Form Par-14-0147 - Workers' Compensation Commissioner - State Of Iowa
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1
2YOUR CLAIM FILE NO.
STATE OF IOWA -- WORKERS' COMPENSATION COMMISSIONER
W.C. COMM. NO.
SUBSEQUENT REPORT OF INJURY
_____________________
(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
TPD
DEA
WEEKS
DAYS $
$
TTD/HP
PTD
TPD
DEA
WEEKS
DAYS
$
$
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)
E5)
Settlement/Commutation approved by W.C. Comm.
BURIAL
PENALTY
(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 (11/03)
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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