TN 4 (09-17)

DI 52140.005 Form SSA-546 Workers’ Compensation/Public Disability Benefit Questionnaire

The Field Office (FO) uses the form SSA-546 (paper form) to obtain workers’ compensation/public disability benefit (WC/PDB) information. They may use the paper form in the disability interview when we are unable to collect information electronically on the Modernized Claims System (MCS) application screens. This causes a need for manual processing because the number holder (NH) indicates she or he has filed, or intends to file, for WC/PDB.

We consider the SSA-546 to be part of the SSA-16-F6 (Application for Disability Insurance Benefits) and its completion cannot be deferred. If the claim is taken electronically through MCS, the completion of the WC screens is the equivalent of a paper SSA-546. An electronic version of the Form SSA-546 is available using the following links:

http://www.ssa.gov/online/ssa-546.pdf or on the intranet site at http://inform.ssahost.ba.ssa.gov/PDFs/ssa546.pdf.

A. Verification of alleged WC/PDB

The information obtained on the SSA-546 or electronically through MCS is not considered proof; therefore, all alleged WC/PDB information must be verified.

  1. Verify any allegation of WC/PDB payment rates, dates, periodic payments, lump sum (LS) settlements, expenses and all changes to current WC/PDB rates, in accordance with DI 52145.001 and DI 52145.005.

  2. For deferral policy, follow DI 11010.030.

  3. If reverse offset is alleged or known, follow policy in DI 52105.001.

B. Completing Form SSA-546 when offset is not applicable

If WC/PDB offset does not apply for reasons other than high ACE (for example, reverse offset applies for all months) only complete the following items on the SSA-546:

  • Name and SSN

  • Item 1. - Type of benefit

  • Item 7. - If reverse offset is involved

  • Item 10. - Explain why offset is not applicable

  • Item 11. - Signature

If WC/PDB offset is not applicable because the ACE is high enough to postpone offset:

  • complete the entire Form SSA-546, and

  • use the Remarks section to explain the case situations.

C. Completing Form SSA-546 when offset applies

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.

  • 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 inf