Workers Compensation Form Subsequent Report
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1IA-2
WORKERS COMPENSATION - SUBSEQUENT REPORT
REPORT
EMPLOYEE NAME (LAST, FIRST, MIDDLE)
DATE OF INJURY
JURISDICTION
EFFECTIVE DATE
DATE DISABILITY BEGAN
PRE-EXISTING DISABLITY?
DATE OF REPRESENTATION
DATE OF DEATH
REPORT PURPOSE
YES
NO
RELEASED/RETURNED TO
RELEASED/
RTW WITHOUT RESTRICTIONS
RELEASED RTW WITHOUT RESTRICTIONS
JURISDICTION CLAIM NUMBER
WORK (RTW) DATE
RTW
QUALIFIER
RELEASED RTW WITH RESTRICITONS
RTW WITH RESTRICTIONS
# OF DEPENDENTS
DATE OF MAXIMUM MED. IMPRVMNT.
DEATH DEPENDENT
WIDOW
CHILDREN
PARENTS
JURISDICTION FUND
PAYEE RELATIONSHIP
INSERT #
WIDOWER
SIBLINGS
HANDICAPPED CHILDREN
OTHER
BODY PART
BODY PART
BODY PART
PERCENT
PERCENT
PERCENT
PERMANENT
IMPAIRMENT
EMPLOYER NAME
FEIN
INSURED REPORT NUMBER
WAGE
AVERAGE WAGE
EFFECTIVE DATE OF
COMP. RATE
EFFECTIVE DATE OF
# DAYS WORKED
SALARY CONTINUED IN
WAGE PERIOD
AVERAGE WAGE CHANGE
COMP. RATE CHANGE
PER WEEK
LIEU OF COMP?
WEEKLY
MONTHLY
YES
NO
PAYMENTS
WEEKLY PYMT
PAID FROM
PAID THROUGH
# WEEKS
# DAYS
AMOUNT PAID TO DATE
PAYMENT TYPE
AMOUNT
(MM/DD/YYYY)
(MM/DD/YYYY)
PAID
PAID
BENEFIT ADJUSTMENTS
WEEKLY AMOUNT
WEEKLY AMOUNT
BENEFIT ADJUSTMENT TYPE
START DATE
BENEFIT ADJUSTMENT TYPE
START DATE
(+ OR -)
(+ OR -)
PAID-TO-DATE
WEEKLY
WEEKLY
PTD AMOUNT
ACTUAL/ DEEMED
WK #
ACTUAL/ DEEMED
PAID-TO-DATE (PTD) TYPE
EARNINGS
EARNINGS
PAID-TO-DATE
RECOVERY TYPE
RECOVERY AMOUNT
CLAIM ADMINISTRATION
INSURER NAME
FEIN
OPEN
REOPENED
CLAIM
STATUS
CLOSED
REOPENED/CLOSED
FEIN
BECAME LOST
THIRD PARTY ADMINISTRATOR NAME
MEDICAL ONLY
NOTIFICATION ONLY
CLAIM
TIME
TYPE
INDEMNITY
BECAME MED ONLY
TRANSFER
CLAIM ADMINISTRATOR CLAIM NUMBER
WITHOUT LIABILITY
AGREEMENT TO
COMPENSATE
WITH LIABILITY
CLAIM ADMINISTRATOR ADDRESS (Include city, state, postal code, and phone number)
LATE REASON
DATE PREPARED
PAGE
_____OF_____
IA-2 (rev. 11/11 IWCC)
REPRINTED WITH PERMISSION OF IAIABC
Please mail to IWCC, 4500 S. Sixth Street Frontage Road, Springfield, IL 62703.
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