Fill and Sign the New Hampshire Disability Compensation Form

Injury Disability/Recurrence- First or Sup. Rep. R'cd First Payment Last PaymentEmployee Employer Carrier Compensation at the rate of $ Beginning Avg. Wkly. Wage of $ When Expected Provisional Payment of $ Total Compensation Paid $ Ending Date Date of Return to Work Earning after R.T.W. Name of Employer (New or same) THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, N.H. 03301 MEMO OF PAYMENT OF DISABILITY COMPENSATION You are required to pay total disability compensation and to file, with the department, copy to employee, memorandum 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 resulting from depart- mental hearing. Failure to pay and to file memorandum promptly, in the absence of a legitimate denial of benefit, (Name) (Soc. Sec. No.) (Name) (Federal Identification No.) (Name) (Carrier Number Assigned by DOL) Date of: • Recurrence refers to subsequent periods of disability 1 per week 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 2 Missing Wage Schedule Subject to Later Adjustment 3 (Dat e) (Signatur e) Dept. Approval 9 WCA (6-94)