WORKSHEET FOR TEMPORARY PARTIAL DISABILITY *Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Employee Name Employee Social Security Number* Employer Name Injury Date Insurance Company Name (not adjusting company) Each period of Temporary Partial Disability (TPD) is to be entered as a line of compensation on the WKC-13-E. Use this form only to verify the TPD rate. Figure TPD on a weekly basis, Sunday to Saturday. This worksheet is provided for informational use only by Insurance Companies, Self-Insurers and Third Party Administrators. Data must be submitted through the Worker's Compensation Pending Reports Internet Application Are the wages reported in column 4 below from the job the employee had at the time of injury? If Yes, compute and pay TPD using the "actual" wages in column 5 below that were used to set the TTD rate. If No, are the earnings from a second job that was held at the time of injury? wages were used to set the TTD rate) Note: If earnings were not from the same job held at the time of injury or were from another full-time or part-time job held at the time of injury and "expanded" wages were not used to set the TTD rate, pay TTD, not TPD. 1 2 3 4 5 6 7 8 9 Week Ending Hours Emp. Worked At Hourly Rate Wages Earned Weekly Wage at Time of Injury Wage Loss % of Wage Loss TTD Rate TPD Rate x-noneTOTALx-none x-none0x-noneWKC-7359 (R. 06/2017) Yes No No Yes American LegalNet, Inc. www.FormsWorkFlow.com