Checklist Partial Commutation Form

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CHECKLIST
PARTIAL COMMUTATION
THIS FORM MUST ACCOMPANY THE SETTLEMENT DOCUMENTS
________
All documents must be legible.
________
One set of papers submitted for each date of injury.
________
8 1/2 x 11 white paper (all documents).
876 IAC 8.7
________
Originals and copies clearly identified.
876 IAC 4.16
________
Self addressed stamped envelope (adequate size with sufficient
postage).
876 IAC 4.16
________
First Report of Injury must be filed.
876 IAC 6.2(1)
________
A current Form 9A (Division of Workers’ Compensation form).
876 IAC 6.4
________
Form 9A must be filled out in its entirety and signed by all
parties, including claimant.
876 IAC 3.1(19) and 876 IAC 6.4
________
Updated payment activity report must be filled out in its entirety and
filed with the settlement documents (all calculations should be
identical to those on form 9A).
876 IAC 6.2(2)
876 IAC 3.1(2)
PREPARED BY:__________________ DATE:_________________, ________
print or type
TELEPHONE NUMBER:_________________
14-0019 (7/05)

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