Fill in the name and SSN at the top of the form. Complete the form as follows:
Item 1. - Check the appropriate box that pertains to the type of payments received.
There are four WC types and three PDB types.
Identify any payment not falling into one of these categories as “Other”.
Item 2. - Enter the WC/PDB claim number(s) and other identifying information, if known, for
each benefit checked in Item 1. Often, the applicant will not have this information
during the disability interview. Secure the claim number(s) after requesting verification.
Item 3. - Enter the State in which the WC injury occurred. If PDB or occupational disease is
involved, enter the State of employment when the illness began.
Item 4. - The offset provisions apply to WC and PDB. If a Federal,
State or local government bases disability on covered earnings, the offset provisions
may not apply. If the worker cannot answer the question, indicate “unknown”. Assume
the employment was non-covered if the worker alleges employment was not covered for
Social Security purposes and there is no evidence to the contrary.
NOTE: Earnings posted on the DEQY during the period in question may be considered conflicting
evidence; investigate any discrepancy.
Item 5. - Indicate the status of the claim. Describe any unusual circumstances in “Remarks”.
Item 6. - Indicate how often the WC/PDB payments are received, or were received, in the past.
Item 7.a. - complete the payment history as accurately as possible. If the claimant
cannot provide an allegation, use the applicable State maximum from the chart in DI 52150.045.
Item 7.b. - Indicate the appropriate cause for termination of WC/PDB payments. If
the reason for termination is not listed, explain in “Remarks”.
Item 8. - Indicate if a LS settlement has been awarded or paid.
Item 9. - Enter the amounts listed in the LS settlement documents. It is important that this
information be as accurate as possible. The amounts are used to compute the proration
of the LS. Only verified expenses are excluded from the LS settlement; see Excludable
Expenses in DI 52150.050.
Item 10. - Enter any remarks to explain unusual circumstances or to provide additional information
or helpful clarification.
Item 11. - Before the applicant signs the form, explain that any entitlement to or change in the WC/PDB payments must be reported
to SSA immediately. If the case comes under the 1981 Amendments (i.e., DIB onset is 03/01/81 or later
or DIB month of entitlement is 09/1981 or later), adjustment of the Social Security
disability benefit is made retroactively. See Notice Provision for Pre-1981 Amendment
cases in DI 52170.040 before processing offset. The longer the delay in reporting, the larger the overpayment
or underpayment can be, which may lead to later requests for reconsideration.