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IVETAIL <br /> ED REVIEW CHECK LIST <br /> Page 3 <br /> Claim No:- _ Claimant Name: 4 7 <br /> COMPLIANCE<DOCUMENTATION <br /> DATE ACTIONIRESPONSE <br /> 4 5 <br /> - 116 y <br /> 1E." <br /> 57 <br /> I, �_- --._.— -_..._._... _...__-........._...._..... ._._ .__.... ..._---_-.•---__..__ ..-_ -._._ . .._-_._. Continued on Reverse <br /> trGlN ,QF:CORI�CTIIIE AGTIOAf COMPLIANCE <br /> Claimant in Corrective Action Compliance <br /> Claimant NOT.in Corrective Action Compliance-at the Time of this Review- 90 Day Letter Required <br /> Claimant NOT in-Corrective Action Compliance - Recommend Rejection <br /> LEAD AGENCY i9NATURE. U DATE// <br /> �P <br /> CLAIMS REVIEWER SIGNATURE DATE <br /> VGJ <br /> USTCF025.DET (Rev 1195) QxtkLR.4.=:, <br />