CLAIM CLOSURE

The following questions should be addressed before submitting a claim to the department for closure.  The answer to these questions should be on the SIF-5 or documented in the claim file.

(When requesting closure, the SIF-5 is submitted to the department along with a complete copy of the claim file exclusive of medical bills.  Documents already submitted to the Department do not have to be resubmitted.)

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1.  Has all time loss been paid?  First three days?  Was the time loss compensation rate correct?  Was the July 1 COLA paid?

2.  Has all the loss of earning power been paid? Was it computed correctly?  Have you included your computations?

3.  Have health care benefits been addressed and reported?

4.  Have vocational issues been addressed and disputes resolved, if applicable?

5.  Is the closing medical less than 6 months old?

6.  Were all contended medical conditions addressed?

7.  Were all accepted conditions addressed in the closing medical?

8.  Has permanent partial disability previously been paid or advanced?

9.  Is there any permanent impairment related to this injury or disease?

10.  If there is permanent impairment, has the examining doctor expressed it correctly?

11.  If an independent medical examination was obtained for closure, did you request/receive attending physician concurrence?

12.  If requesting a wage order, is the required documentation included in the request as outlined in the applicable SIF5A?

13.  Is the SIF5 complete and accurate?  Correct box checked indicating closure request?  Claim number correct?  Have all the requirements been met for reporting time loss and LEP?  Periods of payment and total amount paid?  Worker’s address correct?  Attending physician name/address correct?

 

If you have any questions, please call the Self Insurance Section at 360-902-6901 to speak with the adjudicator assigned to the claim.