Form 9 Wca - Memo Of Payment Of Disability Compensation 1994 printable pdf download

Form 9 Wca - Memo Of Payment Of Disability Compensation 1994

THE STATE OF NEW HAMPSHIRE

DEPARTMENT OF LABOR

CONCORD, NH 03301

MEMO OF PAYMENT OF

DISABILITY COMPENSATION

You are required to pay total disability compensation and to file, with the department, copy to employee, memorandum of

payment in accordance with RSA 281-A:40, 41 and 42 as soon as possible after date of knowledge of disability of four

or more days, but no later than seven days thereafter. Filing shall also be made upon making provisional payment,

upon adjusting such payment, upon making last payment, and upon making payment resulting from departmental hearing.

Failure to pay and to file memorandum promptly, in the absence of a legitimate denial of benefit, shall render a

carrier liable to a civil penalty of up to $2,500.

Employee ______________________________________ _____________________________________

(Name)

(Soc. Sec. No.)

Employer ______________________________________ _____________________________________

(Name)

(Federal Identification No.)

Carrier ______________________________________ _____________________________________

(Name)

(Carrier Number Assigned by DOL)

Date of:

Injury

Disability/Recurrence*

First or Sup. Rep. R’cd

First Payment

Last Payment

*Recurrence refers to subsequent periods of disability

Compensation at the rate of $___________________ per week

Beginning _________________________________________ Avg. WKly. Wage of $_________________________

Check box if compensation payment results from department hearing decision

Chck box if memo indicating provision payment already filed

Check box if memo indicating adjustment in total disability – RSA 281-A:29

SEE ATTACHED WAGE SCHEDULE, EXCEPT IF DISABILITY OF LESS THAN FOURTEEN DAYS

Missing Wage Schedule

When Expected __________________________________

Provisional Payment of $ ________________________ Subject to Later Adjustment

Total Compensation Paid $ _________________________ Ending Date ____________________________

Date of Return to Work ______________________ Earning after R.T.W.___________________________

Name of Employer (New or same) _________________________________________________________

_______________________________________________

____________________________________________________

(Date)

(Signature)

9 WCA (6-94)

Dept. Approval

P&P WHSE STOCK #4610

Form 9 Wca - Memo Of Payment Of Disability Compensation 1994

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