Form 9 Wca - Memo Of Payment Of Disability Compensation - The State Of New Hampshire 1994
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1THE STATE OF NEW HAMPSHIRE
DEPA RTMENT OF L ABOR
CONCORD, N.H. 03301
MEMO OF PAY MENT OF
DISABILIT Y COMPENSATION
You are required to pay total disability compensation and to file, with the department, copy to employee, memoran-
dum of payment in accordance with RSA 281-A:40, 41 and 42 as soon as possible after date of knowledge of
disability of four or more days, but no later than seven days thereafter. Filing shall also be made upon making
provisional payment, upon adjusting such payment, upon making last payment, and upon making payment resulting
from departmental hearing. Failure to pay and to file memorandum promptly, in the absence of a legitimate
denial of benefit, shall render a carrier liable to a civil penalty of up to $2,500.
Employee _______________________________________________
_______________________________________________
(Name)
(Soc. Sec. No.)
Employer ________________________________________________
_______________________________________________
(Name)
(Federal Identification No.)
Carrier __________________________________________________
_______________________________________________
(Name)
(Carrier Number Assigned by DOL)
Date of:
Injury
Disability/Recurrence*
First or Sup. Rep. R’cd
First Payment
Last Payment
*Recurrence refers to subsequent periods of disability
Compensation at the rate of $ __________ per week
1
Beginning ___________________________________ Avg. Wkly. Wage of $ __________________________________
Check box if compensation payment results from department hearing decision
Check box if memo indicating provisional payment already filed
Check box if memo indicating adjustment in total disability - RSA 281-A:29
SEE ATTACHED WAGE SCHEDULE, EXCEPT IF DISABILITY OF LESS THAN FOURTEEN DAYS
Missing Wage Schedule
2
When Expected __________________________________
Provisional Payment of $ ______________________ Subject to Later Adjustment
Total Compensation Paid $ ___________________
Ending Date ___________________________________
3
Date of Return to Work __________________ Earning after R.T.W. ________________________________
Name of Employer (New or same) _____________________________________________________________
________________________________________________
________________________________________________
(Date)
(Signature)
Dept. Approval
9 WCA (6-94)
P&P WHSE STOCK #4610
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