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DATE DISABILITY BEGAN

WORKERS COMPENSATION - SUBSEQUENT REPORT
SOC. SECURITY NUMBER DATE OF INJURY REPORT EFFECTIVE DATE JURISDICTION PRE-EXISTING DISABLITY? YES NO RTW WITHOUT RESTRICTIONS RTW WITH RESTRICTIONS WIDOW WIDOWER PERCENT CHILDREN SIBLINGS RELEASED RTW WITHOUT RESTRICTIONS RELEASED RTW WITH RESTRICITONS PARENTS HANDICAPPED CHILDREN BODY PART JURISDICTION FUND OTHER PERCENT BODY PART PERCENT DATE OF MAXIMUM MED. IMPRVMNT. JURISDICTION CLAIM NUMBER DATE OF REPRESENTATION DATE OF DEATH REPORT PURPOSE

EMPLOYEE NAME (LAST, FIRST, MIDDLE)

RELEASED/RETURNED TO WORK (RTW) DATE

RELEASED/ RTW QUALIFIER

# OF DEPENDENTS

DEATH DEPENDENT PAYEE RELATIONSHIP INSERT # BODY PART

PERMANENT IMPAIRMENT EMPLOYER NAME

FEIN

INSURED REPORT NUMBER

WAGE
WAGE PERIOD WEEKLY MONTHLY 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

PAYMENTS
PAYMENT TYPE WEEKLY PYMT AMOUNT AMOUNT PAID TO DATE PAID FROM (MM/DD/YYYY) PAID THROUGH (MM/DD/YYYY) # WEEKS PAID # DAYS PAID

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 ACTUAL/ DEEMED WK # WEEKLY EARNINGS ACTUAL/ DEEMED WEEKLY EARNINGS

PAID-TO-DATE
RECOVERY TYPE RECOVERY AMOUNT

CLAIM ADMINISTRATION
INSURER NAME FEIN CLAIM STATUS OPEN CLOSED THIRD PARTY ADMINISTRATOR NAME FEIN CLAIM TYPE MEDICAL ONLY INDEMNITY CLAIM ADMINISTRATOR CLAIM NUMBER AGREEMENT TO COMPENSATE CLAIM ADMINISTRATOR ADDRESS (Include city, state, postal code, and phone number) LATE REASON REOPENED REOPENED/CLOSED NOTIFICATION ONLY BECAME MED ONLY WITHOUT LIABILITY WITH LIABILITY BECAME LOST TIME TRANSFER

DATE PREPARED

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IA-2 (1/99 DRAFT)

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