Virginia Workers' Compensation Commission

Claims Transaction Report

Report Title: FROI - EDI Jurisdictional Claim Number: VA00000332215
Report Type: Original (00) Date Acknowledged: 20100904

Section Page
Detailed Claimant Information 2
Detailed Claim Administrator Information 3
Detailed Insurer Information 3
Detailed Employer Information 3
Detailed Insured Information 3
Detailed Injury Information 4

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Detailed Claimant Information
First Name: CATHERINE Middle Name: E
Last Name: ELLSWORTH Last Name Suffix: [No data]
Employee ID: XXXXX0743 Phone Number: 7573049128
ID Type: Employee Social Security Number (S)
Mailing Address Line 1: 31133 DARDEN STREET
Mailing Address Line 2: [No data]
Mailing City: FRANKLIN Mailing State Code: VA
Mailing Country Code: US Mailing Postal Code: 23851
Date of Birth: 19661122 Date of Death: [No data]
Marital Status: Married (M)
Gender: F Number of Dependents: 0
Manual Classification: Adult day care center--professional employees (MA) (8833)

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Detailed Claim Administrator Information
Claim Administrator Name: THE FRANK GATES SERVICE COMPANY
Claim Administrator FEIN: [No data]
Mailing Address Line 1: 5000 BRADENTON AVE
Mailing Address Line 2: [No data]
Attention Line: [No data]
Mailing City: DUBLIN Mailing State Code: OH
Mailing Postal Code: 430173534
Mailing Country Code: [No data] Alternate Postal Code: 23219
Claim Admin Claim Number: 20100040006520

Detailed Insurer Information

Insurer FEIN: 546024817
Insurer Name: COMMONWEALTH OF VIRGINIA
Insurer Type: Self-Insurer (S)

Detailed Employer Information

Employer Name: DEERFIELD CORRECTIONAL CENTER
Employer FEIN: 546001735
Mailing Address Line 1: 21360 DEERFIELD DR
Mailing Address Line 2: [No data]
Mailing City: CAPRON Mailing State Code: VA
Mailing Country Code: US Mailing Postal Code: 23829
Industry Code:
Policy Number: 7777

Detailed Insured Information

Insured Report Number: [No data] Insured FEIN: 546001735
Insured Name: DEERFIELD CORRECTIONAL CENTER
Insured Type: Self-Insured (S)

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Detailed Injury Information
Date of Injury: 20100903 Time of Injury: 0205
Claim Type: Notification Only (Notification Only)
Nature of Injury: Contusion (10)
Cause of Injury: Person in Act of a Crime (89)
Death Result of Injury: [No data]
Accident Site Postal Code: 23829
Part of Body Injured: Eye - Soft Tissue (18)
Jurisdiction Claim Number: VA00000332215 Jurisdiction: Virginia
Date Claim Administrator Had Knowledge of Injury: 20100903
Date Employer Had Knowledge of Injury: 20100903
Initial Date Disability Began: 20100904
Initial Return to Work Date: [No data]
Late Reason: [No data]
Accident/Injury Description Narrative: EE STATES WAS CHANGING HIS BRIEF HE THEN HIT MEON TOP
OF RIGHT EYE

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