The workers’ compensation system uses many forms to document the payment and termination of compensation benefits. The following represents an explanation of some of the forms that are used:
An insurance company may make initial payments of weekly compensation benefits by filing a form called a Non-Prejudicial Agreement. This form allows the insurance company to pay benefits for up to 13 weeks without accepting legal liability for the injury. Payments may be stopped at any time within the 13-week period for any reason. If payments continue for more than 13 weeks, then this creates the acceptance of liability for the injury. The Non-Prejudicial Agreement sets forth the description of the injury for which benefits are being paid as well as the average weekly wage, compensation rate and disability status. The purpose of this form is to allow an insurance company to pay benefits without giving up its right to deny a claim while it is being investigated. View form
Memorandum of Agreement
An insurance company may also make payments of weekly compensation benefits by filing a form called a Memorandum of Agreement. This form documents an insurance company’s acceptance of liability for an injury. Unlike a Non-Prejudicial Agreement, benefits that are paid under a Memorandum of Agreement cannot be stopped without the written agreement of the injured worker (see Suspension Agreement) or a court order.
The Memorandum of Agreement sets forth the description of the injury that the insurance company has accepted as well as the average weekly wage, compensation rate and disability status. The insurance company is only responsible to pay weekly compensation and medical bills related to the injury as it is described in the Memorandum of Agreement. View form
NOTE: The insurance company has the choice of whether to pay benefits using the Non-Prejudicial Agreement or the Memorandum of Agreement. An injured worker who is not satisfied with the payment of benefits under a Non-Prejudicial Agreement has the right to petition the Workers’ Compensation Court for an order establishing the legal liability of the insurance company for the injury. See Original Petition, below.
Termination of Benefits
When payments under a Non-Prejudicial Agreement are being terminated, the insurance is required to file a Report of Indemnity Payment form and check the appropriate box. View form
. By using this form with a Non-Prejudicial Agreement, the insurance company is able to pay workers’ compensation benefits without accepting legal liability for an injury.
If an injured worker receives benefits under a Non-Prejudicial Agreement for less than 13 weeks and then returns to work, the insurance company is not legally responsible for any problems that may develop in the future with regard to the injury, including the payment of medical bills. This is because a Non-Prejudicial Agreement does not establish legal liability on an insurance company for an injury.
The Suspension Agreement is a form that is used to document an agreement between an injured worker and an insurance company that weekly compensation benefits may stop as of a certain date.
The signing of a Suspension Agreement does not mean that the insurance company is not responsible for the claim in the future. Suspension Agreements are only used when the insurance company has already filed a Memorandum of Agreement. Unlike a Non-Prejudicial Agreement, the Memorandum of Agreement means that the insurance company has accepted liability for the injury so any problems that develop after signing a Suspension Agreement will be covered by the insurance company. This includes recurrence of disability from the injury as well as payment of medical bills for treatment related to the injury. View form
The Original Petition is a form that is filed by an injured worker at the Workers’ Compensation Court requesting a court order establishing legal liability upon an insurance company for an injury. This petition can be filed when an insurance company has denied a claim or is paying compensation under a Non-Prejudicial Agreement. This petition seeks a court order that establishes liability on an insurance company in the same manner as a Memorandum of Agreement.
The Mutual Agreement is a form that is used to document an agreement between an
injured worker and the insurance company regarding changes to a Memorandum of Agreement or Court order that established liability for an injury, e.g., change in compensation rate, change in disability status from partial disability to total disability, etc. View form
Report of Specific Payment
The Report of Specific Payment is a form used to document an agreement between an injured worker and the insurance company for the payment of compensation for scarring and loss of use. View form
Employee's Petition to Review
The Employee’s Petition to Review is a form filed by an injured worker at the Workers’ Compensation Court for several different reasons such as to establish a new period of disability for a previous injury (recurrence), to establish an increase in disability status from partial to total, to enforce payment of medical bills or obtain authorization for medical treatment, to change the description of injury on a Memorandum of Agreement and any other relief which has been denied by the insurance company.
Employer's Petition to Review
The Employer’s Petition to Review filed by the insurance company at the Workers’ Compensation Court for a variety of reasons such as to discontinue benefits, to establish a decrease in disability status from total to partial, to obtain a finding of maximum medical improvement, and other forms of relief.