Fill and Sign the Subsequent Report Kentucky Kentucky Form

Paid to Date (PTD Type) PTD Amount Actual/Deemed WK# WeeklyEarnings Actual/Deemed WK # WeeklyEarnings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 YESNO YES NO                                                      RTW Without Restrictions Released RTW Without Restrictions       RTW With Restrictions       Released RTW With Restrictions       Children Parents Jurisdiction Fund       Siblings Handicapped Children Other                                                 Monthly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Reopened             Reopened/Closed Medical Notification Only Became             Became Med Only Transfer Without Liability       With                                     IA-2 WORKERS COMPENSATION - SUBSEQUENT REPORT Employee Name (last, First, Middle) Social Security Number Date of Injury ReportJurisdiction Effective Date Date Disability Began Pre-Existing Disability? Date of Date of Death Report Purpose Representation Released/Returned toWork (RTW) Date Released Jurisdiction Claim Number /RTW Qualifier # of Dependents Death Dependent/ Date of Maximum Payee Relationship Medical Imprvmnt? (insert #) Permanent Body Part Percent Body Part Percent Body Part Percent Impairment Employer Name FEIN Insured Report Number WAGEWage Period Average Wage Effective Date of Average Wage Change Comp Rate Effective Date of Comp # Days Worked Salary Continued Rate Change Per Week in Lieu of Comp? PAYMENT Weekly Pymt Amount Paid to Paid From Paid Through # Weeks # Days Payment Type Amn t Date (MM/DD/YY) (MM/DD/ YY) Paid Paid BENEFIT ADJUSTMENTS Weekly Amount Start Date Benefit Adjustment Type Weekly Amount Start Date Benefit Ad justment Type (+ or -) (+ or -) PAID-TO-DATE REDUCED EARNINGS RECOVERIES Recovery Type Recovery Amount CLAIM ADMINISTRATIONInsured Named FEIN ClaimsStatus Third Party Administrator Name FEIN ClaimType Only Lost Time Claim Administrator Claim Number Agreement toCompensate Claim Administrator Address (Include City, State, Postal Code, and Phone Number) Late Reason Date Prepared Pageof IA 2 (10 95 Draft)