Get Supplementary Report

Completing the Supplementary Report online is a crucial step in the worker's compensation process. This guide offers detailed instructions on how to accurately fill out the form, ensuring that all required information is correctly submitted.

Follow the steps to complete the Supplementary Report effectively

1. Press the ‘Get Form’ button to access the document and open it in the provided editor.
2. Begin with filling in the personal information of the injured employee in Items 1 through 3, including their name, social security number, and address. Ensure that each section has been completed fully and accurately.
3. Provide details regarding the injury, including the date of the injury (Item 4) and the last day the employee worked (Item 5). Make sure these dates are correct, as they impact the assessment process.
4. In Item 6, describe the nature of the injury or illness in clear terms. Then, specify the employer's name and address in Items 7 and 8.
5. Indicate the insurance carrier in Item 9. If the employer is self-insured, please check the appropriate box.
6. Complete Item 10 by filling in the insurance claim number, and provide the insurer's claim handling address in Item 12.
7. Detail the date and type of the first compensation payment in Item 13 and the amount of that payment in Item 14.
8. If payments were delayed beyond 14 days after the injury date, explain the reason in Item 17. Use Item 18 to provide any additional remarks or reasons for payment suspension.
9. List the types of payment in Item 19, marking all applicable boxes for temporary total disability (TTD), temporary partial disability (TPD), or any other relevant categories.
10. Enter the last day worked and the return date in Items 20 and 21, respectively. Item 22 should reflect the number of paid holidays.
11. In Items 24 through 26, fill in all relevant compensation details including accumulated totals and rates.
12. Finally, complete Items 27 and 28, noting the amount of permanent partial disability due and the date of the last payment. Review the entire form for accuracy before proceeding.
13. After completing the form, save your changes. You will have options to download, print, or share the Supplementary Report according to your needs.

Complete the Supplementary Report online today to ensure timely processing of your worker's compensation claim.