WCPC01 – CAPTION
Other Disability Payments Affect Benefits
WCP001 – NUMBER HOLDER INTENDS TO FILE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY
BENEFITS (PDB)
We learned that (1) to file a claim for workers' compensation or public disability
benefits. If (2) these payments, we may have to reduce (3) Social Security benefits.
At that time, (4) may also 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-in values:
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Fill-in (1)
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Choice 1
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NH-NAME plans
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Choice 2
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you plan
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Fill-in (2)
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Choice 1
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you receive
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Choice 2
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he receives
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Fill-in (3)
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Choice 1
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your
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Choice 2
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his
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Choice 3
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her
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Choice 4
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your and your family’s
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Choice 5
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his and his family’s
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Choice 6
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her and her family's
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Fill-in (4)
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Choice 1
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you
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Choice 2
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he
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Choice 3
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she
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Choice 4
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you and your family
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Choice 5
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he and his family
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Choice 6
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she and her family
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Fill-in (5)
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Choice 1
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you were
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Choice 2
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he was
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Choice 3
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she was
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Choice 4
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you and your family were
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Choice 5
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he and his family were
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Choice 6
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she and her family were
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Fill-in (6)
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Choice 1
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you file
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Choice 2
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he files
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Choice 3
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she files
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WCP003 – NUMBER HOLDER RECEIVES WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS
(PDB) PUBLICATION 05-10018
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
Benefits.”
WCP004 – NUMBER HOLDER RECEIVES WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS
(PDB) AND MONTHLY BENEFIT AMOUNT (MBA) IS NOT OFFSET
(1) present (2) payments of (3) do not affect (4) Social Security benefits.
Fill-in values:
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Fill-in (1)
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Choice 1
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NH-NAME plans
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Choice 2
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you plan
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Fill-in (2)
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Choice 1
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workers' compensation
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Choice 2
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public disability
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Choice 3
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workers' compensation and public disability
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Fill-in (3)
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Choice 1
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Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in the format $$$$$.¢¢
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Choice 2
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Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢
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Choice 3
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Sum of Workers’ Compensation Payment Amounts (WCPD-WC-AMT) plus Public Disability
Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢
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Fill-in (4)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Choice 4
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his and his family’s
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Choice 5
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her and her family’s
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Choice 6
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your and your family’s
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WCP007 – WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) APPEAL PENDING
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-in values:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 2
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your
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Fill-in (2)
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NH-NAME
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Fill-in (3)
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Choice 1
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workers' compensation
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Choice 2
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public disability
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Choice 3
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workers' compensation and public disability
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WCP008 – TELLS AUXILIARY THAT NUMBER HOLDER INTENDS TO FILE FOR WORKERS’ COMPENSATION
(WC)/PUBLIC DISABILITY BENEFITS (PDB)
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:
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Fill-in (1)
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NH-NAME
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Fill-in (2)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 2
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your
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WCP009 – NUMBER HOLDER APPEALS WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS
(PDB)
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-in values:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 2
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your
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Fill-in (2)
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Choice 1
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workers' compensation
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Choice 2
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public disability
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Choice 3
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workers' compensation and public disability
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Fill-in (3)
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Choice 1
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you receive
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Choice 2
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he receives
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Choice 3
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she receives
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Fill-in (4)
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Choice 1
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your
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Choice 2
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his
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Choice 3
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her
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Fill-in (5)
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Choice 1
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you
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Choice 2
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he
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Choice 3
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she
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Fill-in (6)
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Choice 1
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you were
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Choice 2
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he was
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Choice 3
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she was
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WCP013 – ADVISES NUMBER HOLDER OF 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-in values:
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Fill-in (1)
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IDET Reverse Jurisdiction Start Date (IDET-RJ-START) in Month CCYY format
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Fill-in (2)
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Choice 1
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NH-NAME
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Choice 2
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you
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Fill-in (3)
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Choice 1
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workers' compensation
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Choice 2
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public disability
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Choice 3
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workers' compensation and public disability
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WCP015 – TRIENNIAL REDETERMINATION (EVERY 3 YEARS)
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:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 2
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your
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Fill-in (2)
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Choice 1
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workers' compensation payment
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Choice 2
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public disability payment
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Choice 3
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workers' compensation and public disability payments
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Fill-in (3)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Fill-in (4)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Fill-in (5)
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Choice 1
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he is
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Choice 2
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she is
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Choice 3
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you are
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WCP016 – MONTHLY BENEFIT AMOUNT (MBA) OFFSET DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC
DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) DUE
A cost-of-living increase is not reduced because of (1) workers' compensation and/or
public disability payments.
Fill-in values:
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Fill-in (1)
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Choice 1
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NH-NAME (possessive)
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Choice 2
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your
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WCP019 – WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS – NUMBER
HOLDER AGE 65 MINUS ONE MONTH PRIOR TO DECEMBER 19, 2015
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:
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Fill-in (1)
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Amount of Offset End Date (AMOF-STOP-REL) plus 1 month
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Fill-in (2)
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Choice 1
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NH-NAME (possessive)
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Choice 2
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your
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Choice 3
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Fill-in (3)
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Choice 1
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workers' compensation
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Choice 2
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public disability
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Choice 3
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workers' compensation and public disability
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Fill-in (4)
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65
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WCP020 – USED WITH WCP003
The pamphlet explains how we reduce (1) Social Security Disability benefits if the
money which (2) and (3) family would receive from Social Security and (4) adds up
to more than 80 percent of (5) monthly average earnings. We found that 80 percent
of (6) average current earnings is (7).
Fill-in values:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 2
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your
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Fill-in (2)
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Choice 1
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he
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Choice 2
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she
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Choice 3
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you
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Fill-in (3)
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Choice 1
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his
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Choice 2
|
her
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Choice 3
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your
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Fill-in (4)
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Choice 1
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workers' compensation
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Choice 2
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public disability
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Choice 3
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workers' compensation and public disability
|
Fill-in (5)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Fill-in (6)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Fill-in (7)
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80 Percent Average Current Earnings (ACE-80) in format $$$$$.¢¢
|
WCP021 – NUMBER HOLDER NEEDS PROOF FOR EXPENSES
If (1) had any 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:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
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Choice 2
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you
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Fill-in (2)
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Choice 1
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your
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Choice 2
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his
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Choice 3
|
her
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Fill-in (3)
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Choice 1
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workers' compensation
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Choice 2
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workers' compensation and public disability benefit
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Choice 3
|
public disability benefit
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Fill-in (4)
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Choice 1
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you
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Choice 2
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he
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Choice 3
|
she
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Fill-in (5)
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Choice 1
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your and your family’s
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Choice 2
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 3
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your family’s
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Choice 4
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your
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Choice 5
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and his family’s”
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Choice 6
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and her family’s
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Choice 7
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“family’s”
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WCP022 – CHANGE IN AVERAGE CURRENT EARNINGS (ACE) AMOUNT
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) (5) working. Using the new facts about
(6) earnings, we found that 80 percent of (7) average current earnings was (8).
Fill-in values:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
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Choice 2
|
you
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Fill-in (2)
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Choice 1
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his
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Choice 2
|
her
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Choice 3
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your
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Fill-in (3)
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Choice 1
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he
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Choice 2
|
she
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Choice 3
|
you
|
Fill-in (4)
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Choice 1
|
he
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Choice 2
|
she
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Choice 3
|
you
|
Fill-in (5)
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Choice 1
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was
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Choice 2
|
were
|
Fill-in (6)
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Choice 1
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his
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Choice 2
|
her
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Choice 3
|
your
|
Fill-in (7)
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Choice 1
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his
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Choice 2
|
her
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Choice 3
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your
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Fill-in (8)
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80 Percent Average Current Earnings (ACE-80) in format $$$$$.¢¢
|
WCP023 – NUMBER HOLDER BENEFITS SUSPENDED FOR WORKERS’ COMPENSATION OFFSET - NO LUMP
SUM INVOLVED
We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits.
Because of (5), (6) monthly Social Security benefits are not payable (7).
Fill-in values:
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Fill-in (1)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation payment
|
Choice 2
|
public disability payment
|
Choice 3
|
workers' compensation and public disability payments
|
Fill-in (3)
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|
Choice 1
|
Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in format $$$$$.¢¢
|
Choice 2
|
Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢
|
Choice 3
|
Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and Public Disability
Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢
|
Fill-in (4)
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Choice 1
|
his
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Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
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|
Choice 1
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this payment
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Choice 2
|
these payments
|
Fill-in (6)
|
|
Choice 1
|
his
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Choice 2
|
her
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Choice 3
|
your
|
Fill-in (7)
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|
Choice 1
|
for this period
|
Choice 2
|
Null
|
WCP024 – NUMBER HOLDER'S MONTHLY BENEFIT AMOUNT (MBA) REDUCED DUE TO WORKERS’ COMPENSATION
(WC)/PUBLIC DISABILITY BENEFITS (PDB)
We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits.
Because of (5), we changed (6) monthly Social Security benefits to (7) beginning (8).
Fill-in values:
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|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation payment
|
Choice 2
|
public disability payment
|
Choice 3
|
workers' compensation and public disability payments
|
Fill-in (3)
|
|
Choice 1
|
Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in format $$$$$.¢¢
|
Choice 2
|
Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢
|
Choice 3
|
Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and Public Disability
Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
this payment
|
Choice 2
|
these payments
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (7)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (8)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
WCP025 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO WCPDB AND ENTITLED
AUXILIARY
We changed (1) monthly benefit to (2) beginning (3) because we started paying another
person on this record. When we figured (4) benefit, we had to take into account (5)
(6) payments.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
NH-NAME (possessive)
|
Fill-in (6)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
WCP026 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO WORKERS’ COMPENSATION
(WC)/PUBLIC DISABILITY BENEFITS (PDB) AND TERMINATED AUXILIARY
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.
WCP027 – NUMBER HOLDER HAS EXCLUDABLE AMOUNTS FOR EXPENSES
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)
|
|
Choice 1
|
NH-NAME (possessive)
|
Choice 2
|
NH-NAME (possessive) plus “and his family's”
|
Choice 3
|
NH-NAME (possessive) plus “and her family's”
|
Choice 4
|
NH-NAME (possessive) plus “family's”
|
Choice 5
|
your
|
Choice 6
|
your and your family's
|
Choice 7
|
your family's
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
Fill-in (4)
|
Total amount of excludable expenses
|
Fill-in (5)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and his family's”
|
Choice 3
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and her family's”
|
Choice 4
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“family's”
|
Choice 5
|
your
|
Choice 6
|
your and your family's
|
Choice 7
|
your family's
|
WCP028 – USED WITH WCP003 ONE BENEFICIARY’S MONTHLY BENEFIT AMOUNT (MBA) IS OFFSET-
NUMBER HOLDER AGE 65 MINUS ONE MONTH PRIOR TO DECEMBER 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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
your
|
Choice 2
|
your and your family’s
|
Choice 3
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 4
|
your family’s
|
Choice 5
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and his family’s”
|
Choice 6
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and her family's”
|
Choice 7
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“family’s”
|
Fill-in (2)
|
|
Choice 1
|
you reach
|
Choice 2
|
he reaches
|
Choice 3
|
she reaches
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
workers' compensation and public disability benefit
|
Choice 3
|
public disability benefit
|
Fill-in (5)
|
|
Choice 1
|
Workers' compensation
|
Choice 2
|
Workers' compensation and public disability benefit
|
Choice 3
|
Public disability benefit
|
Fill-in (6)
|
|
Choice 1
|
You
|
Choice 2
|
He
|
Choice 3
|
She
|
Fill-in (7)
|
|
Choice 1
|
you reach
|
Choice 2
|
she reaches
|
Choice 3
|
he reaches
|
WCP029 – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)
CLAIM PENDING
If (1) workers' compensation and/or public disability benefit payments, we may have
to reduce (2) Social Security benefits.
At that time, (3) may also have to pay back any Social Security benefits that (4)
not due. Please let us know the decision on the claim right away.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
NH-NAME receives
|
Choice 2
|
you receive
|
Fill-in (2)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
you were
|
Choice 2
|
he was
|
Choice 3
|
she was
|
WCP030 – NUMBER HOLDER BENEFITS SUSPENDED FOR WORKERS’ COMPENSATION OFFSET (WCOFFS)
LUMP SUM INVOLVED
We consider (1) (2) of (3) when we figure (4) Social Security benefits. Because of
(5), we cannot pay (6) Social Security benefits (7).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
workers’ compensation lump-sum payment
|
Choice 2
|
public disability benefit lump-sum payment
|
Choice 3
|
workers’ compensation and public disability benefit lump-sum payments
|
Fill-in (3)
|
|
Choice 1
|
Show the Lump Sum Gross Amount (INIL-LS-GROSS) amount in the format 99,999.99
|
Choice 2
|
Show the total of all Lump Sum Gross Amount (INIL-LS-GROSS) amounts in the format
99,999.99
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
this lump-sum payment
|
Choice 2
|
these lump-sum payments
|
Fill-in (6)
|
|
Choice 1
|
you
|
Choice 2
|
him
|
Choice 3
|
her
|
Fill-in (7)
|
|
Choice 1
|
Null
|
Choice 2
|
for plus Month CCYY through plus Month CCYY
|
Choice 3
|
for plus Month CCYY
|
WCP031 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) REDUCED LUMP SUM AWARD PAYMENT
INVOLVED
We consider (1) (2) of (3) when we figure (4) Social Security benefits. Because of
(5), we changed (6) monthly Social Security benefits to (7) starting (8).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
workers’ compensation lump-sum payment
|
Choice 2
|
public disability benefit lump-sum payment
|
Choice 3
|
workers’ compensation and public disability benefit lump-sum payments
|
Fill-in (3)
|
|
Choice 1
|
Show the Lump Sum Gross Amount (INIL-LS-GROSS) amount in the format 99,999.99
|
Choice 2
|
Show the total of all Lump Sum Gross Amount (INIL-LS-GROSS) amounts in the format
99,999.99
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
this lump-sum payment
|
Choice 2
|
these lump-sum payments
|
Fill-in (6)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (7)
|
|
Choice 1
|
Show the post Master Beneficiary Record (MBR) Monthly Benefit Amount (MBA) associated
with the ongoing History Effective Date (EFD) of the MBA change in the format 99,999.99
|
Choice 2
|
Show the NA-HIST-POST-MBA occurrence associated with the embedded History Effective
Date (EFD) in the format 99,999.99
|
Fill-in (8)
|
|
Choice 1
|
Show the History Effective Date (EFD) on the post Master Beneficiary Record (MBR)
associated with the MBA change in the format Month CCYY
|
Choice 2
|
Show the NA-HIST-START month in the format Month CCYY
|
WCP032 – USED WITH WCP003 - INFORMATIONAL REPORTING
Please let us know right away about any:
-
•
Changes in (1) workers' compensation or public disability benefit payments.
-
-
•
Other payments (3) that increase or decrease (4) workers’ compensation or public disability
benefit payments.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (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
|
WCP033 – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)
STOPS < CURRENT OPERATING MONTH (COM) AND < (AGE 65 PRIOR TO DECEMBER 19, 2015 OR
< FRA IF ON OR AFTER DECEMBER 19, 2015)
We do not reduce monthly Social Security benefits once (1) (2) payments stop. We changed
(3) monthly benefit to the full rate of (4) beginning (5).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
Choice 4
|
periodic
|
Fill-in (3)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (4)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (5)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the MBA change in the format
Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
WCP034 – EMBEDDED WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) PERIOD
MONTHLY BENEFIT AMOUNT (MBA) CHANGE AND EFDS
(1) monthly benefit is (2) (3) (4) (5) (6).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
Monthly Benefit Amount (MBA) associated with the first Effective Date (EFD) of MBA
change
|
Fill-in (3)
|
for
|
Fill-in (4)
|
First Effective Date (EFD) associated with the Monthly Benefit Amount (MBA) change
|
Fill-in (5)
|
|
Choice 1
|
and
|
Choice 2
|
through
|
Choice 3
|
Null
|
Fill-in (6)
|
|
Choice 1
|
Null
|
Choice 2
|
Last Effective Date (EFD) associated with this Monthly Benefit Amount (MBA) change
|
WCP035 – LUMP SUM AWARD PAYMENT - METHOD A USED
(1) (2) received a lump-sum award(s) 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 figure 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.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
NH-NAME
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
has
|
Choice 2
|
have
|
Fill-in (3)
|
Using all changed occurrence of Injury/Illness (INIL) Data, show the sum of Lump Sum
Gross Total (INIL-LS-GROSS) amounts
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
Fill-in (6)
|
|
Choice 1
|
NH-NAME (possessive)
|
Choice 2
|
NH-NAME (possessive) plus “and his family's”
|
Choice 3
|
NH-NAME (possessive) plus “and her family's”
|
Choice 4
|
NH-NAME (possessive) plus “family's”
|
Choice 5
|
your
|
Choice 6
|
your and your family's
|
Choice 7
|
your family's
|
Fill-in (7)
|
|
Choice 1
|
NH-NAME
|
Choice 2
|
you
|
Fill-in (8)
|
Sum of IDET Weekly Rate Method A (IDET-WK-RATE-A) amounts that correspond to the changed
occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢
|
Fill-in (9)
|
Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX) amounts that correspond to the
changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢
|
Fill-in (10)
|
Sum of Lump Sum Medical Expenses (INIL-LS-MED-EX) amounts that correspond to the changed
occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢
|
WCP036 – LUMP SUM AWARD PAYMENT - METHOD B USED
(1) (2) received a lump-sum award(s) of (3) to settle (4) (5) claim. A lump-sum award
affects Social Security benefits in the same way that periodic payments do. We treat
a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we treated the lump-sum as if (7)
had been paid (8) each week. We excluded (9) for legal expenses, medical and other
expenses. For this reason, we lowered the weekly rate from (10) to (11).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
NH-NAME
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
has
|
Choice 2
|
have
|
Fill-in (3)
|
Using all changed occurrence of Injury/Illness (INIL) Data, show the sum of Lump Sum
Gross Total (INIL-LS-GROSS) amounts
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
Fill-in (6)
|
|
Choice 1
|
NH-NAME (possessive)
|
Choice 2
|
NH-NAME (possessive) plus “and his family's”
|
Choice 3
|
NH-NAME (possessive) plus “and her family's”
|
Choice 4
|
NH-NAME (possessive) plus “family's”
|
Choice 5
|
your
|
Choice 6
|
your and your family's
|
Choice 7
|
your family's
|
Fill-in (7)
|
|
Choice 1
|
NH-NAME
|
Choice 2
|
you
|
Fill-in (8)
|
Sum of Lump Sum Proration Amount (INIL-LS-PROAMT) amounts that correspond to the changed
occurrence(s) of Injury/Illness (INIL) data in the format $$$$$.¢¢
|
Fill-in (9)
|
Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX), Lump Sum Medical Expenses (INIL-MED-EX),
Lump Sum Special Expenses (INIL-LS-SPECEX), and Lump Sum-Related Expenses (INIL-LS-RLTDEX)
amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS)
in the format $$$$$.¢¢
|
Fill-in (10)
|
Sum of Lump Sum Proration Amounts (INIL-LS-PROAMT) that correspond to the changed
occurrence(s) of Injury/Illness (INIL) data in the format $$$$$.¢¢
|
Fill-in (11)
|
Sum of IDET Weekly Rate Method B (IDET-WK-RATE-B) amounts that correspond to the changed
occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢
|
WCP037 – LUMP SUM AWARD PAYMENT - METHOD C USED – USED FOR NUMBER HOLDER ONLY
(1) (2) received a lump-sum award(s) of (3) to settle (4) (5) claim. A lump-sum award
affects Social Security benefits in the same way that periodic payments do. We treat
a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we excluded (7) for legal expenses,
medical and other expenses. We treated the rest of the lump-sum, (8), as if (9) had
been paid (10) per week. We will pay full benefits beginning (11).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
NH-NAME
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
has
|
Choice 2
|
have
|
Fill-in (3)
|
Using all changed occurrence of Injury/Illness (INIL) data, show the sum of Lump Sum
Gross Total (INIL-LS-GROSS) amounts
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
|
Fill-in (6)
|
|
Choice 1
|
NH-NAME (possessive)
|
Choice 2
|
NH-NAME (possessive) plus “and his family's”
|
Choice 3
|
NH-NAME (possessive) plus “and her family's”
|
Choice 4
|
NH-NAME (possessive) plus “family's”
|
Choice 5
|
your
|
Choice 6
|
your and your family's
|
Choice 7
|
your family's
|
Fill-in (7)
|
Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX), Lump Sum Medical Expenses (INIL-MED-EX),
Lump Sum Special Expenses (INIL-LS-SPECEX), and Lump Sum-Related Expenses (INIL-LS-RLTDEX)
amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS)
in the format $$$$$.¢¢
|
Fill-in (8)
|
Using all changed occurrence(s) of Injury/Illness (INIL) data, show the sum of Lump
Sum Gross Total (INIL-LS-GROSS) amounts minus the total expenses that are shown in
Fill-in (7) in the format $$$$$.¢¢
|
Fill-in (9)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (10)
|
Sum of IDET Weekly Rate Method C (IDET-WK-RATE-C) amounts that corresponds to the
changed occurrence(s) of Lump Sum Gross Total (INIL- LS-GROSS) in the format $$$$$.¢¢
|
Fill-in (11)
|
Changed occurrence of IDET Lump Sum Proration Stop Date Method C (IDET-STOP-C) plus
one month that corresponds to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS)
in the format Month CCYY
|
WCP038 – NUMBER HOLDER RECEIVES PERIODIC PAYMENTS NO PROOF
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)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
WCP039 – AUXILIARY BENEFITS SUSPENDED - WCOFFS DUE TO NUMBER HOLDER'S WORKERS’ COMPENSATION
(WC)/PUBLIC DISABILITY BENEFITS (PDB)
We have to take into account (1) (2) when we figure (3) Social Security benefits.
Because of (4), (5) monthly Social Security benefits are not payable (6).
Fill-in values:
|
|
Fill-in (1)
|
NH-NAME (possessive)
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation payment
|
Choice 2
|
public disability payment
|
Choice 3
|
workers' compensation and public disability payments
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
this payment
|
Choice 2
|
these payments
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
|
Choice 1
|
for this period
|
Choice 2
|
Null
|
WCP040 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO NUMBER HOLDER'S WORKERS’
COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)
We have to take into account (1) (2) when we figure (3) Social Security benefits.
Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7).
Fill-in values:
|
|
Fill-in (1)
|
NH-NAME (possessive)
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation payment
|
Choice 2
|
public disability payment
|
Choice 3
|
workers' compensation and public disability payments
|
Fill-in (3)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (4)
|
|
Choice 1
|
this payment
|
Choice 2
|
these payments
|
Fill-in (5)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (6)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (7)
|
|
Choice 1
|
EFD on the post-MBR associated with the MBA change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
WCP041 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC
DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) NOT PIC A
We have to take into account (1) (2) when we figure (3) Social Security benefits.
Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7).
This change also includes the cost of living increase.
Fill-in values:
|
|
Fill-in (1)
|
NH-NAME (possessive)
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation payment
|
Choice 2
|
public disability payment
|
Choice 3
|
workers' compensation and public disability payments
|
Fill-in (3)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (4)
|
|
Choice 1
|
this payment
|
Choice 2
|
these payments
|
Fill-in (5)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (6)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
WCP042 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION
(WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) NO LUMP
SUM INVOLVED
We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits.
Because of (5), we changed (6) monthly Social Security benefit to (7) beginning (8).
This change also includes the cost of living increase.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
workers' compensation payment
|
Choice 2
|
public disability payment
|
Choice 3
|
workers' compensation and public disability payments
|
Fill-in (3)
|
|
Choice 1
|
Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in the format $$$$$.¢¢
|
Choice 2
|
Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢
|
Choice 3
|
Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and the Public Disability
Benefits Amount (WCPD-PDB-AMT) and show this total as the value in the format $$$$$.¢¢
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
this payment
|
Choice 2
|
these payments
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (7)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (8)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
WCP043 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION
(WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) LUMP SUM
INVOLVED
We have to take into account (1) lump-sum payment(s) of (2) when we figure (3) Social
Security benefits. Because of (4), we changed (5) monthly Social Security benefit
to (6) beginning (7). This change also includes the cost of living increase.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
Lump Sum Gross Total (INIL-LS-GROSS) amount in the format $$$$$.¢¢
|
Choice 2
|
Total of all Lump Sum Gross Total (INIL-LS-GROSS) amounts in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
this payment
|
Choice 2
|
these payments
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (7)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
WCP044 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE FOR WORKERS’ COMPENSATION (WC)/PUBLIC
DISABILITY BENEFITS (PDB), COST-OF-LIVING ADJUSTMENT (COLA) AND BENEFICIARY TERMINATED
We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled
person(s) stopped. When we figured (4) benefit, we had to take into account (5) (6)
payments. This change also includes the cost-of-living increase.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
NH-NAME (possessive)
|
Fill-in (6)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
WCP045 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE FOR NUMBER HOLDER’S WORKERS’
COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB), COST-OF-LIVING ADJUSTMENT (COLA)
AND ANOTHER BENEFICIARY STARTS RECEIVING BENEFITS
We changed (1) monthly benefit to (2) beginning (3) because we started paying another
person(s) on this record. When we figured (4) benefit, we had to take into account
(5) (6) payments. This change also includes the cost-of-living increase.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
NH-NAME (possessive)
|
Fill-in (6)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
WCP046 – AUXILIARY NOTICE – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY
BENEFITS (PDB) STOP – MONTHLY BENEFIT AMOUNT (MBA) NOT AFFECTED
We changed (1) monthly benefit to (2) beginning (3) because (4) present (5) payment(s)
do not affect (6) monthly Social Security benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Fill-in (3)
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Fill-in (4)
|
NH-NAME (possessive)
|
Fill-in (5)
|
|
Choice 1
|
workers' compensation
|
Choice 2
|
public disability
|
Choice 3
|
workers' compensation and public disability
|
Fill-in (6)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
WCP047 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE AMOF DELETED FROM POST-MBR
We changed (1) monthly Social Security benefit to (2) beginning (3) because (4) benefits
are not affected by (5) receipt of workers' compensation and/or public disability
payments.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of
the MBA change in the format $$$$$.¢¢
|
Choice 2
|
NA-HIST-POST-MBA in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA)
change in the format Month CCYY
|
Choice 2
|
NA-HIST-START month in the format Month CCYY
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
WCP060 - WORKER’S COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS- NUMBER
HOLDER AGE 65 MINUS ONE MONTH AFTER DECEMBER 19, 2015
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-in values:
|
|
Fill-in (1)
|
Date of FRA attainment in Month CCYY format
|
Fill-in (2)
|
|
Choice 1
|
NH-NAME (possessive)
|
Choice 2
|
your
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
worker’s compensation
|
Choice 2
|
public disability benefit
|
Choice 3
|
worker’s compensation and public disability benefit
|
Fill-in (5)
|
|
Choice 1
|
you reach
|
Choice 2
|
he reaches
|
Choice 3
|
she reaches
|
WCP061 - BENEFICIARY’S MONTHLY BENEFIT AMOUNT (MBA) IS OFFSET- NUMBER HOLDER AGE 65
MINUS ONE MONTH AFTER DECEMBER 19, 2015
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
your
|
Choice 2
|
NULL plus BGN plus BLN (possessive)
|
Choice 3
|
your and your family’s
|
Choice 4
|
your family’s
|
Choice 5
|
null plus BGN plus BLN (possessive) plus and his family’s
|
Choice 6
|
NULL plus BGN plus BLN (possessive) plus and her family’s
|
Choice 7
|
NULL plus BGN plus BLN (possessive) plus family’s
|
Fill-in (2)
|
|
Choice 1
|
you reach
|
Choice 2
|
he reaches
|
Choice 3
|
she reaches
|
Fill-in (3)
|
Date of FRA attainment in the format Month CCYY
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
worker’s compensation
|
Choice 2
|
public disability benefit
|
Choice 3
|
worker’s compensation and public disability benefit
|
Fill-in (6)
|
|
Choice 1
|
Your
|
Choice 2
|
His
|
Choice 3
|
Her
|
Fill-in (7)
|
|
Choice 1
|
worker’s compensation
|
Choice 2
|
public disability benefit
|
Choice 3
|
worker’s compensation and public disability benefit
|
Fill-in (8)
|
|
Choice 1
|
You
|
Choice 2
|
He
|
Choice 3
|
She
|
Fill-in (9)
|
|
Choice 1
|
you decide
|
Choice 2
|
he decides
|
Choice 3
|
she decides
|
Fill-in (10)
|
|
Choice 1
|
you reach
|
Choice 2
|
he reaches
|
Choice 3
|
she reaches
|