District of Columbia Government Office of Workers325 Compensation Washington, DC 2001 (202) 671-1000 !!!"#$%!%&!'()$#*+!%&!,%-.#-/0!1%$2#*/(+3%*! Employee Name and Address: Employer Name and Address:! Insurer Name and Address:! !!! ! ! The employer is required to pay disability compensation and to file with the Office of Workers325 Compensation (OWC), copy to employee, memorandum of payment in accordance with Section 16, as soon as possible after date of knowledge of injury, but by the fourteenth day thereafter. Filling shall also be made upon making provisional payment, adjusting such payment, and upon making payment resulting from an OWC award. Failure to pay and to file memoranda promptly, in the absence of a legitimate denial of benefit, shall subject the employer to an added ten percent (10%) of payment. Date and time of Injury: Description of Injury: Disability/Recurrence First Supplemental Report- Received Date 1st Payment 2nd Payment Date Compensation at the rate of $ per week. Average weekly wage of $ . Beginning Compensation payment voluntary 000 Yes 000 No Compensation payment results from OWC hearing award 000 Yes 000 No Memo indicating provisional payment already filed 000 Yes 000 No Memo indicating adjustment in total disability 000 Yes 000 No See attached wage schedule, except if maximum compensation or disability is less than seven (7) days. Missing wage schedule 000 Yes 000 No When expected? Provisional Payment of $ , subject to later adjustment. Name (Please Print or Type) Office Approval & Date Signature Telephone Number Form No. 9 DCWC 9-2492 Date of This Report Employee Social Security No. Employer Identification No. Insurer No. ! Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. American LegalNet, Inc. www.FormsWorkFlow.com