Direct Costs to the Organization |
| Workers' compensation benefits |
$_______________ |
| Healthcare costs |
$_______________ |
| Increases in medical insurance premiums |
$_______________ |
| Auto insurance and liability claims and settlements |
$_______________ |
| Physical and vocational rehabilitation costs |
$_______________ |
| Life insurance and survivor benefits |
$_______________ |
| Group health insurance dependent coverage |
$_______________ |
| Property damage (equipment, products, etc.) |
$_______________ |
| Motor vehicle repair and replacement |
$_______________ |
| EMS costs (ambulance or medivac helicopter) |
$_______________ |
| Vehicle towing, impoundment and inspection fees |
$_______________ |
| Municipality or utility fees for damage to roads, signs or poles |
$_______________ |
| |
| Direct Total |
$_______________ |
| |
Indirect Costs |
| Supervisor's time (rescheduling, making special arrangements) |
$_______________ |
| Fleet manager's time to coordinate vehicle repair, replacement, etc. |
$_______________ |
| Reassignment of personnel to cover for missing employees (less efficient) |
$_______________ |
| Overtime pay (to cover work of missing employees) |
$_______________ |
| Employee replacement |
$_______________ |
| Re-entry and retraining of injured employees |
$_______________ |
| Administrative costs (documentation of injuries, treatment, absences, crash investigation) |
$_______________ |
| Inspection costs |
$_______________ |
| Failure to meet customer requirements resulting in loss of business |
$_______________ |
| Bad publicity, loss of business |
$_______________ |
| |
| Indirect Total |
$_______________ |
| |
| TOTAL |
$_______________ |
