TN 4 (08-12)

NL 00720.395 WCP Workers' Compensation

WCP001 N/H EXPRESSED INTENT TO FILE FOR WC AND/OR ANOTHER DISABILITY PAYMENT (J59)

(Requested)

Caption: Information About Other Disability Benefits

We were told that  (1)   (2)  going to file a claim for workers' compensation and/or public disability payments. If  (3)   (4)  these payments, we may have to reduce  (5)  Social Security benefits. At that time, we may also have to recover any money that should not have been paid. If  (6)   (7)  a claim, please let us know as soon as a decision is made.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number Holder's fullname

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: are

Choice 2: is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (4) - Systems Generated

Choice 1: receive

Choice 2: receives

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: you and your family's

Choice 3: his and his family's

Choice 4: her and her family's

Choice 5: his

Choice 6: her

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (7) - Systems Generated

Choice 1: file

Choice 2: files

WCP003 DEFINITION OF WC OFFSET (J48)

(Requested)

Caption: Information About Other Disability Benefits

We have to consider workers' compensation and/or public disability payments when we figure a Social Security benefit. The following will explain how these payments affect Social Security benefits. For more information, please read the enclosed pamphlet, "How Workers' Compensation and Other Disability Payments May Affect Your Social Security Benefit."

WCP004 N/H RECEIVING WC OR OTHER DISABILITY PAYMENTS NO OFFSET (J44)

(Requested)

Caption: Your Benefits

 (1)  present  (2)  payments of  (3)  do not affect  (4)  Social Security benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: NH Name possessive

Choice 2: Your

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢

Amount

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Choice 4: his and his family's

Choice 5: her and her family's

Choice 6: your and your family's

WCP005 WC/PDB - OFFSET DETERMINED BY ACE (J37)

(Requested)

Caption: Your Benefits

The pamphlet explains how we reduce  (1)  Social Security disability benefits. We add the money  (2)  would receive from us and from  (3)  . When this total adds up to more than 80 percent of  (4)  average currently monthly earnings, we reduce  (5)  Social Security disability benefits. We found that 80 percent of  (6)  average currently monthly earnings is  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: you and your family's

Choice 3: your family's

Choice 4: number holder's name possessive

Choice 5: number holder's name and his family's

Choice 6: number holder's name and her family's

Choice 7: number holder's name possessive plus family's

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Choice 4: you and your family's

Choice 5: he and his family's

Choice 6: she and her family's

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability benefit payments

Choice 3: (C) workers' compensation and public disability benefit payments

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: you and your family’s

Choice 3: your family’s

Choice 4: her

Choice 5: his

Choice 6: her and her family’s

Choice 7: his and his family

Choice 8: her family’s

Choice 9: his family’s

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) Requested As A Money Amount

Earning amount

WCP008 WC OR OTHER DISABILITY CLAIM PENDING AUX. ONLY (J30)

(Requested)

Caption: Information About Other Disability Benefits

If  (1)  receives workers' compensation and/or public disability payments, we may have to reduce  (2)  Social Security benefits. At that time, we may also have to recover any money that should not have been paid.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's name

Fill-in (2) - Systems Generated

Choice 1: Full name possessive

Choice 2: your

WCP009 NH APPEALING WC DECISION NH ONLY (J38)

(Requested)

Caption: Your Responsibilities

We will not reduce  (1)  benefit because of  (2)  payments until a decision is made on  (3)  appeal of the claim. Please let us know when a final decision is made. At that time, we may collect any money that should not have been paid.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Fullname possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

WCP010 TOTAL OR PARTIAL WC OFFSET NH ONLY (J21)

(Requested)

Caption: Your Benefits

We have to take into account  (1)   (2)  payment of  (3)  when we figure  (4)  Social Security benefits. Because  (5)   (6)  this payment, we are  (7)  the benefits  (8)  due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Ms + Beneficiary's last name possessive

Choice 2: Mr + Beneficiary's last name possessive

Choice 3: your

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢

Amount (WC or PDB or combined)

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (6) - Systems Generated

Choice 1: receive

Choice 2: receives

Fill-in (7) Requested As A One Position Alpha Character

Choice 1: (A) withholding

Choice 2: (B) reducing

Fill-in (8) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

WCP012 OFFSET IMPOSED FIRST MONTH N/H RECEIVES DIB AND WC AND/OR OTHER DISABILITY PAYMENT (J19)

(Requested)

Caption: Your Benefits

We are  (1)   (2)  monthly payment beginning  (3)  . This is the first month when  (4)  entitled to Social Security disability benefits and  (5)  payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: withholding

Choice 2: reducing

Fill-in (2) - Systems Generated

Choice 1: Beneficiary's Name Possessive

Choice 2: your

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY (first month of offset)

Fill-in (4) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (5) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: both workers' compensation and public disability

WCP013 CHANGE IN REDUCTION OF WORKERS' COMPENSATION BENEFITS (BECAUSE OF CHANGE IN STATE LAW) (J85)

(Requested

Caption: Your Benefits

Beginning  (1)  , we are paying  (2)  a Social Security benefit that is not reduced due to  (3)  payments. This is because of a change caused by the State law which provides for the reduction of these payments to persons who receive Social Security disability benefits.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: Number holder's name

Choice 2: you

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

WCP015 INCREASE IN BENEFITS DUE TO A REDETERMINATION (J31)

(Requested)

Caption: Your Benefits

Based on  (1)   (2)  , every 3 years we check to see if an increase in the national earnings level affects the amount of  (3)  monthly Social Security benefit. When we checked  (4)  monthly benefit amount, we found that  (5)  due more money.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Last Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

WCP017 INCREASE IN BENEFITS AFTER WC OFFSET FIRST IMPOSED (J32)

(Requested)

Caption: Your Benefits

 (1)  benefits were increased beginning  (2)   (3)   (4)   (5)  not reduced because of  (6)  payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name possessive

Choice 2: Number holder's first name possessive

Choice 3: Beneficiary given and last name possessive

Choice 4: Your

Choice 5: Beneficiary given possessive

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY or MM/CCYY through MM/CCYY or MM/CCYY and MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: null

Choice 2: null

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: null

Fill-in (5) - Systems Generated

Choice 1: This increase was

Choice 2: These increases were

Fill-in (6) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers compensation and public disability

WCP018 REMOVAL OF OFFSET WC OR OTHER DISABILITY PAYMENTS TERMINATED (J27)

(Requested)

Caption: Your Benefits

We do not reduce benefits once  (1)  payments have stopped. Therefore, we are paying benefits at the full rate beginning  (2)  . Please let us know right away if  (3)  workers' compensation and/or other public disability payments again.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: Number holder's name receives

Choice 2: you receive

WCP019 REMOVAL OF OFFSET N/H AGE 62 OR 65 (J28)

(Requested)

Caption: Your Benefits

Beginning  (1)  , we are not reducing  (2)  benefit because of  (3)  payments. We do not reduce benefits for months when the disabled worker is age  (4)  or over.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY number holder attains age 62 or 65

Fill-in (2) - Systems Generated

Choice 1: Number holder's name possessive

Choice 2: Number holder's first name possessive

Choice 3: Beneficiary given and last name possessive

Choice 4: Your

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) 62

Choice 2: (B) 65

WCP021 POSSIBLE EXCLUDABLE EXPENSES WC (J33)

(Requested)

Caption: Information About Other Disability Benefits

If  (1)  had expenses related to  (2)  claim for  (3)  payments, please give us proof that  (4)  paid these expenses. These expenses may include medical, legal, or other related expenses. We may be able to deduct some of these expenses when we figure  (5)  Social Security benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) workers’ compensation and public disability benefit

Choice 3: (C) public disability benefit

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: your and your family's

Choice 2: number holder's name possessive

Choice 3: your family's

Choice 4: your

Choice 5: Number holder's name possessive + and his family's

Choice 6: Number holder's name possessive + and her family's

Choice 7: Number holder's name possessive + family's

WCP026 BENEFICIARY NO LONGER ENTITLED TO BENEFITS (J80)

(Requested)

Caption: Your Benefits

We changed  (1)  monthly benefit to  (2)  beginning  (3)  because benefits to another entitled person stopped. When we figured  (4)  benefit, we had to take into account  (5)   (6)  payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's name possessive

Choice 2: your

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Systems Generated

Choice 1: NH Name possessive

Fill-in (6) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

WCP028 BENEFITS OFFSET N/H MAY FILE FOR REDUCED RIB (J20)

(Requested)

Caption: Things To Remember

We may continue to reduce or withhold  (1)  disability benefits until  (2)  age 65. We must take this action because of  (3)   (4)  payments.  (5)  payments do not affect retirement benefits.  (6)  may be eligible for retirement benefits at age 62. To apply, please get in touch with us three months before  (7)  age 62.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: your and your family’s

Choice 3: Number holder’s name possessive

Choice 4: your family’s

Choice 5: Number holder’s name possessive and his family’s

Choice 6: Number holder’s name possessive and her family’s

Choice 7: Beneficiary full name possessive plus family’s

Fill-in (2) - Systems Generated

Choice 1: you reach

Choice 2: he reaches

Choice 3: she reaches

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) workers’ compensation and public disability benefit

Choice 3: (C) public disability benefit

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) Workers' compensation

Choice 2: (B) Workers’ compensation and public disability benefit

Choice 3: (C) Public disability benefit

Fill-in (6) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (7) - Systems Generated

Choice 1: you reach

Choice 2: he reaches

Choice 3: she reaches

WCP029 WC OR OTHER DISABILITY CLAIM PENDING NH ONLY (J29)

(Requested)

Caption: Your Responsibilities

If  (1)   (2)  workers' compensation and/or public disability payments, we may have to reduce  (3)  Social Security benefits. At that time, we may also have to recover any money that should not have been paid. Please let us know as soon as a decision is made on  (4)  claim for these payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Full name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: receive

Choice 2: receives

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

WCP032 ALL LETTERS INVOLVING RECEIPT OF WC OR OTHER DISABILITY PAYMENTS NH (J43)

(System Generated)

Caption: Your Responsibilities

Please let us know right away about any:

  • Changes in  (1)  workers' compensation or public disability benefit payments

  • Lump-sum award(s)  (2) 

  • Other payments  (3)  that increase or decrease  (4)  workers’ compensation or public disability benefit payments

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary full name possessive

Choice 2: your

Fill-in (2)

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (3)

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (4)

Choice 1: your

Choice 2: his

Choice 3: her

WCP048 TOTAL OR PARTIAL OFFSET AUX. ONLY (J22)

(Requested)

Caption: Your Benefits

We have to take into account  (1)   (2)  payments when we figure  (3)  Social Security benefits. Because of these payments, we are  (4)  the benefits  (5)  due  (6)   (7)  .

Note: If the Technician input a date for Fill-in 7 the word “through” will be generated. If the technician selects “A” for null then the notice will end after Fill-in 6.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name of NH (possessive)

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: Auxiliary name possessive

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) withholding

Choice 2: (B) reducing

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Requested As A Date In Format Shown Below
MM/CCYY

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: Null

Choice 2: Through

WCP049 AMOUNT OF BENEFIT RECEIVED AFTER OFFSET (J23)

(Requested)

Caption: Your Benefits

Benefit Amount Beginning Date Reason

 (1)   (2)   (3) 

NOTE: This UTI is flexible, to allow multiple repetitions of the three fill-ins. This allows it to be used once, and provide as many benefit amount, dates and reasons as are needed to explain the action, or twice with the benefit amount, date and reason. An example of how to input this in the ENB is:

C*WCP049,500.00,09/2010,A,530.00,01/2011,C. OR

WCP049,500.00,05/2013,I*WCP049,530.00,06/2013,A.

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Benefit Amount

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1 (A): Entitlement began

Choice 2 (B): Cost of living adjustment

Choice 3 (C): Credit for additional earnings

Choice 4 (D): Your own benefit increased

Choice 5 (E): His own benefit increased

Choice 6 (F): Her own benefit increased

Choice 7 (G): Because we stopped paying another person on this record

Choice 8 (H): Because we started paying another person on this record

Choice 9 (I): Because of the receipt of worker's compensation payments

Choice 10 (J): Because of the receipt of public disability payments

Choice 11 (K): Because of the receipt of worker's compensation and public disability payments

WCP050 SUBSEQUENT ADJUSTMENT TO PRORATION PERIOD BASED ON NEW EVIDENCE (J75)

(Requested)

Caption: Your Benefits

We told  (1)  earlier that we would pay  (2)  full Social Security benefits beginning  (3)  . Because of new facts we have received, we will now pay  (4)  full benefits beginning  (5)  .

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Requested As A Date In Format Shown Below

MM/CCYY when NH was informed full DIB was payable

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

MM/CCYY when full DIB actually payable

WCP051 CHANGE IN AMOUNT OF THE AVERAGE CURRENT EARNINGS (ACE) (J76)

(Requested)

Caption: Your Benefits

We told  (1)  earlier that we might change the amount of  (2)  benefits when we got more facts about the money  (3)  earned while  (4)  working. Using the new facts about  (5)  earnings, we found that 80 percent of  (6)  average current earnings was  (7)  . For this reason, we are increasing  (8)  Social Security benefits beginning  (9)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of the ACE

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Requested As A Date In Format Shown Below

MM/CCYY

WCP052 RESUMPTION OF OFFSET N/H ONLY (J77)

(Requested)

Caption: Your Benefits

Beginning  (1)  , we paid  (2)  full Social Security checks because  (3)   (4)  payments stopped. Now that  (5)  these payments of  (6)  each week, we reduced  (7)  Social Security benefits beginning  (8)  .  (9)  new benefit is shown above.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Worker's compensation

Choice 2: Public disability

Choice 3: Worker's compensation and Public disability

Fill-in (5) - Systems Generated

Choice 1: you again receive

Choice 2: he again receives

Choice 3: she again receives

Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of weekly WC

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (9) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

WCP053 RESUMPTION OF OFFSET AUXILIARIES ONLY (J78)

(Requested)

Caption: Your Benefits

Beginning  (1)  , we paid  (2)  full Social Security checks because  (3)   (4)  payments stopped. Now that these payments have started again, we reduced  (5)  Social Security benefits beginning  (6)  .  (7)  new benefit rate is shown above.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (3) Systems Generated

Choice 1: N/H's full name (possessive)

Fill-in (4) Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (5) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) Requested As A Date In Format Shown Below

MM/CCYY offset resumed

Fill-in (7) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

WCP054 VERIFIED RATE OF WC AND/OR OTHER DISABILITY PAYMENT (J83)

(Requested)

Caption: Your Benefits

We have learned that  (1)  weekly  (2)  payment is  (3)  rather than  (4)  , as we had previously been told. Therefore, we have changed  (5)  Social Security benefits beginning  (6)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

Fill-in (2) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of WC received

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of WC reported

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Requested As A Date In Format Shown Below

MM/CCYY (date of adjustment)

WCP055 THIRD PARTY INVOLVEMENT (J84)

(Requested)

Caption: Your Benefits

We learned that  (1)  received a third-party settlement. Since this was not a workers' compensation payment, we will not have to reduce  (2)  benefit. We also learned that the workers' compensation  (3)  had already received was to be repaid because of the settlement. Since we do not have to reduce  (4)  benefits because of the workers' compensation, we will pay  (5)  the money we have withheld.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

WCP057 REMOVAL OF OFFSET LUMP-SUM PRORATION ENDED (J91)

(Requested)

Caption: Your Benefits

Beginning  (1)  , we can pay  (2)  benefits at the full rate. This is because we are no longer considering the  (3)  lump-sum award when we figure the benefit amount.

Please let us know right away if  (4)  workers' compensation and/or other public disability payments.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Date offset no longer applies

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary Name

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1:A workers' compensation

Choice 2:B public disability

Choice 3:C workers' compensation and public disability

Fill-in (4) - Systems Generated

Choice 1: you again receive

Choice 2: he again receives

Choice 3: she again receives

WCP058 CHANGE IN WC RATE AND/OR OTHER DISABILITY PAYMENT AND OFFSET ADJUSTED NH ONLY (J81)

(Requested)

Caption: Your Benefits

We have learned that  (1)  weekly  (2)  payment was changed to  (3)  . For this reason, we have changed  (4)  Social Security benefits beginning  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (5) - Requested As A Date In Format Shown Below

MM/CCYY

WCPR02 NH APPEALING WC DECISION AUX. ONLY (J39)

(Requested)

Caption: Information About Other Disability Benefits

We will not reduce  (1)  because of  (2)   (3)  payments until a decision is made on the appeal of the claim. At that time, we may collect any money that should not have been paid.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Beneficiary's Name, possessive

Choice 2: your

Fill-in (2) Systems Generated

Choice 1: number holder's name possessive

Fill-in (3) Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

WCPR06 AMOUNT OF OFFSET BASED ON ESTIMATE FOR ONE OR MORE YEARS HIGH 1 (J49)

(Requested)

Caption: Information About Other Disability Benefits

When we figured how much to reduce  (1)  benefits, we used an estimate for part of  (2) 

earnings before  (3)  became disabled. According to our records, the year in which  (4)  earned the most money between  (5)  and  (6)  was  (7)  . We estimated  (8)  earnings for that year to be  (9)  . If  (10)   (11)  that this amount is wrong, please let us know.  (12)  will also need to give us any facts  (13)  to show that the amount is wrong.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your and your family's

Choice 2: number holder's name possessive

Choice 3: your family's

Choice 5: number holder's name and his family

Choice 6: number holder's name and her family

Choice 7: number holder's name possessive plus family's

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (5) - Systems Generated

Choice 1: date of onset minus 5 years

Fill-in (6) - Systems Generated

Choice 1: date of onset in year format

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: CCYY

year of highest regular earnings

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: highest regular earnings

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (11) - Systems Generated

Choice 1: think

Choice 2: thinks

Fill-in (12) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (13) - Systems Generated

Choice 1: you have

Choice 2: she has

Choice 3: he has

WCPR07 AMOUNT OF OFFSET BASED ON ESTIMATE FOR ONE OR MORE YEARS HIGH 5 (J25)

(Requested)

Caption: Information About Other Disability Benefits

When we figured how much to reduce  (1)  benefits, we used an estimate for part of  (2)  earnings before  (3)  became disabled. According to our records, the 5 years in which  (4)  earned the most money were  (5)  to  (6)  . We estimated that  (7)  earned  (8)  during this period. If  (9)  that this amount is wrong, please let us know.  (10)  will also need to give us any facts  (11)  to show that the amount is wrong.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your and your family's

Choice 2: number holder's name possessive

Choice 3: your familys

Choice 4: your

Choice 5: number holder's name and his family

Choice 6: number holder's name and her family

Choice 7: number holder's name possessive plus family's

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (8) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: money amount

Fill-in (9) - Systems Generated

Choice 1: you think

Choice 2: number holder's name thinks

Fill-in (10) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (11) - Systems Generated

Choice 1: has

Choice 2: have

WCPR09 INTERIM NOTICE PENDING ACE DETERMINATION (J57)

(Requested)

Caption: Information About Other Disability Benefits

We may have to change the amount of  (1)  benefits when we receive proof of the amount of  (2)  average current earnings. We use these earnings to figure how much to deduct from  (3)  benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Full name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: number holder's name

Choice 2: your

Choice 3: her

Choice 4: his

Fill-in (3) - Systems Generated

Choice 1: Full name

Choice 2: your

Choice 3: her

Choice 4: his

WCPR13 OFFSET IMPOSED AFTER DATE OF NOTICE (J26)

(Requested)

Caption: Your Benefits

We are reducing  (1)  benefits beginning  (2)  because of workers' compensation payments. We must reduce benefits beginning with the month after the month in which we were told about these payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's name possessive

Choice 2: Number holder's first name possessive

Choice 3: beneficiary given and last name possessive

Choice 4: your

Fill-in (2) - Systems Generated

Choice 1: first month and year of offset

WCPR15 CHANGE IN WC RATE AND/OR OTHER DISABILITY PAYMENT AND OFFSET ADJUSTED AUXILIARY ONLY (J82)

(Requested)

Caption: Your Benefits

We are  (1)   (2)  benefits beginning  (3)  , when  (4)   (5)  payments changed from  (6)  to  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: withholding

Choice 2: reducing

Fill-in (2) - Systems Generated

Choice 1: Number holder's full name possessive

Choice 2: Number holder's first name possessive

Choice 3: your

Fill-in (3) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (5) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: prior money amount

Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: current money amount

WCPR20 OFFSET BASED ON LUMP SUM ENDING DATE OF PRORATION (J36)

(Requested)

Caption: Your Benefits

We changed  (1)  monthly benefit because  (2)  received a  (3)  lump-sum award. We treat a

lump-sum award as if it were paid on a weekly basis. We  (4)  a full Social Security benefit to  (5)  beginning  (6)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's name possessive

Choice 2: beneficiary given name possessive

Choice 3: beneficiary given and last name possessive

Choice 4: your

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (3) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (4) - Systems Generated

Choice 1: will pay

Choice 2: will start paying

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: her

Choice 3: him

Fill-in (6) - Systems Generated

Choice 1: Month and Year

WCPR22 WC EXCLUDABLE AMOUNTS DEDUCTED (J42)

(Requested)

Caption: Information About Other Disability Benefits

When we figure how much to reduce  (1)  benefits, we do not count certain medical, legal, or other expenses which were paid out of  (2)   (3)  payments. We excluded  (4)  when we figured  (5)  benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your and your family's

Choice 2: number holder's name possessive

Choice 3: your family's

Choice 4: your

Choice 5: number holder's name and his family

Choice 6: number holder's name and her family

Choice 7: number holder's name possessive plus family's

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (3) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: actual amount of excludable expenses

Fill-in (5) - Systems Generated

Choice 1: your and your family's

Choice 2: number holder's name possessive

Choice 3: your family's

Choice 4: your

Choice 5: number holder's name and his family

Choice 6: number holder's name and her family

Choice 7: number holder's name possessive plus family's

WCPR23 OFFSET BASED ON LUMP SUM PRORATION METHOD A (J45)

(Requested)

Caption: Your Benefits

 (1)   (2)  received a lump-sum award of  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we treated the lump sum as if  (7)  had been paid  (8)  each week. We excluded  (9)  for legal expenses, and  (10)  for medical expenses. Based on these facts, we can pay  (11)  full benefits for  (12)  through  (13)  . We will reduce  (14)  benefits beginning  (15)  . We will again pay full benefits beginning  (16)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's full name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: have

Choice 2: has

Fill-in (3) - Systems Generated

Choice 1: money amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (5) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (6) - Systems Generated

Choice 1: your and your family's

Choice 2: number holder's name possessive

Choice 3: your family's

Choice 4: your

Choice 5: number holder's name and his family

Choice 6: number holder's name and her family

Choice 7: number holder's name possessive plus family's

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: number holder's full name

Fill-in (8) - Systems Generated

Choice 1: money amount

Fill-in (9) - Systems Generated

Choice 1: attorney fee amount

Fill-in (10) - Systems Generated

Choice 1: amount of medical expenses

Fill-in (11) - Systems Generated

Choice 1: you

Choice 2: you and your family

Choice 3: your family

Choice 4: him and his family

Choice 5: her and her family

Choice 6: her family

Choice 7: his family

Choice 8: him

Choice 9: her

Fill-in (12) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (13) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: you and your family

Choice 3: your family

Choice 4: him and his family

Choice 5: her and her family

Choice 6: her family

Choice 7: his family

Choice 8: him

Choice 9: her

Fill-in (15) - Requested As A Date In Format MM/CCYY

Choice 1: Date (beginning of offset)

Fill-in (16) - Requested As A Date In Format MM/CCYY

Choice 1: Date (end of offset)

WCPR24 OFFSET BASED ON LUMP SUM PRORATION METHOD B (J46)

(Requested)

Caption: Your Benefits

 (1)   (2)  received a lump-sum award of  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we treated the lump sum as if  (7)  had been paid  (8)  each week. We excluded  (9)  for legal expenses, medical and other expenses. For this reason, we lowered the weekly rate from  (10)  to  (11)  . This means that we will send  (12)   (13)  benefits beginning  (14)  .  (15)   (16) 

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's full name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: have

Choice 2: has

Fill-in (3) - Systems Generated

Choice 1: lump sum gross amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: their

Fill-in (5) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: your and your family's

Choice 3: your family's

Choice 4: number holder's name possessive

Fill-in (7) - Systems Generated

Choice 1: Number holder's full name

Choice 2: you

Fill-in (8) - Systems Generated

Choice 1: money amount

Fill-in (9) - Systems Generated

Choice 1: total amount of excludable expenses

Fill-in (10) - Systems Generated

Choice 1: money amount

Fill-in (11) - Systems Generated

Choice 1: money amount

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: you and your family

Choice 3: your family

Choice 4: him and his family

Choice 5: her and her family

Choice 6: her family

Choice 7: his family

Choice 8: him

Choice 9: her

Fill-in (13)- Requested As A One Position Alpha Character

Choice 1: (A) additional

Choice 2: (B) partial

Choice 3: (C) full

Fill-in (14) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (15) - Systems Generated

Choice 1: We will pay full benefits beginning

Choice 2 : null

Fill-in (16) - Systems Generated

Choice 1: ending date plus 1 month

Choice 2: null

WCPR25 OFFSET BASED ON LUMP SUM PRORATION METHOD C (J47)

(Requested)

Caption: Your Benefits

 (1)   (2)  received a lump-sum award of  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we excluded  (7)  for legal, medical and other expenses. We treated the rest of the lump sum,  (8)  , as if  (9)  had been paid  (10)  per week. We will pay full benefits beginning  (11)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder's full name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: have

Choice 2: has

Fill-in (3) - Systems Generated

Choice 1: lump sum gross amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (5) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: your and your family

Choice 3: your family's

Choice 4: number holder's name possessive

Choice 5: number holder's name plus his family's

Choice 6: number holder's name plus her family's

Choice 7: number holder's name possessive plus family's

Fill-in (7) - Systems Generated

Choice 1: sum of attorney and medical expenses

Fill-in (8) - Systems Generated

Choice 1: lump sum which remains

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (10) - Systems Generated

Choice 1: money amount

Fill-in (11) - Systems Generated

Choice 1: lump sum prorated ending date plus one month (month and year full benefits payable)

WCPR27 OFFSET BASED ON UNVERIFIED ALLEGATION (J41)

(Requested)

Caption: Information About Other Disability Benefits

We may have to change the amount of  (1)  benefits when we receive proof of the amount of  (2)   (3)  payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Full name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: Name possessive

Fill-in (3) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

WCPR31 NH APPEALING WC DECISION NH AND AUX (J40)

(Requested)

Caption: Your Responsibilities

We will not reduce  (1)  benefit, or the benefits of  (2)  family, because of  (3)  payments until a decision is made on the appeal of  (4)  claim. Please let us know when a final decision is made. At that time, we may collect any money that should not have been paid.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Number holder full name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (3) - Systems Generated

Choice 1: workers' compensation

Choice 2: public disability

Choice 3: workers' compensation and public disability

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720395
NL 00720.395 - WCP Workers' Compensation - 09/08/2014
Batch run: 09/08/2014
Rev:09/08/2014