Notice Of Suspension Of Compensation And Or Benefits {54217}

NOTICE OF SUSPENSION OF COMPENSATION AND/OR BENEFITS State Form 54217 (R / 3-13) INDIANA WORKER'S COMPENSATION BOARD 402 W Washington Street, Room W196 Indianapolis, IN 46204 Jurisdiction claim number * PRIVACY NOTICE: This agency is requesting disclosure of your Social Security number in accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing. NOTICE is hereby given that the employer intends to suspend compensation and/or benefits for a compensable injury under the Indiana Worker's Compensation Act for the reason listed below. EMPLOYER AND CARRIER INFORMATION Name of employer Address (number and street, city, state, and ZIP code) Name of Insurance Carrier / Third Party Administrator Address (number and street, city, state, and ZIP code) Claim number of insurer Federal Identification number ADJUSTER / ATTORNEY INFORMATION Name of adjuster / attorney (typed or printed) Address (number and street, city, state, and ZIP code) Telephone number Fax number E-mail address Date signed (month, day, year) ( ) ( ) Signature of adjuster / attorney EMPLOYEE INFORMATION Injured workers shall not receive temporary total or partial disability payments, death benefits, employer directed treatment, or partial impairment payments, reimbursement for unauthorized medical care, and may not be entitled to have a case heard, until such refusal ceases. Name of employee Address (number and street, city, state, and ZIP code) Date suspension initiated (month, day, year) Reason compensation and/or benefits are being suspended: Date of injury (month, day, year) Social Security number* Telephone number ( ) Refusal of treatment, services and supplies (IC 22-3-3-4(c)) / (IC 22-3-3-7) Refusal or obstruction of examination (IC 22-3-3-6(a)) Refusal to accept suitable employment (IC 22-3-3-11) Refusal of Board ordered autopsy (IC 22-3-3-6(h)) Actions required to have compensation and/or benefits reinstated Signature of employee acknowledging receipt Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com