YOUR CLAIM FILE NO. _____________________ STATE OF IOWA -- WORKERS' COMPENSATION COMMISSIONER PAYMENT ACTIVITY REPORT (COMPLETE FORM IN ENTIRETY) W.C. COMM. NO. _______________ A) INSURANCE COMPANY:__________________________________________ __________________________________________ Employee: ___________________________________ Social Security Number: ______________________________________ Employer: ____________________________________ _____________________________________ _____________________________________ B) COMMENTS: _____________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ____________ __________________________________________________________________________________________________________________________ ____________ C) RATE CALCULATION - Section 85.36( ) Total Exemptions ______________________________ Weekly Rate _____________________________ PPD Weekly Rate_________________________ Gross Weekly Wage ____________________________ Injury Date ______________________________ Marital Status ___________________________ D) THIS SECTION IS FOR INDICATING WHETHER OR NOT DISABILITY BENEFITS ARE BEING PAID (PAYMENT NOTICE OR DENIAL): D1) Check here if this is a Commencement of Payment Notice (enter Date of First Payment: ________________, Date Disability Began ________________ ) D2) Check here if this is a Denial of Liability D3) Check here if benefits are not being paid - reason? Insufficient lost time Other (explain: _______________________________________ ) E) THIS SECTION IS FOR REPORTING BENEFITS PAID TO DATE (PAYMENT REPORT): E1) Check type of Payment Report: Final Report Enter Date of Last Payment: E2) Payment(s) for period(s) of disability: TYPE OF PAYMENT (CHECK) TTD/HP TPD TTD/HP TPD E3) Payment for PPD: PART OF BODY (SPECIFY) % PPD NO. OF WEEKS AMOUNT PAID PTD DEA PTD DEA PERIOD(S) OF DISABILITY DATE BEGAN (thru) DATE ENDED WEEKS/DAYS AMOUNT PAYABLE WEEKS WEEKS E4) TYPE OF BENEFIT DAYS $ DAYS $ EARNED $ $ PAID IF TPD AMOUNT Interim Report Enter Estimated Completion Date: Other benefit payments: AMOUNT PAID TYPE OF BENEFIT AMOUNT PAID MEDICAL (85.27) E5) Settlement/Commutation approved by W.C. Comm. (85.28) TYPE DATE APPROVED AMOUNT (85.30) E6) Check here if a Medical Report is attached Prepared by: __________________________________________ HP = Healing Period TPD = Temporary Partial Disability PTD = Permanent Total Disability VOC REHAB (85.70) BURIAL (86.13) PENALTY INTEREST MISC (SPECIFY) FORM PAR -- 14-0147 (10-10) LEGEND: TTD = Temporary Total Disability Date Prepared: ____________________________ DEA = Death Benefits PPD = Permanent Partial Disability American LegalNet, Inc. www.FormsWorkFlow.com STATE OF IOWA - WORKERS' COMPENSATION COMMISSIONER PAYMENT ACTIVITY REPORT (FORM PAR) INSTRUCTIONS This form is designed to assist with meeting the various filing requirements of the Iowa Workers' Compensation Act and Administrative Rules. The form (or photocopy of the front side) is to not be filed with the Iowa Workers' Compensation Commissioner's Office, except to support settlement applications. THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE § 22.11. SECTION A - NAMES AND ADDRESSES OF THE PARTIES: This section is to be used to provide the complete names and addresses of the insurer (or adjusting company), employee, and employer. Example: The period from May 1st thru May 8th is 8 days of disability, which if subject to the three day waiting period is 5 days payable, or .714 weeks. TPD AMOUNT EARNED - If TYPE OF PAYMENT checked is TPD, enter the actual amount of wages earned from the employer during the period being reported. AMOUNT PAID - Enter the amount paid for the period. Example: To calculate TTD/HP, PTD, or DEA multiply the WEEKLY RATE times the decimal equivalent of the WEEKS/ DAYS PAYABLE. To calculate TPD multiply the GROSS WEEKLY WAGE times the WEEKS/DAYS PAYABLE minus the TPD AMOUNT EARNED during the period times .66667. Conversion Rule 876 - 8.6 3 days = .429 week 5 days = .714 week 7 days = 1.000 week 1 day = .143 week 4 days = .571 week 6 days = .857 week 2 days = .286 week SECTION B - REPORT OF CHANGE IN PAYMENT STATUS/COMMENTS: This section is to be used to provide information concerning any changes in payment status or any comments pertinent to the handling of the claim. SECTION C - RATE CALCULATION: This section is to be used to verify the employee's weekly compensation rate. If the information upon which the compensation rate is based is the same as the information reflected on the Employer's First Report of Injury, this form may be filed as a "Rate Agreement." If the information upon which the rate is based differs from the information reflected on the Employer's First Report of Injury, a Form 2B must be filed as a "Rate Agreement." SECTION D - COMMENCEMENT OF PAYMENT NOTICE OR DENIAL: This section is to be used by the insurer to indicate whether or not payment of disability benefits to the employee have been initiated. D1. D2. D3. Check this box if this is a "Commencement of Payment Notice" pursuant to 86.13. Check this box if this is "Denial of Liability" pursuant to 85.26. Check this box if payment of disability benefits is not being made for reasons other than Denial, then check Insufficient Lost Time (if disability is 3 days or less), or Other (and include an explanation). E3. Enter payment for PPD: PART OF BODY - Enter the part of the body upon which benefits are based. % PPD - Enter extent of disability as a percentage. NO. OF WEEKS - Multiply the % PPD times the scheduled number of weeks for the PART OF BODY pursuant to 85.34(2) (a-u). Example: A 25% loss of an arm equals .25 x 250 weeks or 62.5 weeks. AMOUNT PAID - Multiply the PPD WEEKLY RATE times the NO. OF WEEKS and enter the amount paid. SECTION E - PAYMENT REPORT: This section is to be used by the insurer to report the benefits paid to date, and to indicate whether an "Interim Report" or "Final Report" is being filed pursuant to Rule 876 - 3.1(2). Attach a separate sheet if necessary. E1. Check and complete the appropriate box for the type of "Payment Report" being made. E4. "Final Report" - Disability benefits have been terminated. Enter the Date of Last Payment. "Interim Report"- Disability benefits are continuing. Enter the Estimated Completion Date when termination of be