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Employees Election For Commuted (Lump Sum) Impairment Income Benefits DWC-51 - Texas
| Employees Election For Commuted (Lump Sum) Impairment Income Benefits Form. This is a Texas form and can be used in Employee Workers Compensation . |
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Send original to: INSURANCE CARRIER Send copy to: TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION FIELD OFFICE HANDLING CLAIM CLAIM # ____________________________________________ Carrier's Claim # _____________________________________ EMPLOYEE'S ELECTION FOR COMMUTED (LUMP SUM) IMPAIRMENT INCOME BENEFITS 1. Employee's Name and Telephone No. ( 4. Mailing Address (Street or P. O. Box) ) 5. Employer's Business Name 2. Social Security Number 3. Date of Injury City State Zip Code 6. Insurance Carrier's Name Notice to Employee: Article 8308-4.27 of the Texas Workers' Compensation Act allows you to elect to collect your impairment income benefits in a lump sum if you have returned to work for at least 3 months or more, earning at least 80% of your pre-injury average weekly wage. The Texas Department of Insurance, Division of Workers' Compensation field office handling your claim will assist you with information to complete this form, if needed. If the carrier denies your request, you may request the Division to set a benefit review conference. WARNING: Supplemental Income Benefits may be available to you at the end of the impairment period if you have an impairment rating of 15% or more, are earning less than 80% of your pre-injury average weekly wage as a direct result of your impairment, and if you in good faith have tried to obtain employment in line with your ability to work. IF YOU TAKE A LUMP SUM PAYMENT OF YOUR IMPAIRMENT INCOME BENEFITS, YOU WILL NOT BE ABLE TO COLLECT SUPPLEMENTAL INCOME BENEFITS OR ANY ADDITIONAL INCOME BENEFITS FOR THE INJURY. Medical benefits related to this injury will not be affected if you receive a lump sum. [Art. 8308-4.27, Commutation of Impairment Income Benefits, Art. 8308-4.10, Average Weekly Wage, Art. 8308-4.28, Supplemental Income Benefits, Texas Workers' Compensation Act; Rule 147.10] 7. Maximum Medical Improvement Date as Determined by a Doctor 8. Impairment Rating _____________ % Did you or insurance company dispute the rating Yes No Rating Doctor's Name ___________________________________________________ Weekly Impairment Income Benefit Amount $________________ Present Rate of Pay $ Yes No Hourly Monthly Weekly Other 9. Date Returned to Work Have you returned to work for at least 3 months? 10. I have read and understood this form, or it has been explained to me. Date _________________________________ Employee's Signature ____________________________________________________________________ TO BE COMPLETED ONLY BY INSURANCE CARRIER 12. Date Received From Employee DENIED - DOES NOT MEET REQUIREMENTS SET BY LAW Employee not earning at least 80% of preinjury average weekly wage Employee not employed for at least 3 months ACCEPTED, PAYMENT ENCLOSED Lump Sum Date Amount Paid $___________________ Paid _______________________ Impairment rating being disputed For Period From ___________________ To ____________________ Carrier Representative's Printed Name _____________________________________________________________________________________________ Signature Date __________________________________ DWC FORM-51 (Rev 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com DWC FORM - 51 Employee's Election for Commuted (Lump Sum) Impairment Income Benefits An injured employee may elect to receive the remainder of impairment income benefits to which the employee is entitled in a lump sum if the employee has returned to work for at least three months earning at least 80% of the employee's pre-injury average weekly wage. The employee may apply to receive a lump sum (commute) by filing an Employee's Election for Commuted (Lump Sum) Impairment Income Benefits (DWC FORM-51) with the insurance carrier. The employee must also send a copy of the completed form to the Texas Department of Insurance, Division of Workers' Compensation Field Office Handling the Claim. The form may be obtained by contacting Claims Services in the field office. The carrier must send a notice of approval or denial to both the Division and the injured employee no later than 14 days after receipt of the request. A notice of approval must include payment of the impairment income benefits in a lump sum. A notice of denial must include the carrier's reasons. If the injured employee does not receive notice of approval or denial timely from the carrier, the injured employee may contact Claims Services in the Division field office handling the claim. If the carrier denies the request, the injured employee may request the Division to set a benefit review conference to resolve the issue. If the injured employee receives a lump sum payment of impairment income benefits, the employee will not be able to collect supplemental income benefits or any other income benefits for the injury. Medical benefits related to this injury will not be affected by receiving the lump sum. [Art. 8308-4.27, Commutation of Impairment Income Benefits, Art. 8308-4.10, Average Weekly Wage, Art. 8308-4.28, Supplemental Income Benefits, Texas Workers' Compensation Act; Rule 147.10] DWC FORM-51 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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