Notice Of Change In Compensation Rate (For Injuries Before) {28}

FORM 28A - NOTICE OF CHANGE IN COMPENSATION RATE (for INJURIES BEFORE JULY 1, 1986). This form is used to officially notify the Workers’ Compensation Division of a change in the weekly compensation rate for injuries that occurred before July 1, 1986. Specifically, this form calculates and documents the updated compensation amount that an injured worker is entitled to receive beginning July 1, 2023, based on an annual cost-of-living adjustment. The form applies to various types of workers’ compensation benefits, including Temporary Total, Temporary Partial, Permanent Partial, Permanent Total, and Fatal benefits. It requires the insurance company or self-insured employer to recalculate the compensation rate by applying a 6% increase (multiplied by 1.060) to the prior rate, ensuring the result does not exceed the statutory maximum of $1,133 or fall below the minimum of $567, not including additional amounts for dependents. For certain benefit types, the form also accounts for dependents under age 21 by adding $20 per dependent. Once completed, the form serves as an amendment to the original compensation agreement and must be filed with the Department of Labor by July 15, 2023. Upon approval, a copy must be provided to the injured employee. www.FormsWorkflow.com