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To provide efficient dispute resolution for injured workers and employers by administering both formal adjudication and informal dispute resolution services; to serve the public by answering inquiries regarding the Indiana Worker's Compensation system; and to collect statistical information regarding workplace injuries in Indiana.
Notice: Please note that the Notice of Suspension of Compensation and/or Benefits - SF 54217 form has been revised to allow for the suspension of compensation as well as benefits. As a result, please refrain from utilizing the Report Of Temporary Total Disability (TTD)/Temporary Partial Disability (TPD) Termination/Reduction - SF 38911 to suspend a TTD/TPD agreement. The purpose of the 38911 is to terminate a TTD/TPD agreement whereas the 54217 should be used to suspend.
Notice: Effective Monday, February 25, 2013, the Worker’s Compensation Board of Indiana will no longer process 1043 agreements or waivers for 0% PPI ratings UNLESS filed as part of an agreed to stipulation, as required by 631 IAC 1-1-11.
Notice: The 2013 Second Injury Fund Report and Assessment, along with relevant certificates, are now ready and have been uploaded to our website. Please click here to review and complete.
Notice: The pilot program which was launched to test a new, online method of forms submission has concluded and the results have been extremely favorable. This tool is now available to the general public. A link to the tool may be found under the "Online Services" portion of this page which is located in the upper, right-hand corner. Upon accessing the tool, you will be given the option to either register or login. Registration is fairly simple but please be prepared to provide the FEIN of your company. The system will automatically assign a username and password and provide that information to the user via e-mail. The password can be changed but the username cannot. Once you have received your credentials, you may login immediately. Upon doing so, you will have the opportunity to edit your account or input forms. Currently, the available forms are limited to the Notice of Inability to Determine Liability/Request for Additional Time - SF 48557, Notice of Denial of Benefits - SF 53914 and Notice of Suspension of Compensation and/or Benefits - SF 54217. Regardless of the form chosen, you will be asked to identify your claim by providing the social security number and date of injury. Upon claim identification, the system will ask a few form-relevant questions. Once answered and submitted, you will receive immediate feedback via e-mail. If no first report of injury is on record for a given claim, you will not be able to proceed.
In response to overwhelming public concern, we have migrated this tool to a secure environment. As such, we have adjusted the timeframe for adoption. While we encourage immediate adoption of this system, we will continue to process forms received via postal mail until Monday, January 7, 2013. If you require additional time to make this change, please petition the Board. If you encounter any issues with this new system, please contact Rob Howell.
Notice: On August 1, 2012, the Board released revised versions of both the Notice of Inability to Determine Liability / Request for Additional Time - SF 48557 and the Notice of Denial of Benefits - SF 53914 forms. The purpose of the revisions is to provide a means for adjustors to communicate the medical-only period of a claim. Our compliance program has demonstrated that many of the penalties we have issued for lack of timely filing are, ultimately, due to a medical-only period preceding an alleged disability. As we appeared to be rescinding a great number of penalties due to this situation, the decision was made to alter the most relevant forms to capture the medical-only period thereby avoiding future, inappropriate notices of penalty. We would ask that all parties begin utilizing these new forms exclusively by no later than September 26, 2012. In addition, the Board is currently conducting a pilot program of an online data capture system that will, eventually, replace these forms. The pilot program will run for no fewer than sixty (60) days. Upon completion, we will post notice and usage instructions on our website along with a timeline for mandatory adoption.
Thank you for your patience and assistance as we continue to develop both our compliance program and our electronic filing system.
Notice: The following is a brief clarification regarding permanent partial impairment (PPI) ratings to the shoulder and hip. Please note that when injuries are specific to either of those body parts, because both are part of the torso, the impairment rating should be made to the body as a whole. This explanation is intended to provide clarity and direction to all involved parties, particularly physicians, who make the actual assessments on which we all rely. Please contact Kathy Haynes for assistance with or questions regarding the calculation of ratings.
Notice: The 2012 Self-Insurance application and guidelines are now available. Please click here for more information and to download these forms.
Notice: Effective May 21, 2012, the Worker's Compensation Board of Indiana will require that all filings be made on the most recent State form. These forms are available on our website and notice will be given via e-mail to our newsletter subscribers when a form has been amended. Filings made on outdated forms will be rejected and may subject the filer to penalties related to tardiness. For questions or assistance with forms, please contact Alan Buckley or Dirinda Asher.
Clarification Regarding Report of Attending Physician Form: As of this date, usage of the new State Form 2118, Report of Attending Physician, shall not be mandatory.
The new SF 2118 is clear, concise and, most importantly, relevant to how PPI awards are accurately calculated for approval. Adjusters will ultimately be required to use it, as well as the electronic versions of SF 1043 and 38911, in the upcoming year. However, the Board will give advance notice of this requirement.
Physicians will not be asked to complete this form but should use it as a guideline while dictating their own. We do encourage all interested parties to begin using this form, to which the physician’s dictated report can be attached, as soon as practicable. Thank you for your consideration and support.
Notice: The Board is hereby and immediately requesting that all Agreement to Compensation (SF 1043), Notice of Suspension of Medical Benefits (SF 54217), Notice of Denial of Benefits (SF 53914) and Request for Additional Time (SF 48557) forms be proceeded by an electronically filed First Report of Injury (FROI). Failure to do so will result in the rejection of your form. This is an administrative ruling.
Notice: Please note that ALL balanced bill provider fee applications must be accompanied by the $60 filing fee. The presence of an existing application for adjustment of claim has no bearing on this mandate. Balanced bill provider fee applications received since 7/1/2011 are subject to this fee and will not be processed unless accompanied by said payment.