District of Columbia Government Office of Workers325 Compensation Washington, DC 2001 (202) 671-1000 !!!"#$%&'!#(!(%")*!+),-'"$!#(!&#-+'".)$%#"!+),-'"$.! Employee Name and Address: Employer Name and Address:! Insurer Name and Address:! !!! ! ! INSTRUCTIONS: This notice must be filed with the Office of Workers325 Compensation, P.O. Box 56098, Washington, D.C. 20011, within 16 days after compensation has ended, subject to civil penalty. Date and time of Injury: Date of Last Payment: Date employee returned to work: Date employee lost pay because of injury: Date employee able to return to work, per physician325s report of work ability: Was compensation paid at the maximum rate? ! Yes ! NO Average weekly wage $ multiplied by 2/3 = Compensation rate $ State reasons for ending of payments: Enter All Disability Payments TYPE OF DISABILITY FROM (mo-day-yr) To (mo-day-yr AMT. PAID PER WEEK NO. OF WEEKS PAID TOTAL Temporary total Temporary partial Permanent Partial (non- schedule) Permanent Partial (Schedule loss, facial or other disfigurement) Percent Part of Body Total $ ENTER OTHER PAYMENTS a. Attorney fees b. Penalty for late payment c. Interest TOTAL: Name of insurance carrier or self- insured employer Signature of person authorized to sign for carrier TITLE EMPLOYEE PLEASE READ CARFULLY If you have any permanent impairment of the body or other disability from the injury for which you have not received compensation, you should inform the Director at the above address of same, and request Form No. 7a DCWC in order to preserve your claim and rights under the law. Form No. 15 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