Fill and Sign the Employees Request for Acceleration of Impairment Income Form

DWC046 Rev. 02/17 Page 1 of 2 Send to the Division field office handling the claim. EMPLOYEE'S REQUEST FOR ACCELERATION OF IMPAIRMENT INCOME BENEFITS 1. Employee's Name 2. Employee’s Telephone Number 3 . Da te of Injury 4. Mailing Address (Street or P.O. Box) 5. Employer's Name City State Zip Code 6. Insurance Company’s Name 7 . Amount of Acceleration Requested (The accelerated payment cannot exceed your weekly net pre -injury wage which is based on 85% of your average weekly wage before your injury.) $____________ 8. Please explain the reasons for your hardship that is the basis for requesting accelerati on of your impairment income benefits. INJURED EMPLOYEE: PLEASE READ CAREFULLY 9. a) T his form is to be completed and filed with the Texas Department of Insurance, Division of Workers’ Compensation only if you are receiving weekly impairment income benefits and if there is not a pending dispute of the impairment rating. b) Acceleration of impairment income benefits will increase the amount of your weekly checks but will reduce the number of weeks you will receive impairment income ben efits. c) If you are entitled to supplemental income benefits and you receive accelerated payment of impair ment income benefits, the payment period for supplemental income benefits will not begin until after the end of the original number of weekly impairment income benefits. This means that you will not receive any weekly benefits between your last accelerated payment of impairment income benefits and the beginning of supplemental incom e benefits. I have read the above and understand how acc eleration will affect my weekly payments. I certify that the information I have provided is correct to the best of my knowledge. Signature of Injured Employee Date ____________________ DIVISION ORDER Acceleration Approved The insurance company shall initiate accelerated payments no later than 7 days after receiving notice of the Division's approval. (See reverse side for calculation of payments.) Number of accelerated payments Amount of accelerated payments $ Acceleration Denied Reason for denial: Authorized DWC Employee's Signature Title Telephone Number Date NOTE : W ith few exceptions, upon your request, you are entitled to be informed about the inform ation TDI-DW C collects about you; get and review the information (Government Code, §§552. 021 and 552.023); and have TDI-DW C correct information that is incorrect (Government Code, §559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure section at www.tdi.texas.gov . DW C CLAIM # CARRIER CLAIM # DWC046 Rev. 02/17 Page 2 of 2 Calculation of Accelerated Payments Date Worksheet Completed: _________________ Interest Rate Used: Impairment Income Benefits (IIBs) Period: From_________________ To_________________ 1. Calculate weekly IIBs rate. $________________ x 70% = $_____________ Average Weekly Wage Weekly IIBs Rate 2. Calculate weekly net pre -injury wage. $ x 85% = $_____________ (The weekly accelerated Average Weekly Wage Weekly Net Pre -injury Wage payment cannot exceed this amount.) 3. Determine number of weeks remaining due in the IIBs period and discount.* *Instructions to Authorized DWC staff: Using the “Present Value of Future Weekly Pay ments Discounted at a Given Discount Rate” chart in effect at the time acceleration is requested, locate the number of weeks of remaining IIBs. The number in the box to the right of the number of remaining weeks is the discounted value of those weeks. Remaining number of weeks ____________ Discounted number/value of weeks ____________ 4. Calculate discounted IIBs amount due. ___________________ x $_____________ = $__________________ Number Discounted Weeks IIBs Weekly Rate Total Disco unted Amount 5. Calculate acceleration payment period. $__________________ ÷ $_____________________ = ________________________ Total Discounted Amount Weekly Net Pre -injury Wage Number Weeks Accelerated IIBs (or requested amount) 6. Calculate number of weeks and weekly amount. _______ Weeks @ $_________ and if necessary, Partial Week _______ @ $____________