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Employees Request For Acceleration Of Impairment Income Benefits DWC-46 - Texas
| Employees Request For Acceleration Of Impairment Income Benefits Form. This is a Texas form and can be used in Employee Workers Compensation . |
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Send To: TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS' COMPENSATION Field Office Handling Claim CLAIM # ________________________________________________ Carrier's Claim # _________________________________________ EMPLOYEE'S REQUEST FOR ACCELERATION OF IMPAIRMENT INCOME BENEFITS 1. Employee's Name 2. Mailing Address (Street or P.O. Box) City State Zip Code 4. Employee's Telephone Number 5. Date of Injury 6. Insurance Company's Name 7. Employer's Name 3. Employee's Social Security Number 8. Amount of Acceleration Requested (The accelerated payment cannot exceed your weekly net pre-injury wage which is based on 85% of your average weekly wage before your injury.) $____________ 9. Please explain the reasons for your hardship that is the basis for requesting acceleration of your impairment income benefits. INJURED EMPLOYEE: PLEASE READ CAREFULLY 010. a) This form is to be completed and filed with the Texas Department of Insurance, Division of Workers' Compensation only if you are receiving weekly impairment income benefits and if there is not a pending dispute of the impairment rating. Acceleration of impairment income benefits will increase the amount of your weekly checks but will reduce the number of weeks you will receive impairment income benefits. If you are entitled to supplemental income benefits and you receive accelerated payment of impairment income benefits, the payment period for supplemental income benefits will not begin until after the end of the original number of weekly impairment income benefits. This means that you will not receive any weekly benefits between your last accelerated payment of impairment income benefits and the beginning of supplemental income benefits. b) c) I have read the above and understand how acceleration will affect my weekly payments. I certify that the information I have provided is correct to the best of my knowledge. Signature of Injured Employee Date ____________________ DIVISION ORDER Acceleration Approved The insurance company shall initiate accelerated payments no later than 7 days after receiving notice of the Division's approval. (See reverse side for calculation of payments.) Amount of accelerated payments $ Number of accelerated payments Acceleration Denied Reason for denial: Authorized DWC Employee's Signature Title Telephone Number Date DWC FORM-46 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com Calculation of Accelerated Payments Date Worksheet Completed: _________________ Interest Rate Used: Impairment Income Benefits (IIBs) Period: From_________________ To_________________ 1. Calculate weekly IIBs rate. $________________ Average Weekly Wage x 70% = $_____________ Weekly IIBs Rate 2. Calculate weekly net pre-injury wage. $ Average Weekly Wage x 85% = $_____________ Weekly Net Pre-injury Wage The weekly accelerated payment cannot exceed this amount.) 3. Determine number of weeks remaining due in the IIBs period and discount.* *Instructions to Authorized DWC staff: Using the "Present Value of Future Weekly Payments Discounted at a Given Discount Rate" chart in effect at the time acceleration is requested, locate the number of weeks of remaining IIBs. The number in the box to the right of the number of remaining weeks is the discounted value of those weeks. Remaining number of weeks ____________ Discounted number/value of weeks ____________ 4. Calculate discounted IIBs amount due. ___________________ Number Discounted Weeks x $_____________ IIBs Weekly Rate = $__________________ Total Discounted Amount 5. Calculate acceleration payment period. $__________________ Total Discounted Amount รท $_____________________ = Weekly Net Pre-injury Wage (or requested amount) ________________________ Number Weeks Accelerated IIBs 6. Calculate number of weeks and weekly amount. _______ Weeks @ $_________ and if necessary, Partial Week _______ @ $____________ DWC FORM-46 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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