IA-2 WORKERS COMPENSATION - SUBSEQUENT REPORT EMPLOYEE NAME (LAST, FIRST, MIDDLE) DATE DISABILITY BEGAN PRE-EXISTING DISABLITY? RELEASED/RETURNED TO WORK (RTW) DATE RELEASED/ RTW QUALIFIER YES # OF DEPENDENTS REPORT EFFECTIVE DATE SOC. SECURITY NUMBER DATE OF DEATH DATE OF REPRESENTATION DATE OF INJURY JURISDICTION REPORT PURPOSE NO RTW WITHOUT RESTRICTIONS RELEASED RTW WITH RESTRICITONS RTW WITH RESTRICTIONS DEATH DEPENDENT PAYEE RELATIONSHIP INSERT # BODY PART PERMANENT IMPAIRMENT JURISDICTION CLAIM NUMBER RELEASED RTW WITHOUT RESTRICTIONS WIDOW CHILDREN PARENTS SIBLINGS HANDICAPPED CHILDREN DATE OF MAXIMUM MED. IMPRVMNT. JURISDICTION FUND WIDOWER OTHER BODY PART PERCENT BODY PART PERCENT EMPLOYER NAME FEIN PERCENT INSURED REPORT NUMBER WAGE AVERAGE WAGE WAGE PERIOD WEEKLY EFFECTIVE DATE OF AVERAGE WAGE CHANGE COMP. RATE EFFECTIVE DATE OF COMP. RATE CHANGE # DAYS WORKED PER WEEK SALARY CONTINUED IN LIEU OF COMP? MONTHLY YES NO PAYMENTS PAYMENT TYPE WEEKLY PYMT AMOUNT PAID FROM (MM/DD/YYYY) AMOUNT PAID TO DATE PAID THROUGH (MM/DD/YYYY) # WEEKS PAID # DAYS PAID BENEFIT ADJUSTMENTS BENEFIT ADJUSTMENT TYPE WEEKLY AMOUNT (+ OR -) START DATE WEEKLY AMOUNT (+ OR -) BENEFIT ADJUSTMENT TYPE START DATE PAID-TO-DATE PAID-TO-DATE (PTD) TYPE PTD AMOUNT RECOVERY TYPE ACTUAL/ DEEMED WEEKLY EARNINGS WEEKLY EARNINGS RECOVERY AMOUNT WK # ACTUAL/ DEEMED PAID-TO-DATE CLAIM ADMINISTRATION INSURER NAME FEIN CLAIM STATUS OPEN REOPENED CLOSED FEIN CLAIM TYPE REOPENED/CLOSED MEDICAL ONLY NOTIFICATION ONLY BECAME LOST TIME INDEMNITY THIRD PARTY ADMINISTRATOR NAME BECAME MED ONLY TRANSFER CLAIM ADMINISTRATOR CLAIM NUMBER AGREEMENT TO COMPENSATE WITHOUT LIABILITY WITH LIABILITY LATE REASON CLAIM ADMINISTRATOR ADDRESS (Include city, state, postal code, and phone number) DATE PREPARED PAGE _____OF_____ IA-2 (1/99 DRAFT) REPRINTED WITH PERMISSION OF IAIABC American LegalNet, Inc. www.USCourtForms.com