUIPMENT PURCHASES & OPERATIONS CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7600 Hand Tool or Machine in Use 1 216.52 216.52 7600 Hand Tool or Machine in Use 1 216.52 216.52







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 152 UNIT 45100 TDOT HIGHWAY MAINTENANCE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 5 518.80 13,317.44 4800 Vehicle Upset 1 790.50 40,502.44 3100 Fall, Slip or Trip, NOC 2 1,959.79 2,300.00 7500 Falling or Flying Object 2 2,435.99 18,731.64 7500 Falling or Flying Object 2 2,435.99 18,731.64 2900 Fall On the Same Level 1 609.09 16,166.90 6800 Stationary Object 2 593.46 15,745.58 6800 Stationary Object 2 593.46 15,745.58 7600 Hand Tool or Machine in Use 1 0.00 525.00 5600 Lifting 5 518.80 13,317.44 6003 Overexertion 1 0.00 0.00 7700 Motor Vehicle 1 7.90 12,619.52 9900 Other Miscellaneous, NOC 1 233.21 233.21 3100 Fall, Slip or Trip, NOC 2 1,959.79 2,300.00 1200 Object Handled 1 298.02 298.02 2800 Fall/Slip into Openings 1 0.00 530.00 6002 Bending 1 0.00 525.00 9999 Unclassified, Insufficient Dat 1 0.00 525.00 6000 Strain or Injury By, NOC 1 472.60 472.60 8500 Animal or Insect 1 0.00 525.00 2800 Fall/Slip into Openings 1 0.00 530.00 7600 Hand Tool or Machine in Use 1 0.00 525.00 8100 Struck or Injured By, NOC 1 53.40 53.40 6002 Bending 1 0.00 525.00 2900 Fall On the Same Level 1 609.09 16,166.90 6001 Bodily Reaction 1 0.00 525.00 7000 Striking Against/Stepping On, 1 103.79 103.79 5300 Twisting 1 0.00 525.00 ALL OTHER CODES 12 971.48 56,970.04 ALL OTHER CODES 12 1,334.10 2,909.10 TOTAL OF CODES 33 8,249.63 125,972.62 TOTAL OF CODES 33 8,249.63 125,972.62

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 7 472.60 3,997.60 5999 Unclassified, Insufficient Dat 3 790.50 41,552.44 1000 Contusion (Bruise, Skin Surfac 4 4,387.88 12,029.68 2800 Fracture 2 1,202.55 31,387.48 4000 Laceration 4 479.00 11,053.06 9000 Multiple Physical Injuries Onl 2 7.90 12,619.52 5999 Unclassified, Insufficient Dat 3 790.50 41,552.44 1000 Contusion (Bruise, Skin Surfac 4 4,387.88 12,029.68 3700 Inflammation 3 0.00 1,575.00 4000 Laceration 4 479.00 11,053.06 4200 Poisoning-General (Not OD or C 2 337.00 337.00 5900 All Other Injuries, NOC 2 518.80 10,317.44 2500 Foreign Body (Eye) 2 53.40 53.40 5200 Strain 7 472.60 3,997.60 2800 Fracture 2 1,202.55 31,387.48 3700 Inflammation 3 0.00 1,575.00 5900 All Other Injuries, NOC 2 518.80 10,317.44 4900 Sprain 2 0.00 1,050.00 4900 Sprain 2 0.00 1,050.00 4200 Poisoning-General (Not OD or C 2 337.00 337.00 9000 Multiple Physical Injuries Onl 2 7.90 12,619.52 2500 Foreign Body (Eye) 2 53.40 53.40


----- PART/TARGET ----- ----- PART/TARGET ----- 1001 Head NEC 5 2,669.20 20,014.85 4400 Chest (Incl. Ribs, Sternum & S 1 790.50 40,502.44 5300 Knee 4 0.00 1,580.00 3600 Finger(s) 3 1,500.57 31,685.50 3600 Finger(s) 3 1,500.57 31,685.50 1001 Head NEC 5 2,669.20 20,014.85 4200 Low Back Area (Incl. Lumbar & 3 991.40 11,315.04 9000 Multiple Body Parts 3 111.69 13,248.31 1400 Eye(s) 3 226.48 226.48 4200 Low Back Area (Incl. Lumbar & 3 991.40 11,315.04 9000 Multiple Body Parts 3 111.69 13,248.31 5100 Hip 1 1,959.79 2,300.00 3800 Shoulder(s) 2 0.00 525.00 2102 Cervical 1 0.00 1,950.00 5500 Ankle 2 0.00 525.00 5300 Knee 4 0.00 1,580.00 5000 Multiple Lower Extremities 1 0.00 525.00 5500 Ankle 2 0.00 525.00 3700 Thumb 1 0.00 525.00 5400 Lower Leg 1 0.00 525.00 5100 Hip 1 1,959.79 2,300.00 5000 Multiple Lower Extremities 1 0.00 525.00 5400 Lower Leg 1 0.00 525.00 3800 Shoulder(s) 2 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 790.50 40,502.44 3700 Thumb 1 0.00 525.00 3500 Hand 1 0.00 525.00 3500 Hand 1 0.00 525.00 ALL OTHER CODES 2 0.00 1,950.00 ALL OTHER CODES 4 226.48 226.48 TOTAL OF CODES 33 8,249.63 125,972.62 TOTAL OF CODES 33 8,249.63 125,972.62


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 153 UNIT 47100 STATE CONSTRUCTION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 797.69 4,000.00 2900 Fall On the Same Level 1 797.69 4,000.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 154 UNIT 48000 HIGHWAY CONSTRUCTION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9000 Other than Physical Cause of I 1 0.00 525.00 9000 Other than Physical Cause of I 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3302 Arm, Multiple 1 0.00 525.00 3302 Arm, Multiple 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 155 UNIT 48200 OTHER CONSTRUCTION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 1 0.00 525.00 5600 Lifting 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 156 UNIT 48700 METROPOLITAN-URBAN CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 9804 Repetitive Motion (reported be 1 0.00 525.00 9804 Repetitive Motion (reported be 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 3500 Hand 1 0.00 525.00 3500 Hand 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 157 UNIT 48800 BRIDGE REPLACEMENT CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 1 0.00 0.00 8500 Animal or Insect 1 0.00 0.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007590 TRANSPORTATION DEPARTMENT - 40000 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 158 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 8 1,401.41 17,272.72 4800 Vehicle Upset 1 790.50 40,502.44 8500 Animal or Insect 5 251.18 1,826.18 2500 Fall/Slip From a Different Lev 2 7,740.10 30,365.15 7500 Falling or Flying Object 4 4,169.77 20,990.42 2700 Fall/Slip From Liquid/Grease S 1 1,007.67 29,661.78 2900 Fall On the Same Level 3 1,406.78 20,691.90 7500 Falling or Flying Object 4 4,169.77 20,990.42 3100 Fall, Slip or Trip, NOC 3 1,959.79 2,825.00 2900 Fall On the Same Level 3 1,406.78 20,691.90 8100 Struck or Injured By, NOC 3 53.40 578.40 5600 Lifting 8 1,401.41 17,272.72 5300 Twisting 3 437.82 10,154.24 6800 Stationary Object 2 593.46 15,745.58 7900 Object Being Lifted or Handled 2 417.58 417.58 4500 Collision with Another Vehicle 1 0.00 14,761.92 7907 Plant 2 0.00 0.00 7700 Motor Vehicle 1 7.90 12,619.52 2500 Fall/Slip From a Different Lev 2 7,740.10 30,365.15 5300 Twisting 3 437.82 10,154.24 1900 Cut, Punctured, Scraped, NOC 2 0.00 1,050.00 5000 Motor Vehicle, NOC 1 7.90 10,056.96 6000 Strain or Injury By, NOC 2 472.60 997.60 3100 Fall, Slip or Trip, NOC 3 1,959.79 2,825.00 7600 Hand Tool or Machine in Use 2 216.52 741.52 8500 Animal or Insect 5 251.18 1,826.18 6800 Stationary Object 2 593.46 15,745.58 1900 Cut, Punctured, Scraped, NOC 2 0.00 1,050.00 ALL OTHER CODES 23 2,622.07 114,715.72 ALL OTHER CODES 29 1,968.20 9,848.20 TOTAL OF CODES 66 21,742.48 238,372.01 TOTAL OF CODES 66 21,742.48 238,372.01

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 14 8,059.92 53,094.56 2800 Fracture 4 2,210.22 61,049.26 4000 Laceration 9 3,464.69 15,088.75 5200 Strain 14 8,059.92 53,094.56 1000 Contusion (Bruise, Skin Surfac 9 5,603.15 17,497.26 5999 Unclassified, Insufficient Dat 5 790.50 42,602.44 3700 Inflammation 6 251.18 2,351.18 9000 Multiple Physical Injuries Onl 5 15.80 23,726.48 9000 Multiple Physical Injuries Onl 5 15.80 23,726.48 1000 Contusion (Bruise, Skin Surfac 9 5,603.15 17,497.26 5999 Unclassified, Insufficient Dat 5 790.50 42,602.44 4000 Laceration 9 3,464.69 15,088.75 5900 All Other Injuries, NOC 4 518.80 10,842.44 5900 All Other Injuries, NOC 4 518.80 10,842.44 2800 Fracture 4 2,210.22 61,049.26 4900 Sprain 3 437.82 10,154.24 2500 Foreign Body (Eye) 3 53.40 578.40 3700 Inflammation 6 251.18 2,351.18 4900 Sprain 3 437.82 10,154.24 2500 Foreign Body (Eye) 3 53.40 578.40 4200 Poisoning-General (Not OD or C 2 337.00 337.00 4300 Puncture 1 0.00 525.00 0400 Burn 1 0.00 525.00 0400 Burn 1 0.00 525.00 4300 Puncture 1 0.00 525.00 4200 Poisoning-General (Not OD or C 2 337.00 337.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 12 758.52 29,116.87 4400 Chest (Incl. Ribs, Sternum & S 1 790.50 40,502.44 5300 Knee 6 1,445.49 40,346.02 5300 Knee 6 1,445.49 40,346.02 3600 Finger(s) 5 1,717.09 31,902.02 3600 Finger(s) 5 1,717.09 31,902.02 1001 Head NEC 5 2,669.20 20,014.85 6300 Lumbar and/or Sacral Vertebrae 1 6,704.71 29,329.76 4200 Low Back Area (Incl. Lumbar & 4 1,235.08 11,558.72 9000 Multiple Body Parts 12 758.52 29,116.87 3500 Hand 4 0.00 1,575.00 1001 Head NEC 5 2,669.20 20,014.85 3800 Shoulder(s) 4 797.69 5,050.00 2102 Cervical 2 0.00 16,711.92 1400 Eye(s) 4 226.48 751.48 4200 Low Back Area (Incl. Lumbar & 4 1,235.08 11,558.72 5100 Hip 2 2,210.97 2,551.18 3800 Shoulder(s) 4 797.69 5,050.00 3400 Wrist 2 417.58 942.58 5100 Hip 2 2,210.97 2,551.18 5400 Lower Leg 2 1,035.39 1,560.39 1500 Nose 1 1,733.78 1,733.78 2102 Cervical 2 0.00 16,711.92 3500 Hand 4 0.00 1,575.00 6100 Abdomen Including Groin 2 0.00 1,050.00 5400 Lower Leg 2 1,035.39 1,560.39 5500 Ankle 2 0.00 525.00 6100 Abdomen Including Groin 2 0.00 1,050.00 ALL OTHER CODES 10 9,228.99 74,715.98 ALL OTHER CODES 15 644.06 5,369.06 TOTAL OF CODES 66 21,742.48 238,372.01 TOTAL OF CODES 66 21,742.48 238,372.01


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 159 UNIT 01000 UT KNOXVILLE (UTK) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2700 Fall/Slip From Liquid/Grease S 3 853.24 1,378.24 5300 Twisting 1 7.90 23,028.76 3300 Fall/Slip On Stairs 3 1,391.30 5,725.00 5800 Reaching 1 0.00 15,831.72 2900 Fall On the Same Level 2 836.37 1,975.00 0100 Chemicals 1 1,503.09 12,866.52 0100 Chemicals 1 1,503.09 12,866.52 3300 Fall/Slip On Stairs 3 1,391.30 5,725.00 1000 Machine/Machinery 1 421.33 421.33 7600 Hand Tool or Machine in Use 1 525.35 2,800.00 7600 Hand Tool or Machine in Use 1 525.35 2,800.00 2900 Fall On the Same Level 2 836.37 1,975.00 7907 Plant 1 302.25 302.25 2700 Fall/Slip From Liquid/Grease S 3 853.24 1,378.24 5600 Lifting 1 132.30 132.30 6800 Stationary Object 1 0.00 525.00 7501 Particles 1 0.00 0.00 1902 Needle Stick 1 0.00 525.00 8100 Struck or Injured By, NOC 1 0.00 0.00 0400 Fire or Flame 1 484.03 484.03 5300 Twisting 1 7.90 23,028.76 1000 Machine/Machinery 1 421.33 421.33 1902 Needle Stick 1 0.00 525.00 7907 Plant 1 302.25 302.25 6800 Stationary Object 1 0.00 525.00 5600 Lifting 1 132.30 132.30 0400 Fire or Flame 1 484.03 484.03 8100 Struck or Injured By, NOC 1 0.00 0.00 ALL OTHER CODES 1 0.00 15,831.72 ALL OTHER CODES 1 0.00 0.00 TOTAL OF CODES 20 6,457.16 65,995.15 TOTAL OF CODES 20 6,457.16 65,995.15

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 6 2,665.87 8,049.57 5200 Strain 4 976.57 40,442.78 5200 Strain 4 976.57 40,442.78 0400 Burn 2 1,987.12 13,350.55 0400 Burn 2 1,987.12 13,350.55 1000 Contusion (Bruise, Skin Surfac 6 2,665.87 8,049.57 4000 Laceration 2 0.00 525.00 5908 Chipped / Broken Tooth 1 525.35 2,800.00 5908 Chipped / Broken Tooth 1 525.35 2,800.00 4300 Puncture 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 0.00 4000 Laceration 2 0.00 525.00 3700 Inflammation 1 302.25 302.25 3700 Inflammation 1 302.25 302.25 4902 Rotator Cuff 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 0.00 2500 Foreign Body (Eye) 1 0.00 0.00 4902 Rotator Cuff 1 0.00 0.00 4300 Puncture 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 3 1,503.09 13,391.52 4200 Low Back Area (Incl. Lumbar & 2 7.90 38,860.48 5300 Knee 2 853.24 1,378.24 9000 Multiple Body Parts 3 1,503.09 13,391.52 4200 Low Back Area (Incl. Lumbar & 2 7.90 38,860.48 1000 Multiple Head Injury 1 1,391.30 5,200.00 2102 Cervical 1 836.37 1,450.00 1600 Teeth 1 525.35 2,800.00 1000 Multiple Head Injury 1 1,391.30 5,200.00 2102 Cervical 1 836.37 1,450.00 3500 Hand 1 421.33 421.33 5300 Knee 2 853.24 1,378.24 1600 Teeth 1 525.35 2,800.00 3700 Thumb 1 0.00 525.00 3000 Multiple Upper Extremities 1 302.25 302.25 3600 Finger(s) 1 0.00 525.00 4000 Multiple Trunk 1 132.30 132.30 3200 Elbow 1 0.00 525.00 3800 Shoulder(s) 1 0.00 0.00 3301 ForeArm 1 484.03 484.03 1400 Eye(s) 1 0.00 0.00 3500 Hand 1 421.33 421.33 1101 Scalp 1 0.00 0.00 3000 Multiple Upper Extremities 1 302.25 302.25 3700 Thumb 1 0.00 525.00 4000 Multiple Trunk 1 132.30 132.30 3600 Finger(s) 1 0.00 525.00 3800 Shoulder(s) 1 0.00 0.00 ALL OTHER CODES 2 484.03 1,009.03 ALL OTHER CODES 2 0.00 0.00 TOTAL OF CODES 20 6,457.16 65,995.15 TOTAL OF CODES 20 6,457.16 65,995.15


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 160 UNIT 02000 SPACE INSTITUTE (UTSI) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 161 UNIT 04000 UT CHATTANOOGA (UTC) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8100 Struck or Injured By, NOC 3 73.09 1,123.09 7500 Falling or Flying Object 1 706.11 2,000.00 8107 Bodily Fluid, Blood, Saliva, E 1 0.00 0.00 8100 Struck or Injured By, NOC 3 73.09 1,123.09 7500 Falling or Flying Object 1 706.11 2,000.00 3000 Slipped, Did Not Fall 1 0.00 700.00 3000 Slipped, Did Not Fall 1 0.00 700.00 3300 Fall/Slip On Stairs 1 0.00 525.00 6800 Stationary Object 1 367.12 367.12 3101 Trip 1 0.00 525.00 3101 Trip 1 0.00 525.00 6800 Stationary Object 1 367.12 367.12 3300 Fall/Slip On Stairs 1 0.00 525.00 8107 Bodily Fluid, Blood, Saliva, E 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 4 0.00 2,100.00 9000 Multiple Physical Injuries Onl 4 0.00 2,100.00 1000 Contusion (Bruise, Skin Surfac 2 440.21 440.21 3700 Inflammation 1 706.11 2,000.00 0100 No Physical Injury 1 0.00 0.00 5999 Unclassified, Insufficient Dat 1 0.00 700.00 3700 Inflammation 1 706.11 2,000.00 1000 Contusion (Bruise, Skin Surfac 2 440.21 440.21 5999 Unclassified, Insufficient Dat 1 0.00 700.00 0100 No Physical Injury 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 4 73.09 1,648.09 5300 Knee 1 706.11 2,000.00 5000 Multiple Lower Extremities 2 0.00 1,225.00 9000 Multiple Body Parts 4 73.09 1,648.09 9100 Body Systems & Multiple Body S 1 0.00 0.00 5000 Multiple Lower Extremities 2 0.00 1,225.00 5300 Knee 1 706.11 2,000.00 5700 Toe(s) 1 367.12 367.12 5700 Toe(s) 1 367.12 367.12 9100 Body Systems & Multiple Body S 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 162 UNIT 05000 UT MARTIN (UTM) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 2 0.00 1,050.00 6001 Bodily Reaction 1 7.90 8,212.98 6001 Bodily Reaction 1 7.90 8,212.98 8500 Animal or Insect 2 0.00 1,050.00 2900 Fall On the Same Level 1 0.00 525.00 2900 Fall On the Same Level 1 0.00 525.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 0.00 1900 Cut, Punctured, Scraped, NOC 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 7.90 8,212.98 5200 Strain 1 7.90 8,212.98 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 4300 Puncture 1 0.00 525.00 4300 Puncture 1 0.00 525.00 4200 Poisoning-General (Not OD or C 1 0.00 525.00 4200 Poisoning-General (Not OD or C 1 0.00 525.00 4000 Laceration 1 0.00 0.00 4000 Laceration 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5500 Ankle 1 7.90 8,212.98 5500 Ankle 1 7.90 8,212.98 3000 Multiple Upper Extremities 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 4400 Chest (Incl. Ribs, Sternum & S 1 0.00 525.00 3000 Multiple Upper Extremities 1 0.00 525.00 1800 Other facial soft tissue 1 0.00 525.00 1800 Other facial soft tissue 1 0.00 525.00 4100 Upper Back Area (Thoracic Area 1 0.00 0.00 4100 Upper Back Area (Thoracic Area 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 163 UNIT 07000 HEALTH SCIENCE CENTER (UTHSC) CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7500 Falling or Flying Object 6 1,659.48 3,759.48 7500 Falling or Flying Object 6 1,659.48 3,759.48 6000 Strain or Injury By, NOC 2 0.00 3,225.00 6000 Strain or Injury By, NOC 2 0.00 3,225.00 2900 Fall On the Same Level 2 0.00 1,050.00 2900 Fall On the Same Level 2 0.00 1,050.00 7400 Fellow Worker, Patient 1 116.54 116.54 9900 Other Miscellaneous, NOC 1 0.00 525.00 7600 Hand Tool or Machine in Use 1 0.00 0.00 6900 Stepping on Sharp Object 1 0.00 525.00 9900 Other Miscellaneous, NOC 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00 2500 Fall/Slip From a Different Lev 1 0.00 525.00 2500 Fall/Slip From a Different Lev 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 1 0.00 525.00 7400 Fellow Worker, Patient 1 116.54 116.54 6900 Stepping on Sharp Object 1 0.00 525.00 8500 Animal or Insect 1 0.00 0.00 8500 Animal or Insect 1 0.00 0.00 7600 Hand Tool or Machine in Use 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 5 1,768.12 2,818.12 5200 Strain 4 0.00 4,275.00 5200 Strain 4 0.00 4,275.00 1000 Contusion (Bruise, Skin Surfac 5 1,768.12 2,818.12 3700 Inflammation 2 0.00 525.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 9000 Multiple Physical Injuries Onl 2 0.00 1,050.00 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 5999 Unclassified, Insufficient Dat 2 0.00 1,050.00 4300 Puncture 1 0.00 525.00 0700 Concussion (Brain, Cerebral) 1 7.90 7.90 3700 Inflammation 2 0.00 525.00 4300 Puncture 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00 0700 Concussion (Brain, Cerebral) 1 7.90 7.90


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 3 0.00 1,575.00 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 1,700.00 1400 Eye(s) 2 0.00 525.00 1001 Head NEC 1 1,651.58 1,651.58 1002 Face, Multiple Parts 1 116.54 116.54 9000 Multiple Body Parts 3 0.00 1,575.00 1001 Head NEC 1 1,651.58 1,651.58 5500 Ankle 1 0.00 1,525.00 1900 Facial Bones 1 0.00 0.00 5700 Toe(s) 1 0.00 525.00 5500 Ankle 1 0.00 1,525.00 5600 Foot 1 0.00 525.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 5001 Leg, Multiple 1 0.00 525.00 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 1,700.00 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 1100 Skull 1 7.90 7.90 3600 Finger(s) 1 0.00 525.00 5001 Leg, Multiple 1 0.00 525.00 3302 Arm, Multiple 1 0.00 525.00 3600 Finger(s) 1 0.00 525.00 2200 Disc (Neck) 1 0.00 525.00 2200 Disc (Neck) 1 0.00 525.00 1400 Eye(s) 2 0.00 525.00 5600 Foot 1 0.00 525.00 1002 Face, Multiple Parts 1 116.54 116.54 5700 Toe(s) 1 0.00 525.00 1100 Skull 1 7.90 7.90 ALL OTHER CODES 1 0.00 525.00 ALL OTHER CODES 1 0.00 0.00 TOTAL OF CODES 18 1,776.02 10,776.02 TOTAL OF CODES 18 1,776.02 10,776.02


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 164 UNIT 08000 GRADUATE SCHOOL OF MEDICINE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1300 Caught In, Under or Between, N 1 0.00 0.00 1300 Caught In, Under or Between, N 1 0.00 0.00




----- PART/TARGET ----- ----- PART/TARGET ----- 5800 Great Toe 1 0.00 0.00 5800 Great Toe 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 165 UNIT 11000 INSTITUTE OF AGRICULTURE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 8500 Animal or Insect 2 129.69 654.69 4800 Vehicle Upset 1 1,004.42 22,617.60 1600 Hand Tool, Utensil; Not Powere 2 0.00 525.00 8500 Animal or Insect 2 129.69 654.69 3300 Fall/Slip On Stairs 1 0.00 525.00 7907 Plant 1 0.00 525.00 4800 Vehicle Upset 1 1,004.42 22,617.60 3300 Fall/Slip On Stairs 1 0.00 525.00 7907 Plant 1 0.00 525.00 1600 Hand Tool, Utensil; Not Powere 2 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 2 129.69 654.69 2800 Fracture 1 1,004.42 22,617.60 4000 Laceration 2 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 2 129.69 654.69 2800 Fracture 1 1,004.42 22,617.60 7120 All Other Occupational Disease 1 0.00 525.00 7120 All Other Occupational Disease 1 0.00 525.00 4000 Laceration 2 0.00 525.00 3700 Inflammation 1 0.00 525.00 3700 Inflammation 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5400 Lower Leg 2 1,134.11 22,747.29 5400 Lower Leg 2 1,134.11 22,747.29 3600 Finger(s) 2 0.00 525.00 9100 Body Systems & Multiple Body S 1 0.00 525.00 5300 Knee 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 9100 Body Systems & Multiple Body S 1 0.00 525.00 5300 Knee 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 3600 Finger(s) 2 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 166 UNIT 12000 AGRICULTURE EXTENSION (UT EXTENSION SVC CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 4500 Collision with Another Vehicle 1 0.00 525.00 4500 Collision with Another Vehicle 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 167 UNIT 18000 COLLEGE OF VETERINARY SERVICE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6003 Overexertion 1 0.00 525.00 8500 Animal or Insect 1 0.00 525.00 8500 Animal or Insect 1 0.00 525.00 6003 Overexertion 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4101 Back (All Other) 1 0.00 525.00 5200 Upper Leg 1 0.00 525.00 5200 Upper Leg 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 168 UNIT 22000 CHATTANOOGA CLINICAL EDUCATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 3101 Trip 1 0.00 525.00 3101 Trip 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007591 UNIVERSITY OF TENNESSEE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 169 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7500 Falling or Flying Object 7 2,365.59 5,759.48 5300 Twisting 1 7.90 23,028.76 2900 Fall On the Same Level 6 836.37 4,075.00 4800 Vehicle Upset 1 1,004.42 22,617.60 8500 Animal or Insect 6 129.69 2,229.69 5800 Reaching 1 0.00 15,831.72 3300 Fall/Slip On Stairs 5 1,391.30 6,775.00 0100 Chemicals 1 1,503.09 12,866.52 8100 Struck or Injured By, NOC 4 73.09 1,123.09 6001 Bodily Reaction 1 7.90 8,212.98 2700 Fall/Slip From Liquid/Grease S 3 853.24 1,378.24 3300 Fall/Slip On Stairs 5 1,391.30 6,775.00 1600 Hand Tool, Utensil; Not Powere 3 0.00 1,050.00 7500 Falling or Flying Object 7 2,365.59 5,759.48 7600 Hand Tool or Machine in Use 2 525.35 2,800.00 2900 Fall On the Same Level 6 836.37 4,075.00 7907 Plant 2 302.25 827.25 6000 Strain or Injury By, NOC 2 0.00 3,225.00 6800 Stationary Object 2 367.12 892.12 7600 Hand Tool or Machine in Use 2 525.35 2,800.00 3101 Trip 2 0.00 1,050.00 8500 Animal or Insect 6 129.69 2,229.69 6000 Strain or Injury By, NOC 2 0.00 3,225.00 2700 Fall/Slip From Liquid/Grease S 3 853.24 1,378.24 0100 Chemicals 1 1,503.09 12,866.52 8100 Struck or Injured By, NOC 4 73.09 1,123.09 1000 Machine/Machinery 1 421.33 421.33 3101 Trip 2 0.00 1,050.00 ALL OTHER CODES 19 1,753.09 74,798.93 ALL OTHER CODES 23 1,823.57 8,298.57 TOTAL OF CODES 65 10,521.51 119,271.65 TOTAL OF CODES 65 10,521.51 119,271.65

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 16 5,003.89 12,487.59 5200 Strain 10 984.47 53,455.76 5200 Strain 10 984.47 53,455.76 2800 Fracture 1 1,004.42 22,617.60 9000 Multiple Physical Injuries Onl 10 0.00 4,725.00 0400 Burn 2 1,987.12 13,350.55 4000 Laceration 6 0.00 1,050.00 1000 Contusion (Bruise, Skin Surfac 16 5,003.89 12,487.59 3700 Inflammation 5 1,008.36 3,352.25 9000 Multiple Physical Injuries Onl 10 0.00 4,725.00 5999 Unclassified, Insufficient Dat 4 0.00 2,275.00 3700 Inflammation 5 1,008.36 3,352.25 4300 Puncture 3 0.00 1,575.00 5908 Chipped / Broken Tooth 1 525.35 2,800.00 0400 Burn 2 1,987.12 13,350.55 5999 Unclassified, Insufficient Dat 4 0.00 2,275.00 2500 Foreign Body (Eye) 2 0.00 525.00 4300 Puncture 3 0.00 1,575.00 5908 Chipped / Broken Tooth 1 525.35 2,800.00 4000 Laceration 6 0.00 1,050.00 4902 Rotator Cuff 1 0.00 0.00 7120 All Other Occupational Disease 1 0.00 525.00 0100 No Physical Injury 1 0.00 0.00 4200 Poisoning-General (Not OD or C 1 0.00 525.00 4200 Poisoning-General (Not OD or C 1 0.00 525.00 2500 Foreign Body (Eye) 2 0.00 525.00 0700 Concussion (Brain, Cerebral) 1 7.90 7.90 0700 Concussion (Brain, Cerebral) 1 7.90 7.90 ALL OTHER CODES 2 1,004.42 23,142.60 ALL OTHER CODES 2 0.00 0.00 TOTAL OF CODES 65 10,521.51 119,271.65 TOTAL OF CODES 65 10,521.51 119,271.65

----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 14 1,576.18 18,714.61 4200 Low Back Area (Incl. Lumbar & 3 7.90 39,385.48 5300 Knee 4 1,559.35 3,903.24 5400 Lower Leg 2 1,134.11 22,747.29 3600 Finger(s) 4 0.00 1,575.00 9000 Multiple Body Parts 14 1,576.18 18,714.61 1400 Eye(s) 3 0.00 525.00 5500 Ankle 2 7.90 9,737.98 4200 Low Back Area (Incl. Lumbar & 3 7.90 39,385.48 1000 Multiple Head Injury 1 1,391.30 5,200.00 3000 Multiple Upper Extremities 2 302.25 827.25 5300 Knee 4 1,559.35 3,903.24 9100 Body Systems & Multiple Body S 2 0.00 525.00 1600 Teeth 1 525.35 2,800.00 5000 Multiple Lower Extremities 2 0.00 1,225.00 3100 Upper Arm (Incl. Clavicle & Sc 1 0.00 1,700.00 5700 Toe(s) 2 367.12 892.12 1001 Head NEC 1 1,651.58 1,651.58 5500 Ankle 2 7.90 9,737.98 3600 Finger(s) 4 0.00 1,575.00 5400 Lower Leg 2 1,134.11 22,747.29 2102 Cervical 1 836.37 1,450.00 2102 Cervical 1 836.37 1,450.00 5000 Multiple Lower Extremities 2 0.00 1,225.00 1000 Multiple Head Injury 1 1,391.30 5,200.00 5700 Toe(s) 2 367.12 892.12 3500 Hand 1 421.33 421.33 3000 Multiple Upper Extremities 2 302.25 827.25 ALL OTHER CODES 22 2,917.70 12,142.35 ALL OTHER CODES 25 1,162.10 7,462.10 TOTAL OF CODES 65 10,521.51 119,271.65 TOTAL OF CODES 65 10,521.51 119,271.65


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007596 TN CORRECTIONS INSTITUTE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 170 UNIT 31609 TN CORRECTIONS INSTITUTE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2500 Fall/Slip From a Different Lev 1 0.00 525.00 2500 Fall/Slip From a Different Lev 1 0.00 525.00 6002 Bending 1 0.00 0.00 6002 Bending 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 3700 Inflammation 1 0.00 0.00 3700 Inflammation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5300 Knee 1 0.00 0.00 5300 Knee 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41007596 TN CORRECTIONS INSTITUTE LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 171 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2500 Fall/Slip From a Different Lev 1 0.00 525.00 2500 Fall/Slip From a Different Lev 1 0.00 525.00 6002 Bending 1 0.00 0.00 6002 Bending 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 9000 Multiple Physical Injuries Onl 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 3700 Inflammation 1 0.00 0.00 3700 Inflammation 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 1 0.00 525.00 9000 Multiple Body Parts 1 0.00 525.00 5300 Knee 1 0.00 0.00 5300 Knee 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137603 BOARD PROBATION & PAROLES - 32400 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 172 UNIT 32402 PROBATION & PAROLE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6004 Running and Training 1 190.69 525.00 2900 Fall On the Same Level 1 7.90 31,561.82 2900 Fall On the Same Level 1 7.90 31,561.82 6004 Running and Training 1 190.69 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 190.69 525.00 2800 Fracture 1 7.90 31,561.82 2800 Fracture 1 7.90 31,561.82 5200 Strain 1 190.69 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 190.69 525.00 5500 Ankle 1 7.90 31,561.82 5500 Ankle 1 7.90 31,561.82 5300 Knee 1 190.69 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137603 BOARD PROBATION & PAROLES - 32400 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 173 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6004 Running and Training 1 190.69 525.00 2900 Fall On the Same Level 1 7.90 31,561.82 2900 Fall On the Same Level 1 7.90 31,561.82 6004 Running and Training 1 190.69 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 190.69 525.00 2800 Fracture 1 7.90 31,561.82 2800 Fracture 1 7.90 31,561.82 5200 Strain 1 190.69 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5300 Knee 1 190.69 525.00 5500 Ankle 1 7.90 31,561.82 5500 Ankle 1 7.90 31,561.82 5300 Knee 1 190.69 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 174 UNIT 34400 MENTAL RETARDATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 1200 Object Handled 1 10,951.88 49,958.96 1200 Object Handled 1 10,951.88 49,958.96 7400 Fellow Worker, Patient 1 0.00 0.00 7400 Fellow Worker, Patient 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 2800 Fracture 1 10,951.88 49,958.96 2800 Fracture 1 10,951.88 49,958.96 9000 Multiple Physical Injuries Onl 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3600 Finger(s) 1 10,951.88 49,958.96 3600 Finger(s) 1 10,951.88 49,958.96 6100 Abdomen Including Groin 1 0.00 0.00 6100 Abdomen Including Groin 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 175 UNIT 34401 ADMINISTRATION CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5700 Pushing or Pulling 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 525.00




----- PART/TARGET ----- ----- PART/TARGET ----- 4101 Back (All Other) 1 0.00 525.00 4101 Back (All Other) 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 176 UNIT 34410 ARLINGTON DEVELOPMENTAL CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 4500 Collision with Another Vehicle 1 7.90 525.00 4500 Collision with Another Vehicle 1 7.90 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 177 UNIT 34411 CLOVER BOTTOM DEVELOPMENTAL CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 6800 Stationary Object 1 0.00 525.00 5700 Pushing or Pulling 1 0.00 1,800.00 5700 Pushing or Pulling 1 0.00 1,800.00 6800 Stationary Object 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00 5200 Strain 1 0.00 1,800.00 5200 Strain 1 0.00 1,800.00 1000 Contusion (Bruise, Skin Surfac 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 3200 Elbow 1 0.00 525.00 5400 Lower Leg 1 0.00 1,800.00 5400 Lower Leg 1 0.00 1,800.00 3200 Elbow 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 178 UNIT 34412 GREENE VALLEY DEVELOPMENTAL CENTER CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 3 548.98 1,825.00 2900 Fall On the Same Level 1 432.55 8,731.60 2700 Fall/Slip From Liquid/Grease S 2 225.09 525.00 7400 Fellow Worker, Patient 2 1,509.64 3,198.14 7400 Fellow Worker, Patient 2 1,509.64 3,198.14 6001 Bodily Reaction 1 439.60 3,000.00 7500 Falling or Flying Object 2 0.00 1,050.00 5600 Lifting 3 548.98 1,825.00 5300 Twisting 2 0.00 1,050.00 7500 Falling or Flying Object 2 0.00 1,050.00 2500 Fall/Slip From a Different Lev 1 761.80 761.80 5300 Twisting 2 0.00 1,050.00 6001 Bodily Reaction 1 439.60 3,000.00 2500 Fall/Slip From a Different Lev 1 761.80 761.80 2900 Fall On the Same Level 1 432.55 8,731.60 6600 Object Being Lifted or Handled 1 0.00 525.00 5500 Holding or Carrying 1 77.00 525.00 5500 Holding or Carrying 1 77.00 525.00 6600 Object Being Lifted or Handled 1 0.00 525.00 2700 Fall/Slip From Liquid/Grease S 2 225.09 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 10 3,769.57 18,566.54 5200 Strain 10 3,769.57 18,566.54 4900 Sprain 3 0.00 1,050.00 9000 Multiple Physical Injuries Onl 2 225.09 1,050.00 9000 Multiple Physical Injuries Onl 2 225.09 1,050.00 4900 Sprain 3 0.00 1,050.00 2500 Foreign Body (Eye) 1 0.00 525.00 2500 Foreign Body (Eye) 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 2 432.55 8,731.60 4200 Low Back Area (Incl. Lumbar & 2 432.55 8,731.60 9000 Multiple Body Parts 2 761.80 1,286.80 5300 Knee 1 439.60 3,000.00 5500 Ankle 2 0.00 1,050.00 2200 Disc (Neck) 1 311.50 2,000.00 5000 Multiple Lower Extremities 1 225.09 525.00 4100 Upper Back Area (Thoracic Area 1 548.98 1,300.00 3200 Elbow 1 0.00 0.00 9000 Multiple Body Parts 2 761.80 1,286.80 2200 Disc (Neck) 1 311.50 2,000.00 2102 Cervical 1 1,198.14 1,198.14 2102 Cervical 1 1,198.14 1,198.14 5500 Ankle 2 0.00 1,050.00 4100 Upper Back Area (Thoracic Area 1 548.98 1,300.00 5000 Multiple Lower Extremities 1 225.09 525.00 1400 Eye(s) 1 0.00 525.00 4101 Back (All Other) 1 77.00 525.00 5300 Knee 1 439.60 3,000.00 3800 Shoulder(s) 1 0.00 525.00 1002 Face, Multiple Parts 1 0.00 525.00 1400 Eye(s) 1 0.00 525.00 4101 Back (All Other) 1 77.00 525.00 1002 Face, Multiple Parts 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 3200 Elbow 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 179 UNIT 34420 WEST TENNESSEE REGIONAL OFFICE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 2 0.00 1,050.00 5600 Lifting 1 7.90 31,496.24 3100 Fall, Slip or Trip, NOC 1 895.13 11,842.14 3100 Fall, Slip or Trip, NOC 1 895.13 11,842.14 2800 Fall/Slip into Openings 1 0.00 0.00 7400 Fellow Worker, Patient 2 0.00 1,050.00 5600 Lifting 1 7.90 31,496.24 8200 Absorption, Ingestion, or Inha 1 0.00 0.00 8200 Absorption, Ingestion, or Inha 1 0.00 0.00 2800 Fall/Slip into Openings 1 0.00 0.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 2 903.03 43,338.38 5200 Strain 2 903.03 43,338.38 4900 Sprain 1 0.00 0.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 9000 Multiple Physical Injuries Onl 1 0.00 525.00 8000 All Other Cumulative Injuries, 1 0.00 0.00 8000 All Other Cumulative Injuries, 1 0.00 0.00 4900 Sprain 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 5500 Ankle 2 895.13 11,842.14 9000 Multiple Body Parts 1 7.90 31,496.24 1001 Head NEC 1 0.00 525.00 5500 Ankle 2 895.13 11,842.14 9000 Multiple Body Parts 1 7.90 31,496.24 6200 Buttocks 1 0.00 525.00 6200 Buttocks 1 0.00 525.00 1001 Head NEC 1 0.00 525.00 9106 Respiratory System 1 0.00 0.00 9106 Respiratory System 1 0.00 0.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 180 UNIT 34421 MIDDLE TENNESSEE REGIONAL OFFICE CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7900 Object Being Lifted or Handled 1 859.83 1,110.00 7900 Object Being Lifted or Handled 1 859.83 1,110.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 4000 Laceration 1 859.83 1,110.00 4000 Laceration 1 859.83 1,110.00


----- PART/TARGET ----- ----- PART/TARGET ----- 6100 Abdomen Including Groin 1 859.83 1,110.00 6100 Abdomen Including Groin 1 859.83 1,110.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 181 UNIT 34422 East TN Regional Office CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 5600 Lifting 1 0.00 525.00 3300 Fall/Slip On Stairs 1 727.49 727.49 3300 Fall/Slip On Stairs 1 727.49 727.49 5600 Lifting 1 0.00 525.00


----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 1 0.00 525.00 4900 Sprain 1 727.49 727.49 4900 Sprain 1 727.49 727.49 5200 Strain 1 0.00 525.00


----- PART/TARGET ----- ----- PART/TARGET ----- 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00 5300 Knee 1 727.49 727.49 5300 Knee 1 727.49 727.49 4200 Low Back Area (Incl. Lumbar & 1 0.00 525.00



CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 182 UNIT 34440 WEST TENNESSEE COMMUNITY HOME CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 2700 Fall/Slip From Liquid/Grease S 1 0.00 525.00 2700 Fall/Slip From Liquid/Grease S 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 183 UNIT 34442 East TN Homes CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 1 0.00 525.00 7400 Fellow Worker, Patient 1 0.00 525.00







CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 ACCOUNT 41137616 DIV MENTAL RET-34400 EFF 7/1/2004 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 184 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 6 1,509.64 4,773.14 1200 Object Handled 1 10,951.88 49,958.96 5600 Lifting 5 556.88 33,846.24 5600 Lifting 5 556.88 33,846.24 2700 Fall/Slip From Liquid/Grease S 3 225.09 1,050.00 3100 Fall, Slip or Trip, NOC 1 895.13 11,842.14 5700 Pushing or Pulling 2 0.00 2,325.00 2900 Fall On the Same Level 1 432.55 8,731.60 7500 Falling or Flying Object 2 0.00 1,050.00 7400 Fellow Worker, Patient 6 1,509.64 4,773.14 5300 Twisting 2 0.00 1,050.00 6001 Bodily Reaction 1 439.60 3,000.00 1200 Object Handled 1 10,951.88 49,958.96 5700 Pushing or Pulling 2 0.00 2,325.00 4500 Collision with Another Vehicle 1 7.90 525.00 7900 Object Being Lifted or Handled 1 859.83 1,110.00 6800 Stationary Object 1 0.00 525.00 7500 Falling or Flying Object 2 0.00 1,050.00 2500 Fall/Slip From a Different Lev 1 761.80 761.80 5300 Twisting 2 0.00 1,050.00 6001 Bodily Reaction 1 439.60 3,000.00 2700 Fall/Slip From Liquid/Grease S 3 225.09 1,050.00 2900 Fall On the Same Level 1 432.55 8,731.60 2500 Fall/Slip From a Different Lev 1 761.80 761.80 5500 Holding or Carrying 1 77.00 525.00 3300 Fall/Slip On Stairs 1 727.49 727.49 6600 Object Being Lifted or Handled 1 0.00 525.00 6800 Stationary Object 1 0.00 525.00 ALL OTHER CODES 5 2,482.45 13,679.63 ALL OTHER CODES 5 84.90 1,575.00 TOTAL OF CODES 33 17,444.79 122,326.37 TOTAL OF CODES 33 17,444.79 122,326.37

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 15 4,672.60 64,754.92 5200 Strain 15 4,672.60 64,754.92 9000 Multiple Physical Injuries Onl 6 232.99 2,625.00 2800 Fracture 1 10,951.88 49,958.96 4900 Sprain 5 727.49 1,777.49 9000 Multiple Physical Injuries Onl 6 232.99 2,625.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 4900 Sprain 5 727.49 1,777.49 2800 Fracture 1 10,951.88 49,958.96 4000 Laceration 1 859.83 1,110.00 2500 Foreign Body (Eye) 1 0.00 525.00 1000 Contusion (Bruise, Skin Surfac 2 0.00 1,050.00 5900 All Other Injuries, NOC 1 0.00 525.00 5900 All Other Injuries, NOC 1 0.00 525.00 8000 All Other Cumulative Injuries, 1 0.00 0.00 2500 Foreign Body (Eye) 1 0.00 525.00 4000 Laceration 1 859.83 1,110.00 8000 All Other Cumulative Injuries, 1 0.00 0.00


----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 5 777.60 33,833.04 3600 Finger(s) 1 10,951.88 49,958.96 5500 Ankle 4 895.13 12,892.14 9000 Multiple Body Parts 5 777.60 33,833.04 4200 Low Back Area (Incl. Lumbar & 3 432.55 9,256.60 5500 Ankle 4 895.13 12,892.14 6100 Abdomen Including Groin 2 859.83 1,110.00 4200 Low Back Area (Incl. Lumbar & 3 432.55 9,256.60 4101 Back (All Other) 2 77.00 1,050.00 5300 Knee 2 1,167.09 3,727.49 3200 Elbow 2 0.00 525.00 2200 Disc (Neck) 1 311.50 2,000.00 5300 Knee 2 1,167.09 3,727.49 5400 Lower Leg 1 0.00 1,800.00 3600 Finger(s) 1 10,951.88 49,958.96 4100 Upper Back Area (Thoracic Area 1 548.98 1,300.00 5400 Lower Leg 1 0.00 1,800.00 2102 Cervical 1 1,198.14 1,198.14 5000 Multiple Lower Extremities 1 225.09 525.00 6100 Abdomen Including Groin 2 859.83 1,110.00 2200 Disc (Neck) 1 311.50 2,000.00 4101 Back (All Other) 2 77.00 1,050.00 2102 Cervical 1 1,198.14 1,198.14 6200 Buttocks 1 0.00 525.00 4100 Upper Back Area (Thoracic Area 1 548.98 1,300.00 5000 Multiple Lower Extremities 1 225.09 525.00 1400 Eye(s) 1 0.00 525.00 3800 Shoulder(s) 1 0.00 525.00 ALL OTHER CODES 6 0.00 2,625.00 ALL OTHER CODES 7 0.00 2,625.00 TOTAL OF CODES 33 17,444.79 122,326.37 TOTAL OF CODES 33 17,444.79 122,326.37


CLIENT 1376 STATE OF TENNESSEE LOSS ANALYSIS REPORT PREPARED: 06/30/2012 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 185 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 81 34,262.18 322,431.63 7400 Fellow Worker, Patient 81 34,262.18 322,431.63 2900 Fall On the Same Level 57 23,345.18 219,045.47 5600 Lifting 38 38,809.36 319,734.73 3100 Fall, Slip or Trip, NOC 40 26,082.81 171,571.09 8100 Struck or Injured By, NOC 31 19,642.61 222,069.12 5600 Lifting 38 38,809.36 319,734.73 2900 Fall On the Same Level 57 23,345.18 219,045.47 8100 Struck or Injured By, NOC 31 19,642.61 222,069.12 3100 Fall, Slip or Trip, NOC 40 26,082.81 171,571.09 6000 Strain or Injury By, NOC 29 12,233.37 88,237.59 1200 Object Handled 7 17,021.60 97,102.13 3300 Fall/Slip On Stairs 27 16,502.13 74,674.10 5300 Twisting 21 8,508.74 88,751.98 8500 Animal or Insect 27 2,170.41 10,045.41 6000 Strain or Injury By, NOC 29 12,233.37 88,237.59 7500 Falling or Flying Object 26 7,453.76 33,121.18 4500 Collision with Another Vehicle 14 7,354.41 81,226.78 6800 Stationary Object 21 4,255.44 46,274.62 3300 Fall/Slip On Stairs 27 16,502.13 74,674.10 5300 Twisting 21 8,508.74 88,751.98 5700 Pushing or Pulling 16 1,603.15 66,050.66 2700 Fall/Slip From Liquid/Grease S 17 10,525.38 64,635.81 2700 Fall/Slip From Liquid/Grease S 17 10,525.38 64,635.81 5700 Pushing or Pulling 16 1,603.15 66,050.66 4800 Vehicle Upset 3 1,794.92 63,645.04 1900 Cut, Punctured, Scraped, NOC 15 1,267.22 16,927.75 6001 Bodily Reaction 9 2,533.00 63,376.92 ALL OTHER CODES 255 100,981.90 970,409.85 ALL OTHER CODES 311 87,424.80 771,427.94 TOTAL OF CODES 701 307,643.64 2,713,980.99 TOTAL OF CODES 701 307,643.64 2,713,980.99

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 170 72,105.43 762,534.90 5200 Strain 170 72,105.43 762,534.90 1000 Contusion (Bruise, Skin Surfac 129 58,416.24 375,160.17 2800 Fracture 29 70,559.38 610,423.59 9000 Multiple Physical Injuries Onl 91 11,697.59 203,567.64 1000 Contusion (Bruise, Skin Surfac 129 58,416.24 375,160.17 4000 Laceration 53 9,698.43 61,384.94 4900 Sprain 53 34,982.61 268,703.96 4900 Sprain 53 34,982.61 268,703.96 9000 Multiple Physical Injuries Onl 91 11,697.59 203,567.64 5999 Unclassified, Insufficient Dat 29 798.40 64,796.02 1601 Herniated Disc 1 17,048.45 106,536.20 2800 Fracture 29 70,559.38 610,423.59 5999 Unclassified, Insufficient Dat 29 798.40 64,796.02 3700 Inflammation 25 1,495.96 11,264.85 4000 Laceration 53 9,698.43 61,384.94 5900 All Other Injuries, NOC 25 1,762.44 30,019.76 4901 Meniscus Tear 3 9,393.88 55,913.82 4300 Puncture 17 3,341.16 9,641.16 9100 Multiple Injuries Including Bo 1 2,531.01 42,114.24 2500 Foreign Body (Eye) 11 874.50 4,024.50 7800 Carpal Tunnel Syndrome 4 7.90 38,858.20 7300 Contagious Disease 9 3,535.56 4,585.56 5900 All Other Injuries, NOC 25 1,762.44 30,019.76 0100 No Physical Injury 8 641.61 9,358.55 0400 Burn 5 1,987.12 14,925.55 0400 Burn 5 1,987.12 14,925.55 3400 Hernia (Rupture) 1 871.57 12,090.76 ALL OTHER CODES 47 35,747.21 283,589.84 ALL OTHER CODES 107 15,783.19 66,951.24 TOTAL OF CODES 701 307,643.64 2,713,980.99 TOTAL OF CODES 701 307,643.64 2,713,980.99

----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 122 33,873.72 370,681.01 9000 Multiple Body Parts 122 33,873.72 370,681.01 5300 Knee 65 35,524.43 311,764.16 3800 Shoulder(s) 39 20,748.50 332,820.27 4200 Low Back Area (Incl. Lumbar & 47 26,829.47 195,312.35 5300 Knee 65 35,524.43 311,764.16 3800 Shoulder(s) 39 20,748.50 332,820.27 3600 Finger(s) 39 32,834.73 233,823.04 3600 Finger(s) 39 32,834.73 233,823.04 4200 Low Back Area (Incl. Lumbar & 47 26,829.47 195,312.35 1400 Eye(s) 30 4,018.25 29,380.17 6300 Lumbar and/or Sacral Vertebrae 6 24,175.84 148,315.89 5500 Ankle 29 14,983.19 95,712.71 5600 Foot 22 23,467.73 102,571.12 5600 Foot 22 23,467.73 102,571.12 4400 Chest (Incl. Ribs, Sternum & S 12 1,624.94 99,131.91 3500 Hand 22 4,706.20 58,227.62 5500 Ankle 29 14,983.19 95,712.71 1001 Head NEC 20 4,822.97 43,378.32 3400 Wrist 19 9,438.93 92,852.88 3400 Wrist 19 9,438.93 92,852.88 2102 Cervical 9 7,139.25 82,059.68 1002 Face, Multiple Parts 18 7,764.35 73,614.51 1002 Face, Multiple Parts 18 7,764.35 73,614.51 9100 Body Systems & Multiple Body S 17 4,599.16 9,492.16 1900 Facial Bones 3 7,899.03 66,959.56 3200 Elbow 15 6,035.91 22,557.23 3500 Hand 22 4,706.20 58,227.62 ALL OTHER CODES 197 77,996.10 741,793.44 ALL OTHER CODES 249 56,633.33 450,134.28 TOTAL OF CODES 701 307,643.64 2,713,980.99 TOTAL OF CODES 701 307,643.64 2,713,980.99


TOTAL FOR REPORT LOSS ANALYSIS REPORT PREPARED: 06/30/2012 LOSS 04/01/2012 - 06/30/2012 AS OF 06/30/2012 PAGE: 186 CMS UNIT: 810 WC REPORTED BY CLAIM COUNT PAID EXPECTED WC REPORTED BY EXPECTED TOTAL PAID EXPECTED CODE DESCRIPTION COUNT TO DATE TOTAL CODE DESCRIPTION COUNT TO DATE TOTAL ----- CAUSE ----- ----- CAUSE ----- 7400 Fellow Worker, Patient 81 34,262.18 322,431.63 7400 Fellow Worker, Patient 81 34,262.18 322,431.63 2900 Fall On the Same Level 57 23,345.18 219,045.47 5600 Lifting 38 38,809.36 319,734.73 3100 Fall, Slip or Trip, NOC 40 26,082.81 171,571.09 8100 Struck or Injured By, NOC 31 19,642.61 222,069.12 5600 Lifting 38 38,809.36 319,734.73 2900 Fall On the Same Level 57 23,345.18 219,045.47 8100 Struck or Injured By, NOC 31 19,642.61 222,069.12 3100 Fall, Slip or Trip, NOC 40 26,082.81 171,571.09 6000 Strain or Injury By, NOC 29 12,233.37 88,237.59 1200 Object Handled 7 17,021.60 97,102.13 3300 Fall/Slip On Stairs 27 16,502.13 74,674.10 5300 Twisting 21 8,508.74 88,751.98 8500 Animal or Insect 27 2,170.41 10,045.41 6000 Strain or Injury By, NOC 29 12,233.37 88,237.59 7500 Falling or Flying Object 26 7,453.76 33,121.18 4500 Collision with Another Vehicle 14 7,354.41 81,226.78 6800 Stationary Object 21 4,255.44 46,274.62 3300 Fall/Slip On Stairs 27 16,502.13 74,674.10 5300 Twisting 21 8,508.74 88,751.98 5700 Pushing or Pulling 16 1,603.15 66,050.66 2700 Fall/Slip From Liquid/Grease S 17 10,525.38 64,635.81 2700 Fall/Slip From Liquid/Grease S 17 10,525.38 64,635.81 5700 Pushing or Pulling 16 1,603.15 66,050.66 4800 Vehicle Upset 3 1,794.92 63,645.04 1900 Cut, Punctured, Scraped, NOC 15 1,267.22 16,927.75 6001 Bodily Reaction 9 2,533.00 63,376.92 ALL OTHER CODES 255 100,981.90 970,409.85 ALL OTHER CODES 311 87,424.80 771,427.94 TOTAL OF CODES 701 307,643.64 2,713,980.99 TOTAL OF CODES 701 307,643.64 2,713,980.99

----- NATURE/RESULT ----- ----- NATURE/RESULT ----- 5200 Strain 170 72,105.43 762,534.90 5200 Strain 170 72,105.43 762,534.90 1000 Contusion (Bruise, Skin Surfac 129 58,416.24 375,160.17 2800 Fracture 29 70,559.38 610,423.59 9000 Multiple Physical Injuries Onl 91 11,697.59 203,567.64 1000 Contusion (Bruise, Skin Surfac 129 58,416.24 375,160.17 4000 Laceration 53 9,698.43 61,384.94 4900 Sprain 53 34,982.61 268,703.96 4900 Sprain 53 34,982.61 268,703.96 9000 Multiple Physical Injuries Onl 91 11,697.59 203,567.64 5999 Unclassified, Insufficient Dat 29 798.40 64,796.02 1601 Herniated Disc 1 17,048.45 106,536.20 2800 Fracture 29 70,559.38 610,423.59 5999 Unclassified, Insufficient Dat 29 798.40 64,796.02 3700 Inflammation 25 1,495.96 11,264.85 4000 Laceration 53 9,698.43 61,384.94 5900 All Other Injuries, NOC 25 1,762.44 30,019.76 4901 Meniscus Tear 3 9,393.88 55,913.82 4300 Puncture 17 3,341.16 9,641.16 9100 Multiple Injuries Including Bo 1 2,531.01 42,114.24 2500 Foreign Body (Eye) 11 874.50 4,024.50 7800 Carpal Tunnel Syndrome 4 7.90 38,858.20 7300 Contagious Disease 9 3,535.56 4,585.56 5900 All Other Injuries, NOC 25 1,762.44 30,019.76 0100 No Physical Injury 8 641.61 9,358.55 0400 Burn 5 1,987.12 14,925.55 0400 Burn 5 1,987.12 14,925.55 3400 Hernia (Rupture) 1 871.57 12,090.76 ALL OTHER CODES 47 35,747.21 283,589.84 ALL OTHER CODES 107 15,783.19 66,951.24 TOTAL OF CODES 701 307,643.64 2,713,980.99 TOTAL OF CODES 701 307,643.64 2,713,980.99

----- PART/TARGET ----- ----- PART/TARGET ----- 9000 Multiple Body Parts 122 33,873.72 370,681.01 9000 Multiple Body Parts 122 33,873.72 370,681.01 5300 Knee 65 35,524.43 311,764.16 3800 Shoulder(s) 39 20,748.50 332,820.27 4200 Low Back Area (Incl. Lumbar & 47 26,829.47 195,312.35 5300 Knee 65 35,524.43 311,764.16 3800 Shoulder(s) 39 20,748.50 332,820.27 3600 Finger(s) 39 32,834.73 233,823.04 3600 Finger(s) 39 32,834.73 233,823.04 4200 Low Back Area (Incl. Lumbar & 47 26,829.47 195,312.35 1400 Eye(s) 30 4,018.25 29,380.17 6300 Lumbar and/or Sacral Vertebrae 6 24,175.84 148,315.89 5500 Ankle 29 14,983.19 95,712.71 5600 Foot 22 23,467.73 102,571.12 5600 Foot 22 23,467.73 102,571.12 4400 Chest (Incl. Ribs, Sternum & S 12 1,624.94 99,131.91 3500 Hand 22 4,706.20 58,227.62 5500 Ankle 29 14,983.19 95,712.71 1001 Head NEC 20 4,822.97 43,378.32 3400 Wrist 19 9,438.93 92,852.88 3400 Wrist 19 9,438.93 92,852.88 2102 Cervical 9 7,139.25 82,059.68 1002 Face, Multiple Parts 18 7,764.35 73,614.51 1002 Face, Multiple Parts 18 7,764.35 73,614.51 9100 Body Systems & Multiple Body S 17 4,599.16 9,492.16 1900 Facial Bones 3 7,899.03 66,959.56 3200 Elbow 15 6,035.91 22,557.23 3500 Hand 22 4,706.20 58,227.62 ALL OTHER CODES 197 77,996.10 741,793.44 ALL OTHER CODES 249 56,633.33 450,134.28 TOTAL OF CODES 701 307,643.64 2,713,980.99 TOTAL OF CODES 701 307,643.64 2,713,980.99

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Sedgwick Claims Management Services, Inc.treasury.tn.gov/risk/LossControlReports/LossAn-DeptDiv.pdfSedgwick Claims Management Services, Inc. TABLE OF CONTENTS PREPARED: 06/30/2012