Temporary Or Permanent Disability Benefits For Job Related Injuries
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Temporary Or Permanent Disability Benefits For Job Related Injuries Form. This is a Wisconsin form and can be use in Workers Comp.
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Tags: Temporary Or Permanent Disability Benefits For Job Related Injuries, DOA-6026, Wisconsin Workers Comp,
STATE OF WISCONSIN
DEPARTMENT OF ADMINISTRATION
DOA-6026 (R05/2007)
S. 102.08 WIS. STATS.
Division of Enterprise Operations
Bureau of State Risk Management
WORKER’S COMPENSATION
Temporary or Permanent Disability
Benefits for Job Related Injuries
Employee Name
Agency Name
Dates absent from work (mm/dd/yyyy); (for TTD use inclusive dates)
Claim No.
TTD (Temporary Total Disability)
From:
TPD (Temporary Partial Disability)
Date of Injury (mm/dd/yyyy)
To:
Claim Examiner / Rep.
TEMPORARY DISABILITY
$
Maximum weekly wage in effect at time of injury
$
Weekly wage (from WC-13A)
Less than maximum
More than maximum
Renewed disability – s. 102.43(7)
Weekly temporary total disability rate (weekly wage x 66.67%)
(If more than maximum wage use Weekly Rate on chart)
$
TEMPORARY TOTAL DISABILITY CALCULATION
$
per week
x
$
weeks
per day (1/6 of weekly rate) x
• • • • • • • • •
$
days
• • • • • • • • •
$
TOTAL TTD BENEFITS DUE
$
TEMPORARY PARTIAL DISABILITY CALCULATION - % FROM WKC-7359 (WC-13b) List each week separately.
=
% wage loss X
$
TPD rate for week of
to
Sunday
Sunday
=
% wage loss X
$
TPD rate for week of
to
Sunday
Sunday
TOTAL TPD BENEFITS DUE
TOTAL BENEFITS DUE (if combined)
Total amount previously paid
$
$
Date payment due (mm/dd/yyyy)
Concede or Final
Report prepared by (name)
Date (mm/dd/yyyy)
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