Free Form IA-2 - Kentucky

IA-2

WORKERS COMPENSATION ­ SUBSEQUENT REPORT
Social Security Number Date of Injury Report Effective Date Jurisdiction

Employee Name (last, First, Middle)

Date Disability Began Released/Returned to Work (RTW) Date # of Dependents

Pre-Existing Disability?

Date of Representation

Date of Death

Report Purpose

Permanent Impairment Employer Name WAGE Wage Period Weekly PAYMENT Monthly

YES NO Released RTW Without Restrictions Released RTW Without Restrictions Jurisdiction Claim Number /RTW RTW With Restrictions Released RTW With Restrictions Qualifier Death Dependent/ Widow Children Parents Jurisdiction Fund Date of Maximum Payee Relationship Medical Imprvmnt? Widower Siblings Handicapped Children Other (insert #) Body Part Percent Body Part Percent Body Part Percent FEIN Insured Report Number

Average Wage

Effective Date of Average Wage Change

Comp Rate

Effective Date of Comp Rate Change

# Days Worked Per Week

Salary Continued in Lieu of Comp? YES NO # Weeks Paid # Days Paid

Payment Type

Weekly Pymt Amnt

Amount Paid to Date

Paid From (MM/DD/YY)

Paid Through (MM/DD/|YY)

BENEFIT ADJUSTMENTS Benefit Adjustment Type Weekly Amount (+ or -) Start Date Benefit Adjustment Type Weekly Amount (+ or -) Start Date

PAID-TO-DATE Paid to Date (PTD Type) PTD Amount

REDUCED EARNINGS Actual/ WK Weekly Deemed # Earnings

Actual/ Deemed

WK #

Weekly Earnings

RECOVERIES Recovery Type Recovery Amount

CLAIM ADMINISTRATION Insurer Named Third Party Administrator Name

FEIN FEIN

Claims Status

Claim Administrator Claim Number Claim Administrator Address (Include City, State, Postal Code, and Phone Number)

Open Closed Claim Medical Type Only Indemnity Agreement to Compensate

Reopened Reopened/Closed Notification Only Became Med Only Without Liability With Liability

Became Lost Time Transfer

Late Reason Date Prepared Page of

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IA-2 (10/95 Draft)