Wisconsin > Workers Comp
Worksheet For Temporary Partial Disability WKC-7359 - Wisconsin
| Worksheet For Temporary Partial Disability Form. This is a Wisconsin form and can be used in Workers Comp . |
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WORKSHEET FOR TEMPORARY PARTIAL DISABILITY The provision of the claimant's social security number is mandatory under Wisconsin Statutes and will be used to identify the claimant. Failure to provide it may result in penalties or delayed payment of benefits. Personal information you provide may be used for secondary purposes [(Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Social Security Number Injury Date Employee Name Employer Name Insurance Company Name (not adjusting company) Each period of Temporary Partial Disability (TPD) is to be entered as a line of compensation on the WKC-13-E. Use this form only to verify the TPD rate. Figure TPD on a weekly basis, Sunday to Saturday. This worksheet is provided for informational use only by Insurance Companies, Self-Insurers and Third Party Administrators. Data must be submitted through the Worker's Compensation Pending Reports Internet Application Yes No Are the wages reported in column 4 below from the job the employee had at the time of injury? If Yes, compute and pay TPD using the "actual" wages in column 5 below that were used to set the TTD rate. Yes No If No, are the earnings from a second job that was held at the time of injury? *(Use "expanded wages in column 5 below if earnings were from a 2nd job held at the time of injury and expanded wages were used to set the TTD rate) Note: If earnings were not from the same job held at the time of injury or were from another full-time or part-time job held at the time of injury and "expanded" wages were not used to set the TTD rate, pay TTD, not TPD. 1 2 3 4 5 6 7 8 9 % of Week Hours Emp. At Hourly Wages Weekly Wage at Wage Ending Worked Rate Earned Time of Injury Wage Loss Loss TTD Rate TPD Rate TOTAL WKC-7359-E (R. 03/2008) 0 American LegalNet, Inc. www.FormsWorkflow.com
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