Claim Filing Details Page 1 of 8 TXCOMP Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Flied By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON WEST FIELD OFFICE IE EDI_148 Employer’s First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp.tdi.state.tx.usITXCOMPWeb/noticeNiewFiling.do?Iinkview&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 08/22/2011 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2011 07/01/2012 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 131938623 City State ZIP/Postal Code County Country State/Province/Region AUSTIN Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number CENIKOR FOUNDATION INC 760031861 Self Insured Indicator Sic Code Business Name Address Line 1 Address Line 2 4525 Glenwood Ave City Deer Park State ZIP/Postal Code County Country State? Province! Region Phone Type Phone Country Code Texas 775367901 Harris United States https ://txcomp (di. state.tx. us/TXCOMPWeb/noticeNiewFiling .do?linkview&isBa... 12/10/2018 iiiii rii;iiy U1dIIS Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ED Number urlsdlctIon Green Card Number Foreign ID Country Date of BIrth Gender Marital Status Male Married Was Injured worker married at the time of death? Did Injured worker have any prior No marriages? Number of Dependents Race/Ethnicity Other Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country United States https://txcomp.tdi.state.tx us!TXCOMPWeb/noticeNiewFiling .do?Iink=view&isBa... 12/10/2018 i-’ãë 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer work day 08/19/2011 Cause of Injury Category Cause of Injury Falling or Flying Object How the injury/occupational disease occurred. WHILE STACKING WOOD Did injured worker see No ONE FELL OFF LINE HITTING EE A a doctor? Date of Death Cause of Death A V Have you returned to N work? Provide the date you returned to work If you have returned to work, what is your work status? If you have returned to work, what is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ProvInce/Region If accident occurred outside of Texas give County Name If accident occurred outside of Texas on what date did the injured worker leave Texas .. 12/10/2018 https://txcomp .tdi .state.tx. usITXCOMPWeb/noticeNiewFiling .do?link=view&isBa Claim Filing Details Page 5 of 8 Occupational Disease/Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Injured Body Injured Body red Nature of Injury jred Toe(s) Fracture cartilage - breaking of bone or Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Company’s) Name Supervisor’s First Name Supervisor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor 4525 Glenwood Ave Deer Park Texas 775367901 tjnlted States Occupation and Wage Information Occupation at time of Injury Dati of HIre WAREHOUSE Was Injured worker hired or https://txcomp .tdi state tx us/TXCOMPWebInoticeNiewFiIing .do?link=view&isBa... 12/1012018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Weekly 35000 Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other Items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employer’s Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Provlnce/ Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line I Address LIne 2 City/Town State 2018 https://txcomp .td i .state.tx us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/ Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State? Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Forel9n ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province? Region Phone Type Phone Country Code https://txcomp .tdi state.tx. us/TXCOM PWeb/noticeNiewFilirig .do?linkview&isBa.. 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name FUed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Bad Back to Top https://txcomp .td i statetx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 TXCOMP Claim Details General Claim Details Claim Number Field Office HOUSTON WEST FIELD OFFICE Role Selected IE Representative SubType Selected Role Specific Flied By Filing Status Date Created Created By EDL148 Claim Received Date Claim Established By Employers First Report Injury/Fatality Carrier Claim Number Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number JurisdIction Texas https://txcomp.tdi.state.tx.usITXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/ 2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 04 05/22/2012 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2011 07/01/2012 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 13138623 City State ZIP/Postal Code County Country State/ Province/Region AUSTIN Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 Address LIne 2 City State ZIP/Postal Code County Country State/ProvInce/Region Phone Type Phone Country Code k=view&isBa,,. 12/10/2018 https :Iltxcomp .tdi .state.tx usITXCOMPWeb/noticeNiewFiling do?lin Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin Business Name Address LIne 1 Address LIne 2 City State ZIP/Postal Code Texas County Country State/ Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number 3urlsdictlon Green Card Number Foreign ID Country Date of Birth Gender Marital Status Female Married Was Injured worker married at the time of death? Did injured worker have any prior No marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Other Address Line 2 City/Town State ZIP/Postal Code Texas County Country United States https://txcomp ,tdi state tx us/TXCOM PWeb/noticeNiewFilirig .do?link=view&isBa.. 12/10/2018 Page 4 of 8 Claim Filing Details State/ Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Timeofznjury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. Cumulative, Not Otherwise Classified - all other PSYCHOLOGICAL ABUSE , V Did Injured worker see a doctor? Date of Death Cause of Death No t.’ V Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? It you have returned to work, what Is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region It accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the injured worker leave Texas https://txcomp.tdi.state.tx.usrrXCOMPWeb/noticeNiewFilingdo?Iinkview&isBa.. 12/10/2018 Page 5 of 8 Claim Filing Details Occupational Disease! Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. . Injured Body Finger or Injured Body ired Nature of Injury jred All Other Cumulative Injuries, Not Otherwise Classified Multiple Body Parts Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Company’s) Name Supervisor’s First Name SupervIsor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Cenikor 11111 Katy Fwy Ste 500 FRWY Houston Texas 770792110 United States State/ Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Occupation and Wage Information Occupation at time of Injury Date of Hire COUNSELOR Was Injured worker hired or https://txcomp.tdi .state.tx.usITXCOMPWeb/noticeNiewFiling ,do?link=view&isBa,.. 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Weekly Gross Wages per Pay Period 50000 Hourly Rate Number of hours per week Days worked per week 5 Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Provlnce/ Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line I Address Line 2 City/Town State https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?( name) Representative Information Representative type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line i Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province? Region Phone Type Phone Country Code https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back Back to Top htts ://txcomp ,tdi state.tx. us/TXCOMPWeb/noticeNiewFiling do?link=view&isBa,.. 12/10/2018 Claim Filing Details Page 1 of 8 Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON EAST FIELD OFFICE IE EDI_148 Employer’s First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number iurlsdlction Texas https://txcomp.tdi.state.tx.usITXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 05/05/2011 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2010 07/01/2011 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State/Province/Region Linkage Employer Details Linkage Employer Name FEIN Email Ensured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code BusIness Name Address LIne 1 Address Line 2 City State ZIP/Postal Code County Country State/Province/Region Phone Type Phone Country Code httos://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFilingdoThnk=view&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin Business Name Address LIne 1 Address Line 2 City State ZIP/Postal Code Texas County Country State? Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. i999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of BIrth Gender Marital Status Was injured worker married at Male Single the time of death? Did Injured worker have any prior No marriages? Number of Dependents Race/Ethnicity Other Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country United States https:Iltxcomp.tdi .state.tx usITXCOMPWeb/noticeNiewFiling .do?Iink=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State? Province? Region Phone Type Phone Country Code Phone Area Code V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. On Same Level EE WAS WCPKING WITH A MANCRIL FELL ,\ \, Did Injured worker see a doctor? Date of Death Cause of Death No ,. \ Have you returned to N work? you Provide the date returned to work If you have returned to work, what Is your work status? If you have returned to work, what is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ Province/ Region If accident occurred outside of Texas give County Name If accident occurred outside of Texas, on what date did the injured worker leave Texas https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFilingdo?link=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease? Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Finger or . B0dV Injured Body Part Injured Injured Low Back Area (Lumbar Area & LumboSacral) :; of Strain Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Companys) Name Supervisors First Name Supervlsors Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Fndtn 4525 Glenwood Ave Deer Park Texas 775367901 United States Occupation and Wage Information Occupation at time of Injury DateotHire LABORER Was Injured worker hired or https://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Weekly Pay Period 35000 Gross Wages per Pay Period Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line I Address Line 2 City/Town State https://txcomptdi .state.tx. usITXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State? Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount PaId Paid by whom?( name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code https://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling ,do?Iink=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back to Top &isBa... 12/10/2018 https://txcomp.tdi,state.tx. us/TXCOMPWeb/noticeNiewFiling do?link=view Claim Filing Details Page 1 of 8 V TXCOMP Back Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON EAST FIELD OFFICE IE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp .tdi state.tx usITXCOMPWeb/noticeNiewF lung ,do?link=view&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 07/19/2011 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2010 07/01/2011 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 131938623 City State ZIP/Postal Code County Country State/Province! Region AUS11N Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code BusIness Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State? Province/Region CENIKOR FOUNDATION INC 760031861 4525 Glenwood Ave Deer Park Texas 775367901 Harris United States Phone Type Phone Country Code https://txcomptdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN TPA Name Claim Admin Business Name Address LIne 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/ProvInce/RegIon Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 710776041 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Gender Marital Status Was injured worker married at the time of death? Did injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Male Single No Other Address Line 1 Address LIne 2 City/Town State ZIP/Postal Coda Texas County Country United States https://txcomp.tdi.state.tx us/TXCOMPWeb/noticeNiewFi)ing .do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupatIonal disease occurred. Twisting ED STEPPING OVER PALLET AND TWISTED ANKLE 1’ ‘., Did Injured worker see a doctor? Date of Death Cause of Death No ,\ \- Have you returned O N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what Is your wage status? Address Business Name Address Line I Address LIne 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region If accident occurred outside of Texas give County Name It accident occurred outside of Texas on what date did the injured worker leave Texas https ://txcomp.tdi state. tx. us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa,, 12/10/2018 . Claim Filing Details Page 5 of 8 Occupational Disease! Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One tern found. Injured Body Category Injured Body Part Ankle - Side Injured Toe Injured tarsais Nature of Injury Sprain Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Companys) Name Supervisors First Name Supervisors Last Name Address Line 1. Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Fndtn 4525 Glenwood Ave Deer Park Texas 775367901 United States Occupation and Wage Information Occupation at time of Injury Date of Hire LABORER Was Injured worker hired or recruited in Texas? On what date did injured worker https://txcomp .tdi.state .tx.usrrXCOMPWeb/noticeNiewFihng .do?link=view&isBa... 12/1012018 Page 6 of 8 Claim Filing Details start this position? Pay Period Gross Wages per Pay Period Weekly 35000 Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employer’s Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County httDs://txcomp.tdi. statetx us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 Country State/Province! Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number 3urlsdictlon Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back BacktoTop https://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number FORT WORTH FIELD OFFICE IE EDI_148 Employer’s First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number 3urlsdictlon Texas https://txcomp.tdi state.tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa. 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 03/17/2016 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2015 07/01/2016 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State? Province? Region GRANITE STATE INSURANCE CO 020140690 C P0 Box 13367 Austin Texas 787113367 Travis United States Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State? Province? Region Phone Type Phone Country Code https://txcomp .td i state.tx. us/TXCOM PWeb/noticeNiewFiling .do?link=view&isBa,.. 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country State? Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 710978841 020140690 GRANITE STATE INSURANCE Co. 132925174 AIG CLAIMS INC 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number 3urlsdlctlon Green Card Number Foreign ID Country DateofBlrth Gender Marital Status Was injured worker married at the time of death? Old injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address Line 2 City/Town State Male Single 0 Other ZIP/Postal Code Texas County Country United States https:/Itxcomp.tdi. state.tx us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State? Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Dateof Injury Timeof Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury Moving Parts of Machine How the Injury/occupational disease occurred. WHILE FEEDING A COMPUND INTO A PRESS MACI-lINE THOUGHT THE MACHINE WAS FINISHED AND WAS NOT Did Injured worker see a doctor? Date of Death Cause of Death No IN Have you returned to N work? Provide the date you returned to work If you have returned to work, what is your work status? If you have returned to work, what Is your wage status? Address Business Name Cenikor Fndtn 2209 S Main St Address Line 1 Address Line 2 Fort Worth City/Town Texas State 761102110 ZIP/Postal Code Texas County United States Country State/Province/RegIon If accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the Injured worker leave Texas https://txcomp,tdi.state.tx. us/TXCOMPWeb/noticeNiewF iling.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease! Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Injured Body Category Injured Body Part Finger(s) - Side Injured other than thumb Toe!njured Nature of Injury Amputation Witnesses First Name No information found Last Name Name Suffix / Claim Employer Information Employer’s (Company’s) Name Supervisor’s First Name Supervisor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Fndtn 2209 S Main St Fort Worth Texas 761102110 United States Occupation and Wage Information Occupation at time of Injury Dat• of Hire Was Injured worker hired or recruited In Texas? UNKNOWN On what date did injured worker https ://txcomp tdi .state.tx. usITXCOMPWeb/noticeNiewFilirig do?link=view&isBa.. 12/10/2018 Page 6 of 8 Claim Filing Details start this position? Pay Period Gross Wages per Pay Period Hourly Rate Number of hours per week Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line I Address LIne 2 City/Town State ZIP/Postal Code Texas County https ://txcomp .tdi. state. tx. us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number https://txcomp .tdi state.tx us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back to Top Back a... 12/10/2018 https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?link=view&isB Claim Filing Details Page 1 of 8 I, I TXCOMP Claim Details General Claim Details Claim Number Field Office HOUSTON WEST FIELD OFFICE Role Selected IE Representative Subtype Selected Role Specific Filed By Filing Status Date Created Created By EDI_148 Claim Received Date Claim Established By Employers First Report Injury/Fatality Carrier Claim Number Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp.tdi.state.tx.usrrXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 03/06/2017 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2016 07/01/2017 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 Aig Property Casualty Co 251118791 City State ZIP/Postal Code County Country State/Province? Region Austin Texas C P0 Box 13367 787113367 Travis United States Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State? Province? Region Phone Type Phone Country Code CENIKOR FOUNDATION INC 760031861 4525 Glenwood Ave Deer Park Texas 775367901 Harris United States https://txcomp ,tdi state tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&is8a... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 251118791 CHARTIS PROPERTY CASUALTY Co 132925174 AIG CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Gender Marital Status Female Married Was injured worker married at the time of death? Did injured worker have any prior No marriages? Number of Dependents 0 Race/Ethnicity Other Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country United States https ://txcomp,tdi .state.tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address V USA Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Fall, Slip, Trip, Not Otherwise Classified Cause of Injury How the WALKING IN FROM THE PARKING LOT AND SHE FELL AT Injury/occupatIonal THE FRONT ENTRANCE. disease occurred. V Did Injured worker see a doctor? Date of Death Cause of Death No ‘V Have you returned to N work? you date Provide the returned to work If you have returned to work, what is your work status? If you have returned to work, what is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region If accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the injured worker leave Texas https://txcomp.tdi.state.tx.usITXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease/Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. j,red Body Injured Nature of Injury Injured Skull Fracture breaking of bone or cartilage - Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Companys) Name Supervisor’s First Name Supervisor’s Last Name Address Line 1. Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Foundation I 4525 Glenwood Ave Deer Park Texas 775365999 United States Occupation and Wage Information Occupation at time of Injury Date of Hire NURSE Was Injured worker hired or https://txcomp.tdi .state.tx. usITXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Hourly Rate Number of hours per week Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line I Address Line 2 City/Town State https://txcomp.tdi .state.tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State? Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver LIcense/ID Number Jurisdiction Green Card Number ForeIgn ID Country Date of Birth Address Business Name Address Line 1 Address LIne 2 City/Town State ZIP/Postal Code Texas County Country State/Province? Region Phone Type Phone Country Code https:lltxcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling ,do?link=view&isBa... 12/1 O/2Q1 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back to Top Back isBa... 12/10/2018 httos://txcomD.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?Iink=view& Claim Filing Details Page 1 of 8 V TXCOMP Back Claim Details p. General Claim Details Claim Number Field Office FORT WORTH FIELD OFFICE Role Selected IE Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By EDI_148 Claim Received Date Claim Established By Employers First Report Injury/Fatality Carrier Claim Number Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp.tdi.state.txusrrXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 09/11/2012 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Fiahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2012 07/01/2013 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address LIne 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 131938623 City State ZIP/Postal Code County Country State? Province? Region AUSTIN Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Sell Insured Indicator Sic Code Business Name Address Line 1 Address LIne 2 CENIKOR FOUNDATION INC 760031861 City State ZIP/Postal Code County Country State, Province/Region Fort Worth Texas 761102110 Tarrant United States 2209 S Main St Phone Type Phone Country Code https://txcomp.tdi. statetx. us/TXCOMPWeb/noticeNiewFiling .do?linkview&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of BIrth Gender Marital Status Was Injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Male Single No Other Address Line 2 City/Town Stat. ZIP/Postal Code T•xas County Country United States https://txcomp.tdi .state.tx. us/TXCOM PWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number V USA Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Timeoflnjury Date Reported to Employer first work day Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. 0 Machine or Machinery FINGERS PINCHED BWT STEEL DIE RESULTING IN BOTH HANDS GETTING CAUGHT IN THE BRAKE PRESS V Did Injured worker see a doctor? Date of Death Cause of Death No -.., V Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what Is your wage status? Address Business Name Address Line I Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region If accident occurred outside of Texas give County Name If accident occurred outside of Texas, on what date did the Injured worker leave Texas https://txcomp,tdi.state.tx.us/TXCOMPWeb/noticeNiewFilingdo?link=view&isBa,.. 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease! Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One tern found. Injured Body Category Injured Body Part Side Injured jed Multiple Upper Extremities Nature of Injury Crushing Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Companys) Name Supervisors First Name Supervisors Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ Province/Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Fndtn 2209 S Main St Fort Worth Texas 761102110 United States Occupation and Wage Information Occupation at time of Injury Date of Hire Was Injured worker hired or recruited In Texas? MANUFACTURING On what date did Injured worker https://txcomp .tdi .state.tx us/TXCOM PWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 6 of 8 Claim Filing Details start this position? Pay Period Gross Wages per Pay Period Weekly 50000 Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County https://txcomp .tdi .state,tx. usITXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number )urisdictlon Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number https://txcomp.tdi state.tx. usITXCOM PWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Extension license Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back BacktoTop https://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 Claim Details General Claim Details Claim Number Field Office WACO FIELD OFFICE Role Selected IE Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By EDI_148 Claim Received Date Claim Established By Employer’s FIrst Report Injury/Fatality Carrier Claim Number Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Beneflt Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm ImpaIrments Number of Ptd Red Earnings RecoverIes Jurisdiction Details Agency Claim Number JurisdictIon Texas https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?Iinkview&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 08/01/2015 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Fiahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2015 07/01/20 16 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State/Provlnce/ Region GRANITE STATE INSURANCE CO 020140690 C P0 Box 13367 Austin Texas 787113367 Travis United States Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured IndIcator Sic Code Cenikor Fndtn 760031861 BusIness Name Address LIne 1 11111 Katy Fwy Ste 500 Address LIne 2 City Houston State ZIP/Postal Code County Country State/Province/Region Phone Type Phon• Country Code Texas 770792114 Harris United States https://txcomp td i ,state.tx. us/TXCOM PWeb/noticeNiewFiling .do?linkview&isBa,.. 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country 020140690 GRANITE STATE INSURANCE CO. 132925174 AIG CLAIMS INC 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 State/Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number ForeIgn ID Country Date of BIrth Gender Marital Status Was Injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Female Married No 0 Other United States https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of InJury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Hand Tool, Utensil; Not Powered Cause of Injury How the Injury/occupational disease occurred. lEE SHARPENING t’NIFE CUT HAND /%, V Did Injured worker see a doctor? Date of Death Cause of Death No 1, V Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what Is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region If accident occurred outside of Texas give County Name If accident occurred outside of Texas, on what date did the injured worker leave Texas httDs :Iltxcomp .td I. state.tx. us/TXCOMPWeb/noticeNiewFiling .do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease/Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Injured Body Injured Body Part Nature of Injured Ljre: Hand metacarpals and corresponding muscles Laceration - Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Company’s) Name Supervisors First Name Supervisor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Fndtn 11111 Katy Fwy Hotiston Texas 770792114 United States Occupation and Wage Information Occupation at time of injury Date of Hire COOK Was injured worker hired or https://txcomp.tdi state tx. usITXCOM PWeb/noticeNiewFiling .do?link=view&isBa,.. 12/10/2018 . Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Hourly Rate Number of hours per week Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province? Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second Job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address Line 2 City? Town State https://txcomp.td i state.tx. usITXCOM PWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State! Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type FIrst Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line I Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa ... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back BacktoTop &isBa... 12/10/2018 httos://txcomp.tdi state.tx. us/TXCOMPWeb/noticeNiewFHing .do?Iink=view Claim Filing Details Page 1 of 8 Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number DALLAS FIELD OFFICE JE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings RecoverIes Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp.tdi .state.tx .uslTXCOMPWeblnoticeNiewFihng .do’?link=view&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 08/08/2012 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2011 07/01/2012 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 131938623 City State ZIP/Postal Code County Country State/Province/Region AUSTIN Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State/Province/Region Phone Type Phone Country Code Cenikor Foundation Inc 760031861 11111 Katy Fwy Ste 500 Ste 535 Houston Texas 770792110 Harris United States https ://txcomp.tdi .state.tx. usrrXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN 131938623 COMMERCE INDUSTRY US 132925174 TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Gender Marital Status Was injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Male Single No Other United States https://txcornp.tdi.state.tx. usITXCOM PWeb/noticeNiewFiling .do?linkview&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State? Province/Region Phone Type Phone Country Code Phone Area Code V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. Lifting EE WAS LIFTING A HANGER PLATE ,.‘ V Did Injured worker see a doctor? Date of Death Cause of Death No /%, V Have you returned to N work? Provide the date you returned to work If you have returned to work, what is your work status? If you have returned to work, what Is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region If accident occurred outside of Texas give County Name If accident occurred outside of Texas, on what date did the Injured worker leave Texas https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa.,. 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease/Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. . Finger or . Injured Body Part ired Injured Low Back Area (Lumbar Area & LumboSacral) of Injury Strain Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Company’s) Name Supervisors First Name Supervisors Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Gst 4201 JANADA HALLOM CITY Texas 76107 Texas County Country Unfted States State/ Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Occupation and Wage Information Occupation at time of Injury Oct.01 Hire WftDER Was Injured worker hired or https ://txcomp .tdi state tx usITXCOMPWeb/noticeNiewFiling .do?tink=view&is6a.. 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Weekly 50000 Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other Items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employer’s Business Name Address Line 1. Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province? RegIon Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone ExtensIon Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address Line 2 City/Town State https ://txcomp .td I .state.tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State? Province/ Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region Phone Type Phone Country Cod. https://txcomp .tdi ,state.tx. us/TXCOM PWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back Back to Top https://txcomp .tdi. state.tx usITXCOMPWeb/noticeNiewFiling do?link=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Flied By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number FORT WORTH FIELD OFFICE IE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp .tdi state tx .usITXCOMPWeb/noticeNiewFiling .do?Iink=view&isBa... 12/1012018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 08/03/2016 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2016 07/01/2017 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address LIne 2 Aig Property Casualty Co 251118791 City State ZIP/Postal Code County Country State? Provlnce/ Region Austin Texas 787113367 Travis United States C P0 Box 13367 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code County Country State/Province? Region Phone Type Phon• Country Code Cenikor Fndtn 760031861 11111 Katy Fwy Ste 500 Houston Texas 770792114 Harris United States https://txcomp.tdi,state.tx.usITXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FUN TPA Name Claim Admin Business Name Address LIne 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 251118791 CHARTIS PROPERTY CASUALTY CO 132925174 AIG CLAIMS INC. 1999 BRYANT ST, 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of BIrth Gender Marital Status Was injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Female MarrIed No 0 Other United States https ://txcomp .td I .state.tx. us/TXCOM PWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State? Province? Region Phone Type Phone Country Code PhoneAreaCode V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Timeof Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. Did Injured worker see a doctor? Date of Death Cause of Death From Different Level (Elevation) - off wall, catwalk, bridge, etc. SHE STATED THAT SHE HAD TRIPPED AND FALLEN DOWN SOME STAIRS. TURNING HER ANELE AND SCRAPING HER ARM No Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what is your wage status? Address Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region If accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the Injured worker leave Texas https://txcomp.tdi. state.tx. us/TXCOM PWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 C1am Filing Details Page 5 of 8 Occupational Disease! Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Injured Body Enjured Body ,red Toeed Multiple Body Parts Nature of Injury All Other Specific Injuries, Not Otherwise Classified Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Company’s) Name Supervisors First Name Supervisor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Foundation I 11111 Katy Fwy Ste 500 Houston Texas 770792144 United States Occupation and Wage Information Occupation at time of Injury Date of Hire ADMIN ASSISTANT Was Injured worker hired or https ://txcomp .tdi .state.tx. us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Hourly Rate Number of hours per week Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health Insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address Line 2 City/Town state https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social SecurIty Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code https ://txcomp.tdi .state.tx. usITXCOMPWeb/noticeNiewFiling ,do?Iinkview&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back Back to Top 2018 https://txcomp.tdi.statetx.usITXCOMPWeb/noticeNiewFiling do?link=view&isBa.. 12/10/ Claim Filing Details Page 1 of 8 V TXCOMP Back Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number WACO FIELD OFFICE IE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https://txcomp.tdi.state.tx.usITXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 04 10/24/2013 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2013 07/01/2014 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address LIne 1 Address Line 2 GRANITE STATE INSURANCE CO 020140690 City State ZIP/Postal Code County Country State/Province? Region Austin Texas 787113367 Travis United States C P0 Box 13367 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 Address LIne 2 City State ZIP/Postal Code County Country State/Province/Region Phone Type Phone Country Code https://txcomp.tdi.state.tx. us/TXCOMPWeb/rioticeNiewFiling do?link=view&isBa,.. 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN TPA Name Claim Admin Business Name Address Line 1 Address LIne 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 020140690 GRANITE STATE INSURANCE Co. 132925174 AIG DOMESTIC CLAIMS INC. 1999 ERYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Gender Marital Status Was Injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address LIne 2 City/Town State ZIP/Postal Code Texas County Country Female Married No 0 Other United States https://txcomp.tdi .state.tx. us/TXCOM PWeb/noticeNiewFiling .do?link=view&isBa.. 12/10/2018 Page 4 of 8 Claim Filing Details State? Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. Strain or Injury By, Not Otherwise Classified EE FOUND FACE UP ON THE FLOOR IN BREAKROCN NONRES PONS IVE V Did Injured worker see a doctor? Date of Death Cause of Death No ,\ V Have you returned to work? Provide the date you 10/14/20 13 returned to work If you have returned to work, what Is your work status? I? you have returned to work, what Is your wage status? Address Business Name Address Line I Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region If accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the Injured worker leave Texas https ://txcomp.tdi state. tx. us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa.. . 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease? Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Injured Body Category Injured Body Part Soft Tissue trachea - Side Injured Finger or Injured other than larynx or Nature of IfljUI•1I Strain Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Company’s) Name Supervisors First Name Supervisor’s Last Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Foundation Inc 3015 Herring Ave Waco Texas 767083238 United States Occupation and Wage Information Occupation at time of Injury Date of Hire BEHAVIORAL HEALTH TECH Was Injured worker hired or https ://txcomp .tdi .state ,tx us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa.. 12110/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address LIne 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province? Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address LIne 1 Address Line 2 City/Town State https://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling. do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code https ://txcomp.tdi state tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back BacktoTop https://txcomp.tdi state. tx. us/TXCOMPWeb/noticeNiewFiling.do?link=view&isBa... 12/10/2018 . Claim Filing Details Page 1 of 8 Back Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON WEST FIELD OFFICE IE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https:/Itxcomp .tdi .state.tx uslTXCOMPWeblnoticeNiewFiling.do?link=view&isBa... 12110/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 03/31/2017 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2016 07/01/20 17 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1. Address Line 2 Aig Property Casuaity Co 251118791 City State ZIP/Postal Code County Country State/ProvInce/RegIon Austin Texas 787113367 Travis United States C P0 Box 13367 Linkage Employer Details FEIN CENIKOR FOUNDATION INC 760031861 Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line 1 4525 Glenwood Ave Linkage Employer Name Address Line 2 City State ZIP/Postal Code County Country State/Province? Region Phone Type Phone Country Code Deer Park Texas 775367901 Harris United States https://txcomp.tdi state.tx us/TXCOM PWeb/noticeNiewFiling .do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country 251118791 AIG CASUALTY 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 State/Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Gender Marital Status Was Injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Male Not Reported No 0 Other Address Line 1 Address Line 2 City/Town State ZIP/Postal Code T.xas County Country United States https://txcomp.tdi .state.tx .us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa,.. 12/10/2018 Page 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Object Handled by Others Cause of Injury How the Injury/occupational disease occurred. ANOTHER INDIVIDUAL THREW A BOX IN THE BACK OF A TRUCK AND STRUCK THE INJURED INDIVIDUALS LEG. V Did Injured worker see a doctor? Date of Death Cause of Death No ,\ ‘V Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what Is your wage status? Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ProvInce/Region It accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the Injured worker leave Texas https://txcomp.tdi.state.tx.usITXCOMPWeb/noticeNiewFiling.do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease/Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment’ On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma Injury Details One item found. Injured Body Category Injured Body Part Knee - Side Injured Finger or Nature of Injury Injured patella Contusion-bruise-intact skin surface, hematoma Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Companys) Name Supervisors First Name Supervisors Last Name Address Line 1 Address LIne 2 City/Town State ZIP/Postal Code Texas County Country State/Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Foundation I 4525 Glenwood Ave Deer Park Texas 775365999 United States Occupation and Wage Information Occupation at time of Injury Date of Hire LABORER Was Injured worker hired or https ://txcomp.td I. state tx. usITXCOM PWeb/noticeNiewFiling .do?hnk=view&isBa... 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Pay Period Gross Wages per Pay Period Weekly 26110 Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other Items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address Line 2 City/Town State https://txcomp.tdi.state.tx us/TXCOM PWeb/noticeNiewFiling .do?Iink=view&isBa... 12/10/2018 . Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number JurIsdiction Green Card Number Foreign 10 Country Date of Birth Address Business Name Address Line I Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province? Region Phone Type Phone Country Code https :I/txcomp .td i .state.tx usITXCOMPWeb/noticeNiewFiling .do?link=view&EsBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back BacktoTop https://txcomp.tdi .state.tx. usITXCOMPWeb/noticeNiewFiling.do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 TXCOMP Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role SpecIfic Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON WEST FIELD OFFICE IE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number )urlsdictlon Texas https://txcomp.td i state.tx. us/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa. 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC f4TC Date 00 03/07/2013 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Flahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2012 07/01/2013 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address LIne 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 131938623 City State ZIP/Postal Code County Country State/ Provlnce/ Region AUSTIN Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Selt Insured Indicator Sic Code BusIness Name Address Line 1 Address Line 2 CENIKOR FOUNDATION INC 760031861 City Deer Park Texas 775367901 Harris United States State ZIP/Postal Code County Country State/ProvInce/RegIon Phone Type Phone Country Code 4525 Glenwood Ave https :/Itxcomp.tdi state tx. us/TXCOMPWeb/noticeNiewFiling .do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin Business Name Address LIne 1 Address LIne 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of BIrth Gender Marital Status Was injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Male Single No Other Address Line 1 Address Line 2 City/Town State ZIP/Postal Code T.xas County Country United States https://txcomp .tdi state .tx ,uslTXCOMPWeblnoticeNiewFiling .do?link=view&isBa. . 12/10/2018 Page 4 of 8 Claim Filing Details State? Province? Region Phone Type Phone Country Code Phone Area Code V USA Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupatIonal disease occurred. Did Injured worker see a doctor? Date of Death Cause of Death Cut, Puncture, Scrape, Not Otherwise CIassified EMPLOYEE WAS HOOKING UP TRAILER AND SMASHED HAND WITH FOEFLI FT - No V Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what Is your wage status? Address Business Name Cenikor Foundation Inc 4525 Gienwood Ave Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Deer Park Texas 775365999 Country United States State/Province/Region It accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the Injured worker leave Texas https://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling.do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease? Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. . Injured Body category Injured Body Part Side Injured Finger or Injured Hand metacarpals and corresponding muscles Nature of Injury Laceration - Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Companys) Name Supervisors First Name Supervisors Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province? Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Cenikor Foundation Inc 4525 Glenwood Ave Deer Park Texas 775365999 United States Occupation and Wage Information Occupation at time of Injury Date of HIre LABORER Was injured worker hired or https :Iltxcomp .tdi .state.tx .us/TXCOMPWeb/noticeNiewFiling .do?linkview&isBa. 12/10/2018 Page 6 of 8 Claim Filing Details recruited in Texas? On what date did injured worker start this position? Weekly Pay Period 50000 Gross Wages per Pay Period Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other Items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employers Business Name Address Line 1 Address LIne 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone ExtensIon Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address LIne 2 CIty/Town State https ://txcomp.tdi.state.tx. us/TXCOMPWeb/noticeNiewFiling.do?linkview&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 ZIP/Postal Code Texas County Country State/ Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?( name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line I Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/ Provlnce/ Region Phone Type Phone Country Code https://txcomp .tdi .state tx .us/TXCOMPWeb/noticeNiewFiling do?link=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Area Code Phone Number Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back Back to Top https://txcomp.tdLstate.tx. us/TXCOMPWeb/noticeNiewFiling do?Iink=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 V TXCOMP Back Claim Details F General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Filed By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON EAST FIELD OFFICE IE EDI_148 Employer’s First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Lost Time Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number JurIsdiction Texas https ://txcomp .td I state.tx us/TXCOMPWeb/noticeNiewFiling do?Iink=view&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 11/24/2010 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2010 07/01/2011 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line I Address Line 2 City State ZIP/Postal Code County Country State/Province/Region Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address Line I Address Line 2 City State ZIP/Postal Code County Country State? Province? Region Phone Type Phone Country Code https://txcomp .tdi. state.tx. us/TXCOMPWeb/noticeNiewFUeng.do?Unk=view&isBa... 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPAFEIN 131938623 COMMERCE INDUSTRY US 132925174 TPA Name Claim Admin Business Name Address LIne 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Phone Extension Injured Worker Personal Information FIrst Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number JurIsdictIon Green Card Number Foreign ID Country Date of BIrth Gender Marital Status Was Injured worker married at the time of death? Did Injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Female MarrIed No Other United States https:/Itxcomp.tdistate.tx. usITXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State? Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address V USA Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category Cause of Injury How the Injury/occupational disease occurred. Into Openings - shafts, excavations, floor openings, etc. EM? FELL IN HALLWAY A \, Did Injured worker see a doctor? Date of Death Cause of Death No —‘ \, Have you returned to N work? Provide the date you returned to work If you have returned to work, what is your work status? If you have returned to work, what is your wage status? Address Business Name Cenikor Foundation Inc 7676 Hilimont St Ste 190 Address Line 1 2 Line Address Houston City/Town Texas State 770406467 ZIP/Postal Code Texas County Country United States State? Province? Region It accident occurred outside of Texas give County Name It accident occurred outside of Texas, on what date did the injured worker leave Texas https://txcomp,tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling .do?linkview&isBa,.. 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease/Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment? On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma? Injury Details One item found. Injured Body Category Injured Body Part Side Injured Toe Injured Multiple Body Parts Nature of Injury Strain Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employer’s (Company’s) Name Supervisors First Name Supervisor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Cenikor Foundation Inc 7676 HilImont St Ste 190 Houston Texas 770406467 United States State/ Provlnce/ Region Phone Country Code Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Occupation and Wage Information Occupation at time of injury Date of Hire Was injured worker hired or recruited in Texas? COUNSELOR On what date did injured worker https ://txcomp .tdi state tx us/TXCOM PWeb/noticeNiewFiling .do?Iinkview&isBa... 12/10/2018 Page 6 of 8 Claim Filing Details start this position’ Weekly Pay Period 45560 Gross Wages per Pay Period Hourly Rate Number of hours per week 5 Days worked per week Did injured worker routinely work overtime? Was injured worker provided with health insurance, meals, rent, laundry, fuel or other items which can be estimated in money? Amount Frequency you were furnished this amount. Second Job Second Job Information Non-Claim Employer Employer’s Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/Region Non-Claim Employer Contact First Name Last Name Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Non-Claim Wage Is there a loss of wages from the second job? Weekly amount of loss Treating Doctor Information First Name Last Name Name Suffix Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County https://txcomp ,tdi. state. tx. us/TXCOMPWeb/noticeNiewFIing.do?link=view&isBa... 12/10/2018 Claim Filing Details Page 7 of 8 Country State! Province? Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Beneficiary Information (no beneficiaries) Injured Worker Prior Marriage Details First Name Last Name No information found Name Suffix Date of Divorce Date of Death Address Medical and Burial Expenses Total Medical Bills Amount of Unpaid Bills Was Autopsy Performed? Amount of Funeral Bill Has bill been paid? Amount Paid Paid by whom?(name) Representative Information Representative Type First Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Address Business Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State? Province/Region Phone Type Phone Country Code Phone Area Code Phon. Number https://txcomp.tdi.state.tx. usITXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Page 8 of 8 Claim Filing Details Phone Extension License Number Firm Name Filed On Behalf Information Name of Person Acting on Behalf of Injured Worker Name of Person Acting on Behalf of Beneficiary Back Back to Top https://txcomp,tdi.state.bcus/TXCOMPWeb/noticeNiewFiling .do?link=view&isBa... 12/10/2018 Claim Filing Details Page 1 of 8 Claim Details General Claim Details Claim Number Field Office Role Selected Representative SubType Selected Role Specific Flied By Filing Status Date Created Created By Claim Received Date Claim Established By Carrier Claim Number HOUSTON WEST FIELD OFFICE IE EDI_148 Employers First Report Injury/Fatality Claim Status Details Claim Type Claim Status Agreement to Compensate Late Reason Code Date of Representation Representative Type Medical Only Number Var Segment Details Number of Benefit Adjustments Number of Death Dependent Payee Number of Payment Adjustments Number of Perm Impairments Number of Ptd Red Earnings Recoveries Jurisdiction Details Agency Claim Number Jurisdiction Texas https:/Itxcomp .tdi state .tx.usrrXCOMPWeb/noticeNiewFiling .do’?Iink=view&isBa... 12/10/2018 Page 2 of 8 Claim Filing Details Transaction Details MTC MTC Date 00 04/02/2012 Linkage Carrier Representative Details Carrier Box Number Carrier FEIN Carrier Name 19 741727735 Fiahive Ogden & Latson Policy Details Policy Effective Date Policy Expiration Date Policy Number 07/01/2011 07/01/2012 Linkage Insurer Details Insurer Name Insurer FEIN Insurer Email Insured Type Business Name Address Line 1 Address Line 2 COMMERCE & INDUSTRY INSURANCE CO 131938623 City State ZIP/Postal Code County Country State/Province/Region AUSTIN Texas 78711 Anderson United States C P0 BOX 133677 Linkage Employer Details Linkage Employer Name FEIN Email Insured Location Number Insured Name Insured Reported Number Self Insured Indicator Sic Code Business Name Address LIne 1 Address Line 2 Cenikor Foundation Inc 760031861 City State ZIP/Postal Code County Country Houston Texas 770406467 Harris United States 7676 HilImont St Ste 190 State/Province? Region Phon• Type Phone Country Code https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?Iink=view&isBa. 12/10/2018 Claim Filing Details Page 3 of 8 Phone Area Code Phone Number Phone Extension Fax Country Code Fax Area Code Fax Number Claim Admin Details Claim Admin Claim Number Email Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admln Business Name Address Line 1 Address Line 2 City State ZIP/Postal Code Texas County Country State/Province! Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension 131938623 COMMERCE INDUSTRY US 132925174 AIG DOMESTIC CLAIMS INC. 1999 BRYANT ST. 24TH FLOOR DALLAS Texas 75201 Injured Worker Personal Information First Name Middle Name Last Name Name Suffix Social Security Number Driver License/ID Number Jurisdiction Green Card Number Foreign ID Country Date of Birth Gender Marital Status Was injured worker married at the time of death? Did injured worker have any prior marriages? Number of Dependents Race/Ethnicity Primary Non-English Language Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country Female Married No Other United States https://txcomp.tdi.state.tx.us/TXCOMPWeb/noticeNiewFiling.do?Iinkview&isBa... 12/10/2018 Page 4 of 8 Claim Filing Details State/Province/Region Phone Type Phone Country Code Phone Area Code Phone Number Phone Extension Email Address Claim Information You are reporting an Are you represented by an Attorney or Lay Representative? If yes, date representation began? Date of Injury Time of Injury Date Reported to Employer Date of first work day missed Cause of Injury Category On Same Level Cause of Injury How the injury/occupational disease occurred. SLIPPED AT DOOR AND STRUCK DOOR FRAME Did Injured worker see a doctor? Date of Death Cause of Death No Have you returned to N work? Provide the date you returned to work If you have returned to work, what Is your work status? If you have returned to work, what is your wage status? Address Business Name Cenlkor Fndtn 11111 Katy Fwy Address Line 1 Address Line 2 Houston City/Town Texas State 770792114 ZIP/Postal Code Texas County Country United States State/Province/Region If accident occurred outside of Texas give County Name If accident occurred outside of Texas, on what date did the injured worker leave Texas https://txcomp .td i state tx. us/TXCOM PWeb/noticeNiewFiling .do?ünk=view&isBa... 12/10/2018 Claim Filing Details Page 5 of 8 Occupational Disease? Repetitive Trauma On what date did it first become known that the occupational disease or condition may be related to employment’ On what date was injured worker last exposed to the cause of the occupational disease or repetitive trauma’ Injury Details One item found. Injured Body Injured Body Part ,red Nature of Injury jred Shoulder(s) Armpit, Rotator Cuff, Trapezius, Clavicle, Scapula - Contusion-bruise-intact skin surface, hematoma Witnesses First Name No information found Last Name Name Suffix Claim Employer Information Employers (Company’s) Name Supervisor’s First Name Supervisor’s Last Name Address Line 1 Address Line 2 City/Town State ZIP/Postal Code Texas County Country State/Province/ Region Phone Country Code Phone Area Code Phone Number Phone Cxtension Fax Country Code Fax Area Code Fax Number Cenikor Fndtn 11111 I