Form Par - Payment Activity Report - 2001 Page 2
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2STATE OF IOWA - WORKERS' COMPENSATION COMMISSIONER
PAYMENT ACTIVITY REPORT (FORM PAR)
INSTRUCTIONS
This form is designed to satisfy the various filing requirements of the Iowa Workers’ Compensation Act and Administrative Rules. The form (or photocopy of the front side) is to
be filed with the Iowa Workers’ Compensation Commissioner's Office after completing the sections which reflect the current status of the claim.
THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE § 22.11.
Example:
The period from May 1st thru
SECTION A - NAMES AND ADDRESSES OF THE PARTIES:
May 8th is 8 days of disability,
This section is to be used to provide the complete names and addresses of the
which if subject to the three
insurer (or adjusting company), employee, and employer.
day waiting period is 5 days
payable, or .714 weeks.
SECTION B - REPORT OF CHANGE IN PAYMENT STATUS/COMMENTS:
TPD AMOUNT EARNED
- If TYPE OF PAYMENT checked is TPD,
enter the actual amount of wages earned
from the employer during the period being
This section is to be used to provide information concerning any changes in
reported.
payment status or any comments pertinent to the handling of the claim.
AMOUNT PAID
- Enter the amount paid for the period.
SECTION C - RATE CALCULATION:
Example:
To calculate TTD/HP, PTD, or
DEA multiply the WEEKLY
This section is to be used to verify the employee’s weekly compensation rate.
If
RATE times the decimal
the information upon which the compensation rate is based is the same as the
equivalent of the WEEKS/DAYS
information reflected on the Employer’s First Report of Injury, this form may be
PAYABLE.
filed as a “Rate Agreement.”
If the information upon which the rate is based
differs from the information reflected on the Employer’s First Report of Injury, a
To calculate TPD multiply the
Form 2B must be filed as a “Rate Agreement.”
GROSS WEEKLY WAGE times
the WEEKS/DAYS PAYABLE
minus the TPD AMOUNT
SECTION D - COMMENCEMENT OF PAYMENT NOTICE OR DENIAL:
EARNED during the period
times .66667.
This section is to be used by the insurer to indicate whether or not payment of
disability benefits to the employee have been initiated.
Conversion Rule 876 - 8.6
1 day
=
.143 week
2 days = .286 week
D1.
Check this box if this is a “Commencement of Payment
3 days =
.429 week
4 days = .571 w
eek
Notice” pursuant to 86.13.
5 days =
.714 week
6 days = .857 week
D2.
Check this box if this is “Denial of Liability” pursuant to
7 days = 1.000 week
85.26.
D3.
Check this box if payment of disability benefits is not being
E3.
Enter payment for PPD:
made for reasons other than Denial, then check Insufficient
Lost Time (if disability is 3 days or less), or Other (and
PART OF BODY
- Enter the part of the body upon which
include an explanation).
benefits are based.
% PPD
- Enter extent of disability as a percentage.
NO. OF WEEKS
- Multiply the % PPD times the scheduled
number of weeks for the PART OF BODY
pursuant to 85.34(2) (a-u).
SECTION E - PAYMENT REPORT:
Example:
A 25% loss of an arm equals
This section is to be used by the insurer to report the benefits paid to date, and to
.25 x 250 weeks or 62.5 weeks.
indicate whether an “Interim Report” or “Final Report” is being filed pursuant to
Rule 876 - 3.1(2).
A
ttach a separate sheet if necessary.
AMOUNT PAID
- Multiply the PPD WEEKLY RATE times the
E1.
Check and complete the appropriate box for the type of
NO. OF WEEKS and enter the amount
“Payment Report” being made.
paid.
“Final Report” Disability benefits have been terminated.
Enter
E4.
Enter other benefit payments:
the Date of Last Payment.
“Interim Report” Disability benefits are continuing.
Enter the
TYPE OF BENEFIT - Find the appropriate box(es) for other
Estimated Completion Date when termination
benefits paid.
If a type
of benefit is not
of benefits is anticipated.
shown, specify the type of benefit in the
MISC. box.
The number in parentheses
E2.
Enter the payment(s) for the period(s) of disability:
under each type of benefit refers to the
TYPE OF PAYMENT
- Check if TTD/HP, TPD, PTD, or DEA
section of the Iowa Code applicable to these
benefits.
payments.
DATE BEGAN
- Enter the first date of disability for the
AMOUNT PAID
- Enter the amount paid.
type and period being reported.
E5
Enter settlement/commutation payment(s) approved by the workers'
DATE ENDED
- Enter the last date of disability for the
compensation commissioner:
type and period being reported.
TYPE - Indicate type
SPC S
= Special Case Settlement
WEEKS/DAYS PAYABLE - Enter the number of weeks and days
pursuant to 85.35
Payable during the period.
AGFS
= Agreement for Settlement
pursuant to 86.13
FCOMM = Full Commutation pursuant to
85.45 & 85.47.
PCOMM = Partial Commutation pursuant
to 85.45 & 85.48.
DATE APPROVED - Enter the date the workers' compensation
commissioner approved the settlement/commutation.
AMOUNT - Enter the amount of the settlement/commutation.
E6
Check this box if a “Medical Report” is attached pursuant to rule 876-
3.1(2).
A medical report must be filed if an injury involves PPD or
PTD, or if the disability period exceeds 13 weeks on TTD/HP or TPD.
Please sign and date this report where indicated.
14-0147 back (9-01)
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