Wisconsin > Workers Comp
Temporary Or Permanent Disability Benefits For Job Related Injuries DOA-6026 - Wisconsin
| Temporary Or Permanent Disability Benefits For Job Related Injuries Form. This is a Wisconsin form and can be used in Workers Comp . |
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STATE OF WISCONSIN DEPARTMENT OF ADMINISTRATION DOA-6026 (R05/2007) S. 102.08 WIS. STATS. WORKER'S COMPENSATION Temporary or Permanent Disability Benefits for Job Related Injuries Agency Name Claim No. Division of Enterprise Operations Bureau of State Risk Management Employee Name Dates absent from work (mm/dd/yyyy); (for TTD use inclusive dates) TTD (Temporary Total Disability) TPD (Temporary Partial Disability) From: Date of Injury (mm/dd/yyyy) Claim Examiner / Rep. To: TEMPORARY DISABILITY $ $ Maximum weekly wage in effect at time of injury Weekly wage (from WC-13A) Less than maximum More than maximum Renewed disability s. 102.43(7) $ Weekly temporary total disability rate (weekly wage x 66.67%) (If more than maximum wage use Weekly Rate on chart) TEMPORARY TOTAL DISABILITY CALCULATION $ $ per week x weeks days ········· ········· $ $ $ per day (1/6 of weekly rate) x TOTAL TTD BENEFITS DUE TEMPORARY PARTIAL DISABILITY CALCULATION - % FROM WKC-7359 (WC-13b) List each week separately. = % wage loss X $ TPD rate for week of Sunday % wage loss X $ TPD rate for week of Sunday to Sunday $ $ to Sunday = TOTAL TPD BENEFITS DUE TOTAL BENEFITS DUE (if combined) Total amount previously paid Date payment due (mm/dd/yyyy) Concede or Final Report prepared by (name) Date (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkflow.com
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