Form Par - Payment Activity Report - 2001
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1
2YOUR CLAIM FILE NO.
STATE OF IOWA -- WORKERS' COMPENSATION COMMISSIONER
W.C. COMM. NO.
PAYMENT ACTIVITY REPORT
_____________________
(COMPLETE FORM IN ENTIRETY)
_______________
A)
Employee: _______________________________________________
INSURANCE COMPANY:
___________________________________
_______
Social Security
_________________________________________
Number
_______________________________________________
:
Employer: _______________________________________________
_______________________________________________
_______________________________________________
B)
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 FOR REPORTING BENEFITS PAID TO DATE (PAYMENT REPORT):
E)
E1)
Check type of Payment Report:
�
�
Final Report
Interim Report
Enter Date of Last Payment:
Enter Estimated Completion Date:
E2)
Payment(s) for period(s) of disability:
TYPE OF PAYMENT
PERIOD(S) OF DISABILITY
WEEKS/DAYS
IF TPD
AMOUNT
AMOUNT
(CHECK)
DATE BEGAN
(thru) DATE ENDED
PAYABLE
EARNED
PAID
TTD/HP
PTD
WEEKS
DAYS
$
$
TPD
DEA
TTD/HP
PTD
WEEKS
DAYS
$
$
TPD
DEA
E3)
Payment for PPD:
E4)
Other benefit payments:
PART OF BODY
% PPD
NO. OF
AMOUNT
TYPE OF
AMOUNT
TYPE OF
AMOUNT
(SPECIFY)
WEEKS
PAID
BENEFIT
PAID
BENEFIT
PAID
MEDICAL
VOC REHAB
(85.27)
(85.70)
Settlement/Commutation approved by Workers' Compensation Comm .
BURIAL
PENALTY
E5)
(85.28)
(86.13)
TYPE
DATE APPROVED
AMOUNT
INTEREST
(85.30)
MISC (SPECIFY)
E6)
Check here if a Medical Report is attached.
Prepared by: __________________________________________
Date Prepared: ____________________________
FORM PAR -- 14-0147 (9-01)
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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