Workers' Compensation/Public Disability Benefit Questionnaire

WC/PDB
WORKERS’ COMPENSATION/PUBLIC DISABILITY BENEFITS SELECTION MENU
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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM WO RKE RS’ C OM PENS ATI ON/ PUB LI C DISA BIL ITY BE NE FI TS S ELE CTI ON ME NU
WP MU TZW
NUMB ER HOL DER S SN : SS S-S S-S SSS
N UMB ER HO LD ER N AME : S SSS S SS SSSS SSS S

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WC /PD B
CL AIM
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WC/P DB
WC/P DB
WC/P DB
WC/P DB

INJ UR Y/
ILL NE SS
DAT E
SSS SS SS S
SSS SS SS S
SSS SS SS S
SSS SS SS S

CLA IM
CLA IM
CLA IM
CLA IM

1
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S OUR CE OF
C OMP ENS ATI ON

WC/P DB CLA IM NU MB ER

SS
SS
SS
SS

SSSS SSS SSS SSS SS SS SSSS SSS
SSSS SSS SSS SSS SS SS SSSS SSS
SSSS SSS SSS SSS SS SS SSSS SSS
SSSS SSS SSS SSS SS SS SSSS SSS

SC REEN S:
SC REEN S:
SC REEN S:
SC REEN S:

SSS S
SSS S
SSS S
SSS S

S SS S
S SS S
S SS S
S SS S

SSSS
SSSS
SSSS
SSSS

SS SS
SS SS
SS SS
SS SS

SSS S
SSS S
SSS S
SSS S

I NJU RY /
I LLN ES S
S TAT E
SS
SS
SS
SS

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0
0

SSS SSS

X
X
X
X

SS SS
SS SS
SS SS
SS SS

ADD NEW OC CUR RE NC E (Y /N) : X

PF1 HEL P A VAI LA BL E
TRA NS FE R TO : X XXX
**** *** *** *** ** ** **** **A PPL ICA TI ON ERR OR MES SAG E* ** **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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WC/PDB
WC/PDB CLAIM DATA
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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM
WC /P DB C LAI M D ATA
WP CL TZW
NUMB ER HOL DER S SN : SS S-S S-S SSS
N UMB ER HO LD ER N AME : S SSS S SS SSSS SSS S
*INJ URY /IL LNE SS D ATE (MM DDC CYY ): 9 9999 999
* SO URCE OF CO MPE NS AT ION: XX
*WC/ PDB CL AIM N UM BER: XX XXX XXX XX XX XXXX XXX XXX XX
IN JURY /IL LNE SS ST AT E: X X

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*PER IOD IC PAY ME NT S AW ARD ED (Y/ N) : X
*LU MP SUM A WA RDED (Y /N) : X
*WC/ PDB CL AIM P EN DING (Y /N) : X
*CL AIM DE NI ED (Y/ N): X
*APP EAL PE NDI NG ( Y/N) : X
I F Y ES , EXPE CTE D D ECI SI ON DAT E ( MMD DCC YY ): 999 999 99
INTE ND TO FIL E (Y /N): X
WI LL BE DE LE TED FRO M T HIS I NJ URY – C ONT INU E (Y /N): X
*REV ERS E J URI SD IC TION IN VOL VED ( Y/ N): X
R
IF YE S, ST AR T (M MDD CCY Y): 9 99 9999 9
S TOP ( MM CCYY ): 999 999
E
S DO T HE PDB ’S ME ET THE CO VER ED SE RV ICE EXC LUS ION ( Y/ N): X
E
CO VER ED EA RN INGS PE RCE NTA GE : 999
R DO Y OU NEE D T O MA NUAL LY ENT ER A HI GHER AC E ( Y/N ): X
V
IF YE S, MA NU AL 1 00 PER CEN T AC E: 9 999 9
E SELE CT MET HOD U SE D: 9
D
1 =HI GH 1
2=H IGH 5
3=A VER AG E MONT HLY WA GE.
DELE TE THI S C LA IM (Y/ N): N
THIS OC CUR REN CE O F DA TA WIL L B E DE LETE D F ROM CL IE NT AND MB R-C ONT IN UE (Y/ N): X
PF1 HEL P A VAI LA BL E
TRA NS FE R TO : X XXX
**** *** *** *** ** ** **** *** **A PPL IC AT ION ERR OR MES SA GE **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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WC/PDB
WC/PDB CLAIM DATA EMPLOYER/PAYER NAME AND ADDRESS
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N
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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM
WC /P DB C LAI M D ATA E MP LOYE R/P AYE R N AM E AND ADD RES S
WP AD TZW
NUMBER HOLDER SSN: SSS-SS-SSSS
NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
INJU RY/ ILL NES S DA TE: SSS SSS SS
SO URCE OF CO MPE NS AT ION: SS
WC/P DB CLA IM NU MB ER: SSS SSS SSS SS SS SSSS SSS SSS S
IN JURY /IL LNE SS ST AT E: S S

EMPL OYE R N AME : XX XXXX XXX XXX XXX XX XX XXXX XXX XXX X
ADDR ESS 1: XX XX XX XXXX XXX XXX XXX XX X
ADD RES S 2 :
ADDR ESS 3: XX XX XX XXXX XXX XXX XXX XX X
ADD RES S 4 :
CI TY: XX XX XX XXXX XXX XXX XXX XX X
ST ATE :
CO NTA CT: XX XX XX XXXX XXX XXX XXX XX XX XXX
PH ONE :
R
E -MA IL: XX XX XX XXXX XXX XXX XXX XX XX XXXX X
FAX :
E
S
E PAYE R N AME : X XX XX XXXX XXX XXX XXX XX XX XXXX
R ADDR ESS 1: XX XX XX XXXX XXX XXX XXX XX X
ADD RES S 2 :
V ADDR ESS 3: XX XX XX XXXX XXX XXX XXX XX X
ADD RES S 4 :
E
CI TY: XX XX XX XXXX XXX XXX XXX XX X
ST ATE :
D
CO NTA CT: XX XX XX XXXX XXX XXX XXX XX XX XXX
PH ONE :
E -MA IL: XX XX XX XXXX XXX XXX XXX XX XX XXXX X
FAX :

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X XX XX XXXX XXX XXX XXX XX XX
X XX XX XXXX XXX XXX XXX XX XX
XX
ZI P: 999 99
X XX XX XXXX XXX
E XTE NS IO N: 9 999
X XX XX XXXX XXX

X XX XX XXXX XXX XXX XXX XX XX
X XX XX XXXX XXX XXX XXX XX XX
XX
ZI P: 999 99
X XX XX XXXX XXX
E XTE NS IO N: 9 999
X XX XX XXXX XXX

PF1 HEL P A VAI LA BL E
TRA NS FE R TO : X XXX
**** *** *** *** ** ** **** *** **A PPL IC AT ION ERR OR MES SA GE **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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WC/PDB
WC/PDB PERIODIC PAYMENTS
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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM
W C/ PD B PE RIO DIC PA YM EN TS
WP PR TZW
NUMB ER HOL DER S SN : SS S-S S-S SSS
N UMB ER HO LD ER N AME : S SSS S SS SSSS SSS S
INJU RY/ ILL NES S DA TE: SSS SSS SS
SO URCE OF CO MPE NS AT ION: SS
WC/P DB CLA IM NU MB ER: SSS SSS SSS SS SS SSSS SSS SSS S
IN JURY /IL LNE SS ST AT E: S S
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*S TAR T
(M MDD CCY Y)
99 999 999
99 999 999
99 999 999
99 999 999
99 999 999
99 999 999
99 999 999
99 999 999

STOP
(MMD DCC YY)
9999 999 9
9999 999 9
9999 999 9
9999 999 9
9999 999 9
9999 999 9
9999 999 9
9999 999 9

*P ERIO DIC
AM OUNT
99 999. 99
99 999. 99
99 999. 99
99 999. 99
99 999. 99
99 999. 99
99 999. 99
99 999. 99

*F RE Q
X
X
X
X
X
X
X
X

TYP E O F
PAY MEN T
XX
XX
XX
XX
XX
XX
XX
XX

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* PAYM ENT
P ROOF (Y /N)
X
X
X
X
X
X
X
X

R
E
S
E
R
V IF P ERI ODI C P AY ME NTS ARE TO BE GI N AGAI N, EXP ECT ED D ATE (MM DDC CYY ): 9 9999 999
E ARE ONG OIN G P ER IO DIC EXP ENS ES IN VO LVED (Y /N) : X
D ARE ONE -TI ME EX CL UDAB LE EXP ENS ES F ROM PER IOD IC PA YM ENTS IN VOL VED ( Y/ N): X
E XPE NS ES WIL L B E D ELE TE D FROM TH IS INJ UR Y - CO NTI NUE (Y /N ): X
MORE PE RIO DIC P AY MENT S ( Y/N ): X
PF1 HEL P A VAI LA BL E
TRA NS FE R TO : X XXX
**** *** *** *** ** ** **** *** **A PPL IC AT ION ERR OR MES SA GE **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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WC/PDB
WC/PDB PERIODIC PAYMENTS ONGOING EXPENSES
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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM
WC/P DB PER IOD IC P AYME NTS ON GOI NG E XPEN SES
WP OX TZW
NUMB ER HOL DER S SN : SS S-S S-S SSS
N UMB ER HO LD ER N AME : S SSS S SS SSSS SSS S
INJU RY/ ILL NES S DA TE: SSS SSS SS
SO URCE OF CO MPE NS AT ION: SS
WC/P DB CLA IM NU MB ER: SSS SSS SSS SS SS SSSS SSS SSS S
IN JURY /IL LNE SS ST AT E: S S

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ST ART
(M MDD CCY Y)
SS SSS SSS
SS SSS SSS
SS SSS SSS
SS SSS SSS
SS SSS SSS
SS SSS SSS
SS SSS SSS
SS SSS SSS

S TO P
( MM DDCC YY)
S SS SSSS S
S SS SSSS S
S SS SSSS S
S SS SSSS S
S SS SSSS S
S SS SSSS S
S SS SSSS S
S SS SSSS S

P ERI OD IC
A MOU NT
S SSS SS S
S SSS SS S
S SSS SS S
S SSS SS S
S SSS SS S
S SSS SS S
S SSS SS S
S SSS SS S

FR EQ
S
S
S
S
S
S
S
S

TY PE OF
PA YME NT
SS
SS
SS
SS
SS
SS
SS
SS

ONGO ING
EXPE NSE S
9999 9.9 9
9999 9.9 9
9999 9.9 9
9999 9.9 9
9999 9.9 9
9999 9.9 9
9999 9.9 9
9999 9.9 9

ONG OI NG
PER CE NT
999
999
999
999
999
999
999
999

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PR OOF
(Y /N)
X
X
X
X
X
X
X
X

R
E
S
E
R
V
E
D IF P ERI ODI C P AY ME NTS ARE TO BE GI N AGAI N, EXP ECT ED D ATE (MM DDC CYY ): P PPPP PPP
MORE PE RIO DIC P AY MENT S ( Y/N ): X
PF1 HEL P A VAI LA BL E
TRA NS FE R TO : X XXX
**** *** *** *** ** ** **** *** **A PPL IC AT ION ERR OR MES SA GE **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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WC/PDB
ONE-TIME ONLY EXCLUDABLE EXPENSES FOR PERIODIC PAYMENTS
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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM
O NE- TI ME ONL Y E XCL UDA BL E EXPE NSE S F OR PE RI ODIC PA YME NTS
WP EX TZW
NUMB ER HOL DER S SN : SS S-S S-S SSS
N UMB ER HO LD ER N AME : S SSS S SS SSSS SSS S
INJU RY/ ILL NES S DA TE: SSS SSS SS
SO URCE OF CO MPE NS AT ION: SS
WC/P DB CLA IM NU MB ER: SSS SSS SSS SS SS SSSS SSS SSS S
IN JURY /IL LNE SS ST AT E: S S

ONE- TIM E E XCL UD AB LE A TTO RNE Y E XP EN SES: 99 999 99. 99

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P ROO F ( Y/N ): X

ONE- TIM E E XCL UD AB LE M EDI CAL EX PE NS ES: 999 999 9.9 9
P ROO F ( Y/N ): X
R
E ONE- TIM E E XCL UD AB LE R ELA TED EX PE NS ES: 999 999 9.9 9
P ROO F ( Y/N ): X
S
E
R *SPE CIF IED EX PE NS E PE RIO D S TAR T DA TE ( MMD DCC YY) : 99 9999 99
V
E
D

PF1 HEL P A VAI LA BL E
T RAN SF ER TO: XX XX
**** *** *** *** ** ** **** *** **A PPL IC AT ION ERR OR MES SA GE **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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WC/PDB
WC/PDB LUMP SUM AWARD DATA
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0
1
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L
U
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N
*
O
N
E
R
E
S
E
R
V
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D

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2345 678 901 234 56 78 9012 345 678 901 23 45 6789 012 345 678 90 12 3456 789 012 345 67 89 0123 456 789
COMM
WC/ PDB L UM P SU M A WAR D D AT A
WP LS TZW
NUMB ER HOL DER S SN : SS S-S S-S SSS
N UMB ER HO LD ER N AME : S SSS S SS SSSS SSS S
INJU RY/ ILL NES S DA TE: SSS SSS SS
SO URCE OF CO MPE NS AT ION: SS
WC/P DB CLA IM NU MB ER: SSS SSS SSS SS SS SSSS SSS SSS S
IN JURY /IL LNE SS ST AT E: S S

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*LUM P S UM AMO UN T: 999 999 9.9 9
*P ROOF (Y /N) : X
*LUM P S UM STA RT D ATE (MM DDC CYY ): 9 9999 999
*RAT E A T W HIC H LU MP S UM IS TO BE P RORA TED : 9 999 9. 99
*FRE QUE NCY FO R LU MP S UM PRO RAT IO N: X
TYPE OF PA YME NT : XX
EXCL UDA BLE AT TO RN EY E XPE NSE S: 99 99 999. 99
P ROOF (Y /N) : X
EXCL UDA BLE ME DI CA L EX PEN SES : 9 99 99 99.9 9
P ROOF (Y /N) : X
EXCL UDA BLE RE LA TE D EX PEN SES : 9 99 99 99.9 9
P ROOF (Y /N) : X
SPEC IAL AM OUN TS T O BE DE DUC TED F RO M LU MP SUM : 9 99 99 99.9 9
PRO OF ( Y/N) : X
IF D ESI RED , S EL EC T PR ORA TIO N M ET HO D TO BE US ED IN C OMPU TAT ION : 9
1= MET HOD A
2 =ME THO D B
3=M ETH OD C.

PF1 HEL P A VAI LA BL E
TRA NS FE R TO : X XXX
**** *** *** *** ** ** **** *** **A PPL IC AT ION ERR OR MES SA GE **** *** *** *** ** ** **** *** ***
**** *** *** *** *( LI NE 2 4 R ESE RVE D FO R OP ERA TIN G S YS TE MS I NFO RMA TIO N) ** **** *** **

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