Agenda - Council - 04/27/1982 - Laserfiche WebLink

Home

e~ vs. Employer ard Luchite Ramsey, City of tess -- c~i~;;22~ e~ Date of Inju~ urer's Claim 51-C-68639~ .,- ...i\ NOTICE OF INTENTION TO · ~'" . .nO') ':"."\ DISCONTINUE COMPENSATION '"'i" ~,,?;,~ [~"- ,'.?.~ BENEFITS N~IC~O EMPLOYEE: The benefits listed on this form are being discontinued for the reasons stated, Please read the instructions for ad- ditional information. ARE HEREBY NOTIFIED THAT WE INTEND TO DISCONTINUE PAYMENT OF COMPENSATION BENEFITS TO YOU, EXCEPT MEDICAL lENSES, EFFECTIVE ~/_2~/~ FOR THE FOLLOWING REASON(S). ~_. tYOU have returned to work on he attached medical report indicates you are no longer entitled to benefits. other (explain) Paymant of aw~rrl. ~'1 HAVE PAID THE FOLLOWING BENEFITS TO YOU: Temporary Total Disability Tlporary Partial Disability RJabilitation Benefits, Permanent Total Disability award on stipulatio~ anent Partial Benefits* Si[:ify method of payment~ F Permanency rating ave been received, not From Through % of *Medical reports indicating permanency ratings must be attached. A .ey member(s) # Weeks Rate $ $ $ $ $ $ Tota I $ $ $. $, $ Total Compensation Paid Total Supplementary Benefits Paid Total Dependency Benefits Paid $ fees (if represented by an attorney) Paid $~ Withheld $. ABILITATION PLAN STATUS: ~3,~_~_"h~-r,~_ _~___ ' .X~ No Rehabilitation Provided Signature _j lan In Progress Phone~N2~m~r_~ lan Completed Date Se~ed on Employ~ INSTRUCTIONS TO EMPLOYEE is your responsibili~ to review this form to make sure that you agree we have properly paid you the benefits you are entitled to receive. BELIEVE YOU HAVE RECEIVED ALL BENEFITS PAYABLE TO YOU AT THIS TIME, NO FURTHER ACTION IS NECESSARY. Distribution: 1st Copy~Workers' ~mpensation Division, 2nd Copy~Employee, 3rd Copy~Employer (OVER) WC7609e iEd. 7-$1) UNIFORM PRINTING ~ BUPPLY