Free Report of Claim Status - SF 38911 - Indiana


File Size: 465.3 kB
Pages: 1
Date: May 19, 2009
File Format: PDF
State: Indiana
Category: Workers Compensation
Author: sbundy
Word Count: 552 Words, 3,710 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.in.gov/icpr/webfile/formsdiv/38911.pdf

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INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204

REPORT OF TEMPORARY TOTAL DISABILITY (TTD) TERMINATION / REDUCTION
State Form 38911 (R5 / 4-09)

* Your Social Security number is being requested by this state agency in accordance with IC 22-3-4-13; disclosure is voluntary, and you will not be penalized for refusal. INSTRUCTIONS: 1. 2. You must report all compensation payments on this prescribed form. (IC 22-3-3-7) Mail to the Worker's Compensation Board at the above address.
Accident number

Date of injury (month, day, year)

CLAIM INFORMATION
Name of employer Address of employer (number and street, city, state, and ZIP code) Name of insurer Address of insurer (number and street, city, state, and ZIP code) Name of adjuster / case manager Name of employee Address of employee (number and street, city, state, and ZIP code) Telephone number E-mail address Telephone number E-mail address Employee Social Security number * Insurer claim number Federal identification number Telephone number

(

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(

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(

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BENEFIT TERMINATION / REDUCTION (check all that apply) In accordance with IC 22-3-3-7 (c), TTD benefits are terminated due to the following (check all that apply): The employee has returned to ANY employment for (name of employer) ; The employee has died; The employee has refused to undergo a medical examination or treatment ordered by treating physician; The employee has refused to accept suitable employment; The employee has received five hundred (500) weeks of TTD benefits or has been paid the maximum compensation allowed under IC 22-3-3-22; The employee is unable or unavailable to work for reasons unrelated to the compensable injury. (IF BOXES BELOW ARE CHECKED, YOU MUST ATTACH MEDICAL DOCUMENTATION.) TTD benefits shall be reduced to the appropriate Temporary Partial Disability (TPD) because employee has been released to part time work suitable to employee's disability. Employer intends to terminate TTD benefits on (must be at least 4 days after mailing or 2 days after personal service) because: Treating physician has released employee to full time light duty work and employer has appropriate light duty work available. Treating physician finds employee has reached MMI and/or employee has returned to full time work (check one): With restrictions Without restrictions Other
Explanation

COMPENSATION PAYMENTS All compensation payments should be reported to the Board on the below prescribed form (IC 22-3-3-7).
Average weekly wage Number of weeks paid Check one. Weekly rate Start date of payments (month, day, year) Reason(s) for ending payments Total amount paid

$
Paid to (name)

$

$

Employee Dependent EMPLOYEE'S OBJECTION TO TERMINATION OF TTD BENEFITS Employees who disagree with proposed benefit termination must complete, sign and return a copy of this form to the Worker's Compensation Board and the employer within seven (7) days after receipt of this notice. Please check all that apply. Employee disagrees with the termination / reduction of benefits. Employee requires further medical care. Employee believes an independent medical examination (IME) may be helpful to resolve this dispute.
Explanation

EMPLOYER CERTIFICATION / RECEIPT OF EMPLOYEE / DEPENDENT Employer and employee must sign below to certify service or acknowledge receipt of this notice.

I certify that the foregoing is true and that a copy of the relevant medical documentation is attached.
Signature of employer Printed name Date signed (month, day, year) By (check one):


Signature of employee Printed name

US Mail

Personal service

Date signed (month, day, year) By (check one):



US Mail

Personal service