Form 2a - Supplemental Claim Activity Report
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1YOUR CLAIM FILE NO.
STATE OF IOWA -- WORKERS' COMPENSATION COMMISSIONER
W.C. COMM. NO.
SUPPLEMENTAL CLAIM ACTIVITY REPORT
_____________________
(INSTRUCTIONS ON REVERSE SIDE)
___________________
A)
Employee: ________________________________________
INSURANCE COMPANY: ________________________
_________________________________________
Social Security
_____________________________
_______________________________________
Number:
Employer: _______________________________________
______________________________
______________________________________
_______________________________________
B) REPORT OF CHANGE IN PAYMENT STATUS/COMMENTS:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
C) RATE CALCULATION
Injury Date ___________________________
Total Exemptions
_____________________
Weekly Rate __________________________
Marital Status _______________________
Gross Weekly Wage ____________________
PPD Weekly Rate______________________
D) THIS SECTION IS FOR INDICATING WHETHER OR NOT DISABILITY BENEFITS ARE BEING PAID (PAYMENT NOTICE OR DENIAL):
D1)
Check here if this is a Commencement of Payment Notice (enter Date of First Payment: ________________, Date Disability Began
________________ )
D2)
Check here if this is a Denial of Liability
D3)
Check here if benefits are not being paid - reason?
Insufficient lost time
Other (explain:
________________________________________________________________________________________________________________________________ )
THIS SECTION IS NOT TO BE COMPLETED ON THE FORM 2A.
E) THIS SECTION IS FOR
SEE REVERSE SIDE FOR EXPLANATION.
E1)
Check here if th
E2)
Check here if the rate in section C above is incorrect or not shown (attach FORM 2B to show calculations)
THIS SECTION IS FOR REPORTING BENEFITS PAID TO DATE (PAYMENT REPORT):
F)
F1)
Check type of Payment Report:
Final Report
Interim Report
Enter Date of Last Payment:
Enter Estimated Completion Date:
F2)
Payment(s) for period(s) of disability:
PERIODS OF DISABILITY
TYPE OF
WEEKS/DAYS
PAYMENT
IF TPD,
AMOUNT
(CHECK)
DATE BEGAN (thru) DATE ENDED
PAYABLE
AMOUNT EARNED
PAID
TTD/HP
PTD
TPD
DEA
WEEKS
DAYS
TTD/HP
PTD
WEEKS
DAYS
TPD
DEA
F3) Payment for PPD
F4) Other Benefit payments:
PART OF BODY
NO. OF WEEKS
AMOUNT OF
TYPE OF
(SPECIFY)
%PPD
PAID
BENEFIT
TYPE OF BENEFIT
AMOUNT PAID
BENEFIT
AMOUNT PAID
MEDICAL
VOC REHAB
(85.27)
(85.70)
BURIAL
PENALTY
F5) Settlement/Commutation approved by W.C. Commissioner
(85.28)
(86.13)
INTEREST
MISC
TYPE
DATE APPROVED
AMOUNT
(85.30)
(SPECIFY)
F6)
Check here if a Medical Report is attached
____________________________
Prepared by: __________________________________________
Date Prepared:
FORM 2A -- 14-0003 (front) (8-98)
LEGEND: TTD = Temporary Total Disability
HP = Healing Period
TPD = Temporary Partial Disability
PTD = Permanent Total Disability
PPD = Permanent Partial Disability
DEA = Death Benefits
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