Section 11.107. Documentation of loss.

(1) A claim shall be accompanied by documentation of loss,  if available, and the amount of loss sustained. Documentation of loss, if available at the time of application, shall include all of the following:

(a)   A copy of the police report of the accident.

(b)   A medical examination report.

(c)   Medical bills.

(d)  Work loss verification.

(e)   Additional information as required by the assigned claims  facility or servicing insurer.

(2)   A medical examination report shall include all  of  the  following information:

(a)   The date of examination.

(b)   Probable cause and diagnosis of injury.

(c)   Treatment and prescribed medication.

(d)    Prognosis  and  probable   date  the  patient  may  return      to      work,      where applicable.

(e)   Signature, name, address, and professional designation of  the  person furnishing the medical services or preparing the medical report.

(3)   A medical bill shall contain  an  itemized  list  of  the  services rendered and the dates of the services and charges  or  the   medication supplied and the dates supplied and charges. The bill shall contain identifying information of the person or organization   furnishing   the services or medication.

(4)   An application for survivor's benefits shall be accompanied     by    a copy of the death certificate of the deceased person.

History: 1979 AC; 1989 AACS.