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Form Use Update

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Dear Indiana Workers’ Compensation Professional:

Please find below a list of Board forms and some explanation of how the Board views the proper use of each form.

o   A 38911 should be used only after TTD or TPD benefits have been initiated and are being terminated or reduced.  This form should not be used to deny claims or to deny requests for TTD after a claim has been accepted.

o   Please do not use a 38911 to report a PPI.

o   Carriers should not wait for a signed 38911 to be returned from the injured worker before notifying the Board of the proposed termination. The 38911 should be sent to the injured worker and a copy sent to the Board at the same time.  Carriers need not resubmit the signed 38911 to the Board if the injured worker signs the 38911 and returns it or a copy to the carrier. 

o   Notice that TTD is being denied when medical is being accepted does not require notice to the Board or the use of a Board form.  A letter from you to the injured worker will suffice.  However, if you feel more comfortable using a Board form:

§  You may, if you choose, use a 53914 to deny TTD.  Indicate in the “Explanation” box on the 53914 that TTD is denied and the reason for the denial, along with an explanation that the medical aspect is being accepted.

o   You may copy the Board at the time that a 1043 (Agreement to Compensation for TTD/TPD) is sent to the injured worker in order to demonstrate compliance with the statutory requirement that the 1043 be tendered to the injured worker within fifteen (15) days of date that the first payment of benefits is due.  If you choose to do so, these 1043s should have “Copy for Compliance” written into the “Employee Signature” box.  These forms will be returned with our file stamp to evidence submission to the Board, if an extra copy and a SASE are provided to the Board.  Please be aware that this procedure is not required at this time, but rather is voluntary.  These 1043s will not be stamped “Approved.” 

o   If the injured worker returns a signed 1043 to the carrier/TPA, the adjuster should submit the executed 1043 to the Board for approval.  An “Approved” copy will be returned if a copy is sent to the Board along with a SASE.

o   This procedure does not apply to 1043s that report a PPI.  These 1043s require the injured worker’s signature and a signed waiver for approval, and the employer/adjuster’s signature for approval.

o   Requests for more than thirty (30) days should be submitted only after making an initial request for thirty (30) days.  This is to say that a first request for additional time must have the upper box checked, requesting thirty (30) days additional time.  These will be summarily approved.

o   Before the initial thirty (30) days extension has expired, you may request additional time by submitting a second 48557 that requests an extension beyond the end of the first extension.  These requests must include the “extraordinary circumstances” that necessitate the additional time as well as an estimated time needed to make a determination, as requested on the 48557. 

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