Workers Compensation - Subsequent Report {IA-2}

IA-2 DATE DISABILITY BEGAN WORKERS COMPENSATION - SUBSEQUENT REPORT 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 # OF DEPENDENTS RELEASED/ RTW QUALIFIER DEATH DEPENDENT PAYEE RELATIONSHIP INSERT # BODY PART PERMANENT IMPAIRMENT EMPLOYER NAME FEIN INSURED REPORT NUMBER WAGE WAGE PERIOD WEEKLY MONTHLY WEEKLY PYMT AMOUNT PAID FROM (MM/DD/YYYY) PAID THROUGH (MM/DD/YYYY) 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 # WEEKS PAID NO # DAYS PAID PAYMENTS PAYMENT TYPE AMOUNT PAID TO DATE 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 CLAIM TYPE OPEN CLOSED MEDICAL ONLY INDEMNITY AGREEMENT TO COMPENSATE LATE REASON REOPENED REOPENED/CLOSED NOTIFICATION ONLY BECAME MED ONLY WITHOUT LIABILITY WITH LIABILITY BECAME LOST TIME TRANSFER THIRD PARTY ADMINISTRATOR NAME FEIN CLAIM ADMINISTRATOR CLAIM NUMBER CLAIM ADMINISTRATOR ADDRESS (Include city, state, postal code, and phone number) DATE PREPARED PAGE _____OF_____ IA-2 (rev. 11/11 IWCC) Please mail to IWCC, 4500 S. Sixth Street Frontage Road, Springfield, IL 62703. REPRINTED WITH PERMISSION OF IAIABC American LegalNet, Inc. www.FormsWorkFlow.com