IA-2 WORKERS COMPENSATION - SUBSEQUENT REPORT EMPLOYEE NAME (LAST, FIRST, MIDDLE) DATE DISABILITY BEGAN RELEASED/RETURNED TO WORK (RTW) DATE RELEASED/ RTW QUALIFIER # OF DEPENDENTS DEATH DEPENDENT PAYEE RELATIONSHIP INSERT # DATE OF REPRESENTATION PRE-EXISTING DISABLITY? YES DATE OF DEATH JURISDICTION REPORT PURPOSE NO JURISDICTION CLAIM NUMBER RELEASED RTW WITHOUT RESTRICTIONS RTW WITHOUT RESTRICTIONS RELEASED RTW WITH RESTRICITONS RTW WITH RESTRICTIONS BODY PART PERMANENT IMPAIRMENT REPORT EFFECTIVE DATE DATE OF INJURY 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 THIRD PARTY ADMINISTRATOR NAME FEIN FEIN CLAIM ADMINISTRATOR CLAIM NUMBER CLAIM STATUS OPEN CLOSED REOPENED/CLOSED CLAIM TYPE MEDICAL ONLY NOTIFICATION ONLY BECAME LOST TIME INDEMNITY BECAME MED ONLY TRANSFER AGREEMENT TO COMPENSATE REOPENED WITHOUT LIABILITY WITH LIABILITY LATE REASON CLAIM ADMINISTRATOR ADDRESS (Include city, state, postal code, and phone number) DATE PREPARED PAGE _____OF_____ IA-2 (rev. 11/11 IWCC) REPRINTED WITH PERMISSION OF IAIABC American LegalNet, Inc. www.FormsWorkFlow.com