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