05/25/2006                      Confidential Company Name                           Page: 1
18:20:18             Aetna WC Claim #200505047780001 as of 04/30/2006                     
                                                                                           
                             C L A I M   D E T A I L

Adjustor: Aetna/2005       Claim Status: R-ReOpened   Occurred: 05/02/2005 12:00
Claim No: 200505047780001    Closed  On:           Client Told: 05/03/2005     1
Coverage: WC-WC              Deleted On:              TPA Told: 05/03/2005     0

  Clmnt/Occ: Confidential Name (Age 29)/Salesman(77 Months)
 Supervisor: Confidential Name
   Location: ABC12345678-Confidential Location Name                State: IL

             -----------------------Accident Description---------------------
             The ee was delivering 45 pounds of product to an upstairs
             location when he felt pain in his groin area and his knees.   

  Body Part: 9000-Multiple Body Parts
      Cause: 6000-Strain/Injury by NOC
     Result: 3400-Hernia (Rupture)
     Nature: 0008-Lifting
     Injury: 
     Agency: 
  Job Class: 8810-Clerical
 Causative Agent: 
   Severe Injury: 
  Special Status: Deferred

      -------Paid------- -----Reserves----- -----Incurred----- -----YTD Cost-----
  Med:          3,430.61             730.39           4,161.00           1,599.93
  Ind:              0.00               0.00               0.00
  Lgl:              0.00               0.00               0.00
  Exp:          1,145.27              33.98           1,179.25 ----Total Cost----
  Tot:          4,575.88             764.37           5,340.25           6,690.25

                        V A L U A T I O N   H I S T O R Y

  AsOf Date  St  -------Paid------- -----Reserves----- -----Incurred-----
  03/31/2006  R            4,575.88             764.37           5,340.25
  02/28/2006  R            4,534.35             118.27           4,652.62
  01/31/2006  R            3,740.32             912.30           4,652.62
  10/31/2005  C            3,740.32               0.00           3,740.32
  09/30/2005  C            3,731.22               0.00           3,731.22
  08/31/2005  O            3,551.22          11,351.18          14,902.40
  06/30/2005  O              685.25               0.00             685.25
  05/31/2005  O                0.00               0.00               0.00

                             C O S T   H I S T O R Y

  AsOf Date  --Location-- -------Paid------- ----Total Cost---- ----MTH Charge----
  03/31/2006 ABC12345678            5,925.88           6,690.25             687.63
  02/28/2006 ABC12345678            5,884.35           6,002.62               0.00
  01/31/2006 ABC12345678            5,090.32           6,002.62             912.30
  10/31/2005 ABC12345678            5,090.32           5,090.32               9.10
  09/30/2005 ABC12345678            5,081.22           5,081.22         -11,171.18
  08/31/2005 ABC12345678            4,901.22          16,252.40          14,217.15
  06/30/2005 ABC12345678            2,035.25           2,035.25             685.25
  05/31/2005 ABC12345678            1,350.00           1,350.00           1,350.00

05/25/06 18:20        Aetna WC Claim #200505047780001 as of 04/30/2006              Page: 1
05/25/2006                      Confidential Company Name                           Page: 2
18:20:18              Aetna WC Claim #200505047780001 as of 04/30/2006                     
                                                                                           
                         A C C I D E N T   H I S T O R Y

  -Loss Date- --Adjustor-- --Cov-- ------Claim #------ St ----Total Cost----
  05/02/2005  Aetna        WC      ** This Claim **    R            6,690.25
 
             The ee was delivering 45 pounds of product to an upstairs
             location when he felt pain in his groin area and his knees.   
 
  07/26/2004  Liberty      WC      WC608513570         C            1,276.46
 
             07/26/04 Cfr 00-00-00 Delivering Products When He Felt Pain In H
             is Groin Area That Continued To Get Worse                       
 
  05/27/2004  Liberty      WC      WC608508441         C              416.04
 
             05/27/04Cfr 00-00-00   Making A Delivery And Dog Sniffed Employe
             e And Then Bit Employee On Right Lower Leg                      
 
  07/21/2003  Liberty      WC      WC608473387         C           23,308.62
 
             07/22/03 Cfr 00/00/00  Pulling Package From Crate When He Felt Pa
             in In Lower R Groin Area                                        
 
  06/26/2000  Kemper       WC      792CU092687         F           17,063.46
 
             REPETITIVE JOB DUTIES-HERNIA GROIN

05/25/06 18:20        Aetna WC Claim #200505047780001 as of 04/30/2006              Page: 2