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Memo Of Payment Of Disability Compensation 9 WCA - New Hampshire

Memo Of Payment Of Disability Compensation Form. This is a New Hampshire form and can be used in General Workers Comp .
 Fillable pdf Last Modified 4/11/2005
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LAB 500 THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, NH 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 departmental hearing. Failure to pay and to file memorandum promptly, in the absence of a legitimate denial of benefit, shall render a carrier liable to a civil penalty of up to $2,500. Employee Employer Carrier (Name) (Soc. Sec. No.) (Name) (Federal Identification No.) (Name) (Carrier Number Assigned by DOL) Date of: Injury Disability/Recurrence* First or Sup. Rep. R'cd First Payment Last Payment *Recurrence refers to subsequent periods of disability Compensation at the rate of $ Beginning per week Avg. WKly. Wage of $ 1 2 3 9 WCA (6/1994) Check box if compensation payment results from department hearing decision Chck box if memo indicating provision 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 Missing Wage Schedule When Expected Provisional Payment of $ Subject to Later Adjustment Total Compensation Paid $ Date of Return to Work Name of Employer (New or same) Ending Date Earning after R.T.W. (Date) Dept. Approval (Signature) American LegalNet, Inc.
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