REPORT OF TEMPORARY TOTAL DISABILITY (TTD) / TEMPORARY PARTIAL DISABILITY (TPD) TERMINATION State Form 38911 (R8 / 1-14) INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204 Telephone: (317) 232-3808 www.in.gov/wcb * Your Social Security number is being requested by this state agency in accordance with IC 22-3-4-13; disclosure is voluntary, and you will not be penalized for refusal. INSTRUCTIONS: 1. 2. You must report all compensation payments on this prescribed form. (IC 22-3-3-7) Mail to the Worker's Compensation Board at the above address. Accident number Date of injury (month, day, year) CLAIM INFORMATION Name of employer Address of employer (number and street, city, state, and ZIP code) Name of insurer Address of insurer (number and street, city, state, and ZIP code) Name of adjuster / case manager Name of employee Address of employee (number and street, city, state, and ZIP code) Telephone number E-mail address Telephone number E-mail address Employee Social Security number * Insurer claim number Federal identification number Telephone number ( ) ( ) ( ) BENEFIT TERMINATION / REDUCTION (check all that apply) In accordance with IC 22-3-3-7 (c), TTD/TPD benefits have been terminated due to the following (check all that apply): The employee has returned to ANY employment; The employee has died; The employee has refused to accept suitable employment under Section 11 (IC 22-3-3-11); The employee has refused to undergo a medical examination under Section 6 (IC 22-3-3-6); The employee has received five hundred (500) weeks of TTD benefits or has been paid the maximum compensation allowed under IC 22-3-3-22; The employee is unable or unavailable to work for reasons unrelated to the compensable injury. Other (IF CHECKED, MEDICAL DOCUMENTATION MUST BE SERVED ON INJURED PARTY.) TTD benefits shall be terminated and Temporary Partial Disability (TPD) begun because employee has been released to part time work suitable to employee's disability. Employer intends to terminate TTD/TPD benefits on __________ (must be at least four (4) days after mailing or two (2) days after personal service) because: Treating physician has released employee to full time light duty work and employer has appropriate light duty work available. Treating physician finds employee has reached MMI and/or employee is released to full time work (check one): With restrictions Without restrictions Explanation COMPENSATION PAYMENTS Average weekly wage Number of weeks paid Check one. Weekly rate Start date of payments (month, day, year) Reason(s) for ending payments End date (month, day, year) $ Total amount paid $ Employee Dependent $ EMPLOYEE'S OBJECTION TO TERMINATION OF TTD BENEFITS If the employee disagrees with the proposed benefit termination, the employee must complete, sign and return a copy of this notice to the Worker's Compensation Board and the employer within seven (7) days after receipt. This notice can also be filed via the Dispute Termination of Benefits link on the Board's website. Please check all that apply. Employee disagrees with the termination / reduction of benefits. Employee requires further medical care. Employee believes an independent medical examination (IME) may be helpful to resolve this dispute. Explanation EMPLOYER CERTIFICATION / RECEIPT OF EMPLOYEE / DEPENDENT Employer and employee must sign below to certify service or acknowledge receipt of this notice. I certify that the foregoing is true and that a copy of the relevant medical documentation is attached. Signature of employer Printed name Signature of employee Printed name Date of service (month, day, year) By (check one): US Mail Personal service Date received (month, day, year) By (check one): US Mail Personal service American LegalNet, Inc. www.FormsWorkFlow.com