Fill and Sign the Formsworkers Compensation Divisionnh Department of

THE STATE OF NEW HAMPSHIRE DEPARTM ENT OF LABOR CONCORD, N.H. 03301 M EM O OF PAYM ENT OF DISABILIT Y COM PENSATION You are required to pay total disability compensation and to file, with the department, copy to employee, memoran- dum of payment in accordance with RSA 281-A:40, 41 and 42 as soon as possible after date of knowledge of disability of four or more days, but no later than seven days thereafter. Filing shall also be made upon making provisional payment, upon adjusting such payment, upon making last payment, and upon making payment resultingfrom departmental hearing. Failure to pay and to file memorandum promptly, in the absence of a legitimate denial of benefit, shall render a carrier liable to a civil penalty of up to $2,500. Employee _______________________________________________ _______________________________________________ (Name) (Soc. Sec. No.) Employer ________________________________________________ _______________________________________________ (Name) (Federal Identification No.) Carrier __________________________________________________ _______________________________________________ (Name) (Carrier Number Assigned by DOL) 9 WCA (6-94) P&P WHSE STOCK #4610 ________________________________________________ ________________________________________________ (Date) (Signature) Dept. Approval Date of: Injury Disability/Recurrence* First or Sup. Rep. R’cd First Payment Last Payment *Recurrence refers to subsequent periods of disability Compensation at the rate of $ __________ per week Beginning___________________________________ Avg. Wkly. W age of $__________________________________ Check box if compensation payment results from department hearing decision Check box if memo indicating provisional payment already filed Check box if memo indicating adjustment in total disability - RSA 281-A:29 SEE ATTACHED WAGE SCHEDULE, EXCEPT IF DISABILITY OF LESS THAN FOURTEEN DAYS Missing Wage Schedule When Expected __________________________________ Provisional Payment of $ ______________________ Subject to Later Adjustment Total Compensation Paid $ ___________________Ending Date___________________________________ Date of Return to Work __________________ Earning after R.T.W. ________________________________ Name of Employer (New or same) _____________________________________________________________ 1 2 3