Form 74 Wca - Report Of Extended Disability
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1THE STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
CONCORD, NH 03301
REPORT OF EXTENDED DISABILITY
This form shall be completed by the Insurer or Self-Insurer and filed with the Department on every
case where total disability benefits are anticipated to or have continued for six months as required by
Administrative Rule Lab 509.03 in accordance with RSA 281-A:25.
Claimant_______________________________________________ S.S. No.___________________
(First Name)
(Middle Initial)
(Last name)
Address__________________________________________________________________________
(No.)
(Street/P.O. Box or RFD No.)
(City/Town)
(State)
(Zip Code)
Telephone Number____________________________
(Area)
(Number)
Check (√): Male
Female
Single
Married
Age___________
Education, Circle Highest: 1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4
(Primary)
(Secondary)
(College)
Injury Date___________________________ Disability Date_______________________________
(Mo.)
(Day)
(Year)
(Mo.)
(Day)
(Year)
Nature and Location of Injury_________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Employer’s Name__________________________________________________________________
Office Address____________________________________________________________________
(No.)
(Street/P.O. Box or RFD No.)
(City/Town)
(State)
(Zip Code)
Telephone Number___________________________ Employer’s I.D. #______________________
Carrier Name_________________________________________ Carrier #_____________________
Address__________________________________________________________________________
Date employer was contacted as to claimant’s return to employment__________________________
Employer’s response: Yes
No
___________________________________________
(Name of Person Contacted)
If yes, in what capacity______________________________________________________________
__________________________
_______________________________________________
(Date)
(Carrier Representative’s Signature)
74 WCA (7-89)
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