MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

INSTRUCTIONS FOR COMPLETING NOTICE OF COMMENCEMENT/ TERMINATION OF COMPENSATION
This form has been designed as a tool to help calculate lost time benefits. It is password protected and you will not be able to change any of the labels or formulas. The form will perform lost time calculations based on the information you enter. There are several new fields added to this form which makes calculating the lost time feasible. Instructions for these fields are listed below. If you have problems accessing the form or using its calculations please contact LaTreva Smith by phone at 573-522-1963 or e-mail at latreva.smith@dolir.mo.gov. Injury Number: Please enter one digit of the injury number in each box, the dash is provided for you. 1A. SS Number: Please enter the employee's social security number without dashes; the form will fill them in for you. 5. Average Weekly Wage: Please enter the average weekly wage of the employee, the form will then calculate the rate of compensation and display it in box 6C. 6. Max AWW: If the injured employee will be receiving the State determined maximum amount of AWW, change the indicator in box 6A to "Y" and enter the maximum AWW rate in box 6B. The form will then display this amount as the rate of compensation in box 6C. 8. Type of LT (lost time): This form is designed to calculate the amount of benefits paid to the employees, and it separates TTD, TTS and TPD benefits from each other. In order to arrive at the correct calculations you will need to indicate which type of lost time each date range represents. In the preceding boxes type TTD for temporary total disability, TTS for temporary total disability salary and TPD for temporary partial disability. The form will then perform the correct calculations based on this information. Up to 10 different date ranges may be entered per form. 9. Disability Began: This is the first day that you started paying disability benefits to the injured employee. Note: If the employee was off work for more then 14 days and you ARE paying for the three day waiting period, the first day of the waiting period needs to be the date in this box. Please enter the date as follows: mm/dd/yy. Example for January 1, 2006 you would enter 01/01/06. 10. Disability Ended: This the last day disability benefits were paid to the employee. Please enter the date as follows mm/dd/yy. Example for March 15, 2006 you would enter 03/15/06. Total Days and Total Weeks: This form was designed to calculate the total number of day and total number of weeks for the date ranged entered. These are protected fields and cannot be changed. The form will perform the calculations automatically. 11. Total Weeks of Compensation: The form will automatically calculate the total weeks of compensation for the injured employee. This number will reflect TTD, TTS and TPD date ranges. 12. Temporary Total Disability Benefits Paid to Date: The form will automatically calculate the dollar amount of the benefit based on the number of TTD weeks and rate of compensation. This amount will not reflect TTS or TPD benefits paid. 13. Temporary Partial Disability Benefits Paid to Date: The Division does not calculate the amount of TPD paid to injured employees. The form will not perform an auto calculation for this field. You will need to type in the amount of TPD paid to the injured employees. 14. Temporary Total Disability Salary Benefits: The Division calculates TTS benefits in the same manor that TTD benefits are calculated, this form will perform auto calculations based on the information entered in the type of lost time fields. 16. Statutory Penalties: The form will calculate penalty reductions, however it will only calculate one amount. If you enter a dollar amount and a percentage the form will pick up the dollar amount before the percentage. It is best to only enter one of the two amounts. The calculations in box 12 and 14 will reflect the reduction once you have entered the reduction amount.
WC-2 (09-07) AI

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

INJURY NUMBER

NOTICE OF COMMENCEMENT/ TERMINATION OF COMPENSATION
INSURER'S OR SELF-INSURED EMPLOYER'S NAME ADDRESS

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CLAIM NO.

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ZIP CODE

THIS FORM NEEDS TO BE COMPLETED IF THE EMPLOYEE RECEIVED COMPENSATION BENEFITS AFTER THE THREE DAY WAITING PERIOD AND AS REQUIRED BY §§287.170 AND 287.180, RSMo, AND 8 CSR 50-2.010. SEND ORIGINAL TO THE DIVISION AND ONE COPY TO THE EMPLOYEE. TO EMPLOYERS/INSURERS/THIRD PARTY ADMINISTRATOR: BE SURE TO COMPLETE THE COST OF MEDICAL AID AND ALL OTHER DATA ITEMS. EMPLOYER MUST NOTIFY EMPLOYEE OF TERMINATION OF BENEFITS WITHIN 10 DAYS OF WHEN BENEFITS WERE DUE. (THIS FORM IS REQUIRED TO BE FILED WITHIN 30 DAYS OF THE DATE OF THE ORIGINAL NOTIFICATION OF THE INJURY. THIS FORM MUST BE UPDATED AND REFILED WITHIN TEN DAYS AFTER TERMINATION OF COMPENSATION.) 1. EMPLOYEE 4. EMPLOYEE ADDRESS 5. AVERAGE WEEKLY WAGE 8. Type of LT 6A. MAX AWW 6B. MAX RATE Total Days 6C. RATE OF COMPENSATION 1A. SS NUMBER 2. DATE OF ACCIDENT 3. COST OF MEDICAL AID ZIP CODE 7. WAITING PERIOD DATES

N
9. DISABILITY BEGAN 10. DISABILITY ENDED

$0.00
Total Weeks 11. TOTAL WEEKS OF COMPENSATION

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0
12. TEMPORARY TOTAL DISABILITY BENEFITS PAID TO DATE

$0.00
13. TEMPORARY PARTIAL DISABILITY BENEFITS PAID TO DATE

14. IF EMPLOYEE WAS PAID FULL SALARY FOR ANY PERIOD OF DISABILITY, TYPE AN "X" IN THIS BOX .

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TT Salary

$0.00

THE INFORMATION YOU VOLUNTARILY PROVIDE IN BOXES 15 & 16 BASED UPON SB 1 & 130 EFFECTIVE AUGUST 28, 2005 IS FOR STATISTICAL PURPOSES ONLY.
15. HAS STATUTORY PENALTY BEEN ASSESSED FOR: SAFETY VIOLATION: DRUG/ALCOHOL VIOLATION YES YES NO NO 16. I F YOU CHECKED YES IN BOX 15, PLEASE INDICATE THE FOLLOWING: AMOUNT REDUCED MEDICAL TTD/TPD PERCENTAGE REDUCED

DISABILITY PAYMENT
17. DATE FIRST PAYMENT WAS MADE TO EMPLOYEE 18. FIRST DAY OF PERIOD COVERED BY PAYMENT

NOTICE OF TERMINATION OF COMPENSATION
19. THIS IS TO NOTIFY THE DIVISION OF WORKERS' COMPENSATION AND THE EMPLOYEE THAT COMPENSATION PAYMENTS IN THE ABOVE MATTER HAVE TERMINATED, THE LAST PAYMENT HAVING BEEN MADE ON REASON (MUST BE STATED) 20 FOR THE FOLLOWING

PLEASE INDICATE WHETHER EMPLOYEE'S "POST-INJURY MISCONDUCT" SET FORTH IN SECTION §287.170.4 RSMO EFFECTIVE AUGUST 28, 2005 RESULTED IN TERMINATION OF TTD/TPD DISABILITY BENEFITS 20. RETURN TO WORK DATE 21. PREPARED BY 24. DATE

YES

NO

22. PREPARER'S PHONE NUMBER 25. PREPARER'S E-MAIL ADDRESS

23. EMPLOYER'/INSURER/THIRD PARTY ADMINISTRATOR SIGNATURE

DEATH BENEFIT PAYMENT
26. TO WHOM PAID 27. WEEKLY AMOUNT PAID

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WC-2-2 (09-07) AI