TN 25 (06-18)
NL 00725.470 WCP UTIs – Workers' Compensation
Other Disability Payments Affect Benefits
WCP001 WC/PDB – Number Holder Expressed Intent to File for WC/PDB
We learned that (1) to file a claim for workers' compensation or public disability benefit. If (2) these payments, we may have to reduce (3) Social Security benefits.
At that time, (4) may have to pay back any Social Security benefits that (5) not due. If (6) a claim, please tell us the decision made on the claim right away.
Fill-ins:
(1) NH FN “plans”/“you plan”
(2) “you receive”/“he receives”/“she receives”
(3) “your”/“your and your family's”/“his and his family's”/“her and her family's”/“his”/“her”
(4) “you”/“you and your family”/“he”/“he and his family”/“she”/“she and her family”
(5) “you were”/“he was”/“she was”/“you and your family were”/“he and his family were”/“she and her family were”
(6) “you file”/“he files”/“she files”
WCP003 WC/PDB – Definition of WC/PDB Offset
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 Benefits May Affect Your Social Security
Benefit.”
WCP004 WC/PDB – Number Holder Receiving WC/PDB – No Offset
(1) present (2) payments of $ (3) do not affect (4) Social Security benefits.
Fill-ins:
(1) NH FN possessive/“Your”
(2) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(3) Money amount
(4) “your”/“you and your family's”/“his”/“his and his family's”/“her”/“her and her family's”
WCP005 WC/PDB – Offset Determined by ACE
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 current monthly earnings, we reduce (5) Social Security disability benefits. We found that 80 percent of (6) average current monthly earnings is (7) .
Fill-ins:
(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name “and his family's”/NH name “and her family's”/NH's name possessive plus “family's”
(2) “you”/“he”/“she”/“you and your family”/“he and his family”/“she and her family”
(3) “workers' compensation”/“public disability benefit payments”/“workers' compensation and public disability benefit payments”
(4) “your”/“his”/“her”
(5) “your”/“your and your family's”/“your family's”/“her”/“his”/“her and her family's”/“his and his family's”/“her family's”/“her”/“his family's”
(6) “your”/“his”/“her”
(7) Money amount
WCPR06 WC/PDB – Amount of Offset Based on Estimate for 1 or More Years High 1
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-ins:
(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name possessive “and his family's”/NH name possessive “and her family”/NH's name possessive plus “family's”
(2) “your”/“her”/“his”
(3) “you”/“she”/“he”
(4) “you”/“she”/“he”
(5) Date of onset minus 5 years in the format “YYYY”
(6) Date of onset in the format YYYY
(7) Year of highest regular earnings in the format “YYYY”
(8) “your”/“her”/“his”
(9) Highest regular earnings in the format “$$$$$.¢¢”
(10) “you”/“she”/“he”
(11) “think”/“thinks”
(12) “You”/“She”/“He”
(13) “you have”/“she has”/“he has”
WCPR07 WC/PDB – Amount of Offset Based on Estimate for 1 or More Years – High 5
When we figured how much to reduce (1) benefits, we used an estimate for part of (2) earnings before (3) became disabled. According to our records, the 5 years in which (4) earned the most money were (5) to (6) . We estimated that (7) earned $ (8) during this period. If (9) that this amount is wrong, please let us know. (10) will also need to give us any facts (11) to show that the amount is wrong.
Fill-ins:
(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name possessive “and his family's”/NH name possessive “and her family's”/NH's name possessive plus “family's”
(2) “your”/“her”/“his”
(3) “you”/“she”/“he”
(4) “you”/“she”/“he”
(5) Year in the format “YYYY” *
(6) Year in the format “YYYY” *
(7) “you”/“she”/“he”
(8) Money amount in the format $$$$$.¢¢ *
(9) “you think”/NH name “thinks”
(10) “You”/“She”/“He”
(11) “you have”/“she has”/“he has”
(*) indicates that the fill-in is manual
WCP007 Number Holder Appealing WC/PDB Decision (Auxiliary Only)
We will not reduce (1) benefit 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-ins:
(1) BGN plus BLN, possessive/your
(2) NH-NAME, possessive
(3) “workers' compensation”/“public disability”/“worker's compensation and public disability”
WCP008 WC/PDB - WC/PDB Claim Pending – Auxiliary Only
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-ins:
(1) NH name
(2) FN possessive/“your”
WCPR09 WC/PDB – Interim Notice – Pending ACE Determination
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-ins:
(1) FN possessive/“your”
(2) NH name possessive/“your”/“her”/“his”
(3) “your”/“her”/“his”/FN possessive
WCP009 Number Holder Appealing WC/PDB Decision (Number Holder Only)
We will not reduce (1) benefit because of (2) payments until (3) a decision on (4) appeal of the claim. Please let us know the decision on the appeal right away. At
that time, (5) may have to pay back any Social Security benefits that (6) not due.
Fill-ins:
(1) BGN plus BLN possessive/“your”
(2) “workers' compensation”/“public disability benefit”/“worker's compensation and public disability benefit”
(3) “you receive”/“he receives”/“she receives”
(4) “your”/“his”/“her”
(5) “you”/“he”/“she”
(6) “you were”/“he was”/“she was”
WCP010 WC/PDB – Total or Partial WC/PDB Offset – Number Holder Only
We have to take into account (1) (2) of $ (3) (4) (5) when we figure (6) Social Security benefits. Due to this payment, we are (7) (8) benefits.
Fill-ins:
(1) your/BGN plus BLN (possessive)
(2) “workers' compensation payment”/“public disability payment”/“workers' compensation and public disability payments”
(3) Money amount
(4) “beginning”/“for”
(5) “Month YYYY”/“Month YYYY plus through plus Month YYYY”
(6) “your”/“his”/“her”
(7) “withholding”/“reducing”
(8) “your”/“his”/“her”
WCP011 WC/PDB – Total or Partial Offset – Auxiliary Only
We have to take into account (1) (2) payments when we figure (3) Social Security benefits. We are (4) the benefits (5) due because of these payments.
Fill-ins:
(1) NH name possessive
(2) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(3) FN possessive/“your”
(4) “withholding”/“reducing”
(5) “you are”/“she is”/“he is”
WCP012 WC/PDB –Offset Imposed First Month Number Holder Received DIB and WC/PDB
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-ins:
(1) “withholding”/“reducing”
(2) null plus FN possessive/“your”
(3) Show the month and year withholding or reduction began in the format “Month YYYY”
(4) “he is”/“she is”/“you are”
(5) “workers' compensation”/“public disability benefit”/“both workers' compensation and public disability benefit”
WCPR13 WC/PDB Offset Imposed After Date of Notice
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-ins:
(1) NH name possessive/BGN plus BLN possessive/“your”
(2) First month and year of offset in the format “May 1999”
WCP013 Change in Reduction of WC/PDB Due to Change in State Law (Reverse Jurisdiction)
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-ins:
(1) Month YYYY
(2) “you”/BGN plus BLN
(3) “worker's compensation”/“public disability”/“workers' compensation and public disability”
WCP014 WC/PDB – Amount of Benefit Received after Offset
(1) benefit will be $ (2) beginning (3) .
Fill-ins:
(1) NH first name (possessive)/NH given name plus last name (possessive)/Beneficiary
Full name (possessive)/“Your”
(2) Money amount in the format “$$$$.¢¢”
(3) Month of offset in the format “December 1999”
WCPR15 WC/PDB – Number Holder in Offset Due to Receipt of WC/PDB – Adjustment Made
We are (1) (2) benefits beginning (3) , when (4) (5) payments changed from $ (6) to $ (7) .
Fill-ins:
(1) “withholding”/“reducing”
(2) NH FN possessive/“your”
(3) Date *
(4) “your”/“her”/“his”
(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(6) Prior money amount *
(7) Current money amount *
(*) indicates that the fill-in is manual
WCPR16 WC/PDB – Auxiliary in Offset Due to Number Holder Receipt of WC/PDB Adjustment Necessary
We are (1) (2) benefits beginning (3) , when the (4) payments changed.
Fill-ins:
(1) “withholding”/“reducing”
(2) FN possessive/BGN possessive
(3) Month and year *
(4) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(*) indicates that the fill-in is manual
WCP017 WC/PDB – Increase in Benefit After WC/PDB First Imposed
(1) benefits were increased beginning (2) (3) (4) . (5) not reduced because of (6) payments.
Fill-ins:
(1) NH SN name (possessive)/BGN plus BLN possessive/BGN possessive/“Your”
(2) Earliest month/year
(3) “and”/null
(4) Month and year/null
(5) “This increase was”/“These increases were”
(6) “workers' compensation”/“public disability”/“workers' compensation and public disability”
WCP018 WC/PDB – Removal of Offset - WC/PDB Terminated
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.
Fill-ins:
(1) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(2) Month and year in the format “September 1999”
(3) NH name “receives”/“you receive”
WCP019 WC/PDB – Removal of Offset – Number Holder Age 62 or 65 (Before 12/19/2015)
Beginning (1) , we are not reducing (2) benefits because of (3) payments. We do not reduce benefits for months when the disabled worker is age (4) or over.
Fill-ins:
(1) Month and year NH attains 65 in format “July 2012”
(2) NH SN possessive/BGN plus BLN possessive/BGN possessive/“your”
(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(4) “65”
WCPR20 Workers' Compensation – Lump Sum and Ending Date of Proration
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-ins:
(1) “Ms.” plus BLN possessive/“Mr.” plus BLN possessive/BGN possessive/null plus FN possessive/“your”
(2) “she”/“he”/“you”/FN
(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(4) “will pay”/“started paying”
(5) “her”/“him”/“you”
(6) Month and year in the format March 1999
WCP021 WC/PDB –Possible Excludable Expenses
If (1) had any expenses related to (2) claim for (3) payments, please give us proof that (4) paid these expenses. We may be able to deduct some of these expenses when we figure
(5) Social Security benefits.
Fill-ins:
(1) NH FN/“you”
(2) “your”/“his”/“her”
(3) “workers' compensation”/“workers' compensation and public disability benefit”/“public disability benefit”
(4) “you”/“he”/“she”
(5) “your and your family's”/“NH name possessive”/“your family's”/“your”/“NH name possessive plus” “and his family's”/“NH name possessive plus” “and her family”/NH name possessive plus “family's”
WCPR22 WC/PDB – Exclusion of Expenses from WC/PDB Periodic Payments
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-ins:
(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name possessive plus “and his family's”/NH name possessive plus “and her family's”/NH name possessive plus “family's”
(2) “your”/“her”/“his”
(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(4) Actual amount of excludable expenses in format $$$$$.¢¢ *
(5) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name possessive plus “and his family's”/NH name possessive plus “and her family's”/NH name possessive plus “family's” *
(*) indicates that the fill-in is manual
WCPR23 WC/PDB Offset Based Upon Lump Sum Proration – Method A
(1) (2) received a lump-sum award of $ (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic
payments do. We treat a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we treated the lump sum as if (7) had been paid $ (8) each week. We excluded $ (9) for legal expenses, and $ (10) for medical expenses. Based on these facts, we can pay (11) benefits for (12) through (13) . We will reduce (14) benefits beginning (15) . We will again pay full benefits beginning (16) .
Fill-ins:
(1) NH FN/“You”
(2) “have”/“has”
(3) Money amount in the format “$$$$$.¢¢”
(4) “your”/“her”/“his”
(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name possessive plus “and his family's”/NH name possessive plus “and her family's”/NH name possessive plus “family's”
(7) NH FN/“you”
(8) Money amount in the format “$$$$.¢¢”
(9) Attorney fee amount in the format “$$$$.¢¢”
(10) Amount of medical expenses in the format “$$$$.¢¢”
(11) “you”/“you and your family”/“your family”/“him and his family”/“her and her family”/“him”/“her”/“her family”/“his family”
(12) Month and year of no offset *
(13) Month and year of no offset *
(14) “your”/“your and your family's”/“your family's”/“his and his family's”/“her and her family's”/“his”/“her”/“her family's”/“his family's”
(15) Month and year of no offset *
(16) Month and year of no offset
WCPR24 WC/PDB – Offset Based Upon Lump-Sum Proration – Method B
(*) indicates that the fill-in is manual
(1) (2) received a lump-sum award of $ (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic
payments do. We treat a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we treated the lump sum as if (7) had been paid $ (8) each week. We excluded $ (9) for legal expenses, medical and other related expenses. For this reason, we lowered
the weekly rate from $ (10) to $ (11) . This means that we will send (12) (13) benefits beginning (14) . (15) (16) .
Fill-ins:
(1) NH FN/“You”
(2) Lump sum gross amount “$$$$$.¢¢”
(3) “have”/“has”
(4) “your”/“her”/“his”
(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name plus “and his family's”/NH name plus “and her family's”/NH name possessive “family's”
(7) NH FN/“you”
(8) Money amount “$$$$.¢¢”
(9) Total amount of excludable expenses “$$$$.¢¢”
(10) Money amount “$$$$.¢¢”
(11) Money amount “$$$$.¢¢”
(12) “you”/“you and your family”/“your family”/“her”/“him”/“his family”/“her family”/“him and his family”/“her and her family”
(13) “additional”/“partial”/“full” *
(14) Month and year *
(15) “We will pay full benefits beginning [15a]”/null
[15a] Month and year/null (Period is part of fill-in.)
(*) indicates that the fill-in is manual
(16) Lump Sum Ending Date in the format “March 1999”/Null
WCPR25 WC/PDB Offset Based Upon Lump-Sum Proration – Method C
(1) (2) received a lump-sum award of $ (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic
payments do. We treat a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we excluded $ (7) for legal, medical and other expenses. We treated the rest of the lump sum, $ (8) , as if (9) had been paid $ (10) per week. We will pay full benefits beginning (11) .
Fill-ins:
(1) NH FN/“You”
(2) “have”/“has”
(3) Lump sum gross amount in the format “$$$$$.¢¢”
(4) “your”/“her”/“his”
(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/NH name possessive plus “and his family's”/NH name possessive plus “and her family's”/NH name possessive “family's”
(7) Sum of attorney and medical expenses in the format “$$$$$.¢¢”
(8) Lump sum which remains in the format “$$$$$.¢¢”
(9) “you”/“she”/“he”
(10) Money amount in the format “$$$$.¢¢”
(11) Lump sum prorated ending date plus one month (month and year full benefits payable)
in the format “June 1999”
WCPR27 WC/PDB – Offset Based Upon Unverified Allegation
We may have to change the amount of (1) benefits when we receive proof of the amount of (2) (3) payments.
Fill-ins:
(1) FN possessive/“your”
(2) NH name possessive/“his”/“her”/“your”
(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”
WCP028 WC/PDB – Benefits Offset – Number Holder May File for Reduced RIB (NH Age 65 before
12/19/2015)
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-ins:
(1) “your”/“your and your family's”/“NH name possessive”/“your family's”/NH name possessive “and his family's”/NH name possessive “and her family's”/NH name possessive plus “family's”
(2) “you reach”/“he reaches”/“she reaches”
(3) “your”/“his”/“her”
(4) “workers' compensation”/“workers' compensation and public disability benefit”/“public disability benefit”
(5) “Workers' compensation”/“Workers' compensation and public disability benefit”/“Public disability benefit”
(6) “You”/“He”/“She”
(7) “you reach”/“she reaches”/“he reaches”
WCP029 WC/PDB - WC/PDB Claim Pending – Number Holder Only
If (1) workers' compensation or public disability benefit payments, we may have to reduce
(2) Social Security benefits. At that time, (3) may have to pay back any Social Security benefits that (4) not due. Please let us know the decision on the claim right away.
Fill-ins:
(1) “FN receives”/“you receive”
(2) “your”/“his”/“her”
(3) “you”/“he”/“she”
(4) “you were”/“he was”/“she was”
WCPR31 WC/PDB –Number Holder Appealing WC/PDB –Number Holder and Auxiliary
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-ins:
(1) NH FN possessive/“your”
(2) “your”/“her”/“his”
(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”
(4) “your”/“her”/“his”
WCP032 WC/PDB –Reporting Responsibilities Involving Receipt of WC/PDB – Number Holder
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-ins:
(1) FN/“your”
(2) “you receive”/“he receives”/“she receives”
(3) “you receive”/“he receives”/“she receives”
(4) “your”/“his”/“her”
WCP060 WC/PDB – Removal of Offset – Number Holder Attains FRA
Starting (1) , we will stop reducing (2) Social Security disability benefits because of (3) (4) payments. We stop reducing disability benefits when (5) full retirement age.
Fill-ins:
(1) Month and year NH attains FRA in format “July 2012”
(2) NH name possessive/“your”
(3) “your”/“his”/“her”
(4) “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”
(5) “you reach”/“he reaches”/“she reaches”
WCP061 WC/PDB – Benefits Offset – Number Holder May File for Reduced RIB
We will continue to reduce or withhold (1) disability benefits until (2) full retirement age in (3) . We must take this action because of (4) (5) payments. (6) (7) payments do not affect retirement benefits. (8) may be eligible for reduced retirement benefits at age 62. If (9) to apply for retirement benefits, please contact us three months before (10) age 62.
Fill-ins:
(1) “your”/“NH name possessive”/“your and your family's”/“your family's”/NH name possessive “and his family's”/NH name possessive “and her family's”/NH name possessive plus “family's”
(2) “you reach”/“he reaches”/“she reaches”
(3) Month and year NH attains FRA in format “July 2012”
(4) “your”/“his”/“her”
(5) “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”
(6) “Your”/“His”/“Her”
(7) “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”
(8) “You”/“He”/“She”
(9) “you decide”/“he decides”/“she decides”
(10) “you reach”/“he reaches”/“she reaches”