Fill and Sign the Indiana Claim Workers Compensation Form

Name of insurer Insurer claim number Address (city, state, ZIP code) Telephone number          No                                                                                Return to work Claim deemed not compensable Benefit termination (see compensation payments section below) Refusal to accept medical treatment, services and supplies, provided by or on behalf of your employer, shall bar your compensa- Refusal to allow an autopsy shall result in a suspension of all compensation (IC 22-3-3-6). Refusal to accept employment suitable to your partial disability shall bar any compensation during such refusal unless, in the Other (specify)       Employee                                     TPD PPI PTD Yes No Yes No Yes U.S. Mail Personal service       U.S. Mail       Accidentnumber( ) ( ) ( ) REPORT OF CLAIM STATUS PRIVACY NOTICE REQUEST FOR INDEPENDENT MEDICAL EXAMINATIONState Form 38911 (R4 / 5-97) *This agency is requestingdisclosure of your SocialSecurity number in accor-dance with IC 22-3-4-13. Thisdisclosure is not mandatoryand you will not be penalizedfor refusing. INSTRUCTIONS- Complete appropriate sections of this document and sign in the space below CLAIM INFORMATION Name of employer Federal I.D. NumberAddress of employer Telephone Date of injury Telephone number Name of employee *Social Security Number Address of employee BENEFIT TERMINATION / DENIAL NOTICE (check appropriate action) Notice of denial must be made writing and mailed not later than twenty nine(IC 22-3-3-7). Report compensation payments the appropriate section below, if applicable. (29) days after the employer's knowledge of the injury tion otherwise payable during the period of refusal (IC 22-3-3-4). opinion of the Worker's Compensation Board of Indiana, such refusal was justified (IC 22-3-3-11). If the employee disagrees with the proposed termination, the employee must give a written notice to the Worker's CompensationBoard and employer within seven (7) days after receipt of this termination notice (IC 22-3-3-7). See Independent MedicalExamination Request section below. COMPENSATION PAYMENTS All compensation payments should be reported to the Board on the below prescribed form (IC 22-3-3-7). No. weeks paid Paid to (name) Total amount paid Beginning date of payments Ending date of payments Dependent $ Reason(s) for ending payments INDEPENDENT MEDICAL EXAMINATION REQUEST Employees who disagree with proposed benefit termination must serve (7) days after receipt of the termination portion of this notice. a copy of this disagreement notice to the Worker's Compensa- Please sign below to make Board and the employer within an independent medical examination request. An employee may request an independent medical examination to resolve a medicalissue dispute. Employee disagrees with proposed termination: Employee requests independent medical examination: Employer requests independent medical examination: MAIL TO: Worker's Compensation Board402 W. Washington St. Rm. W196Indianapolis, IN 46204-2753 EMPLOYER CERTIFICATION / RECEIPT OF EMPLOYEE I DEPENDENT Employer and employee must sign below to certify service or acknowledge receipt of this notice. Signature of employer Signature of employee X X Date signed (month, day, year) By: ~ Date signed (month, day, year) By: ~ Personal service