Fill and Sign the Partial Disability Compensation Form

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         TEMPORARY PARTIAL DISABILITY Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161P.O. Box 7901Madison, WI 53707-7901Telephone: (608) 267-1360Fax: (608) 267-0394 Information you provide may be used for secondary purposes [Privacy Law, s. 15.04(l)(m)]. e-mail: DWDDWC@dwd.state.wi.us WC Claim Number Employee Name Employee Social Security Number Employer Name Injury Date Insurance Company Name (not adjusting company) Each period of Temporary Partial Disability TPD) is to be entered as a line of compensation on the WKC-1 3. Use this form only to verify the TPD rate. Figure TPD on a weekly basis, Sunday through Saturday. Attach this form as a part of the WKC-13 showing Temporary Partial Disability paid. Read instructions on reverse side before calculating Temporary Partial Disability below.1 2 3 4 5 6 7 8 9 Week Hours @ Wages Weekly Wage Wage % of TTD Rate TPD Ending Worked Hourl y Earned at Time of Injury Loss Wage Payment Rate Loss Calculation Calculation Calculation Calculation Calculation Calculation Calculation Calculation Calculation WKC-7359 (R. 6/99)/                                    $7.67 , $153.40                                     $7.67       , $122.72                               r - -- r - -- r - -- r - -- TEMPORARY PARTIAL DISABILITY INSTRUCTIONS Abbreviation Key: TTD- - - - Temporary Total Disability; TPD Temporary Partial Disability The numbered columns below correspond to the numbered worksheet columns on the reverse side. A completed sample calculation for a two week period appears at the bottom of this page. 1 . Week Ending: Use the Saturday of the week for which you are computing Temporary Partial Disability TPD). A week of TPD is Sunday through Saturday. 2. Hours Employee Worked:' Enter the number of hours worked during the week. If you are not paying for the waiting period, but you are paying the week which includes the waiting period, include the hours lost during the waiting period as hours worked during the week. 1 TPD calculations involving the 3-day waiting period: Indemnity is due for the first 3 days after the injury only if the disability exists more than 7 calendar days after the day of injury. Do not count Sunday in the first 3 days for which indemnity is due unless the employee works Sunday, but always count Sunday in the 7 calendar days after the injury to determine if indemnity is due for the waiting period. If the employee is not entitled to indemnity for wages lost during the 3-day waiting period, ONLY for purposes of computing TPD in columns 2 to 4, below, treat wages lost during the 3-day-waiting period as though the hours were worked and the wages were earned. Add the hours lost during the 3-day-waiting period to the ''hours employee worked'' in column 2, below. Otherwise, you may pay more than the law requires in TPD benefits. This period will need to be recomputed if employee has a renewed period of disability beyond the 7 calendar days. 3. At (a) Hourly Rate: Enter the hourly rate at which the employee was paid or would have been paid for the hours worked in #2 above during the week of TPD. 4. Wages Earned: Multiply the hours worked (Column #2) by the hourly rate (Column #3). (If hourly rate is not available, show gross amount earned for the week and skip Columns #2 and #3.) 5. WeekIy Wage at Time of In ury: Enter the employee's weekly wage at the time the injury occurred. Use the weekly wage that was used to compute the employee's TTD rate. Use only the ''actual'' wage. Do not use an''expanded'' wage. 6. Wage Los : Subtract the amount earned (Column #4) from the wage (Column #5) at the time the injury occurred. 7. Percent (%) of Wage Los : Divide the wage loss (Column #2) by the wage (Column #3) at the time the injury occurred. 8. TTD Rate: Use the TTD rate in effect at the time the injury occurred. (Use escalated rate only if TTD has been paid at an escalated rate.) 9. TPD Payment: Multiply the TTD rate (Column #8) by the percent of wages lost (Column #7). (This is the TPD owed for the week.) Completed Sample: 1 2 3 4 5 6 7 8 9 Week Hours Emp. @ Wages Weekly Wage Wage Loss % of TTD TP D Ending Worked Hourl y Earne d at Time of Injury Wage Rate Payment Rate Loss 1 4/6/97 , 20 1 1 1 1 1 1 1 $306.80 1 $153.40 , 50 204.53 1 11 1 1 1 1 1 102.27 Calculatio n306.80 - 153.40 = 153.40 153.40 - 306.80 = .5 (50.00%) 204.53 x 50% = 102.27 1 4/13/97 , 16 1 $306.80 1 1 1 1 1 $184.08 ,1 1 1 60 204.53 122.72 . Calculatio n306.80 - 122.72 = 184.08 184.08 - 306.80 = .6 (60.00%) 204.53 x 60% = 122.72