Workers' Compensation/Public Disability Benefit Questionnaire

Page 1 of7

WCIPDB COMMON SCREENS MATRIX

WC/PDB
WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFITS SELECTION MENU
LnNo 0
1
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2
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COMM WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFITS SELECTION MENU WPMU
TZW
NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
NUMBER HOLDER SSN: SSS-SS-SSSS

WC/PDB CLAIM NUMBER

INJURY/

SS

SSSSSSSSSSSSSSSSSSSSSSSS

ILLNESS
STATE
SS

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SSSSSS
[ CLAIM

INJURY/

SOURCE OF
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DATE
SSSSSSSS

I 2

,
(

~

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WC/PDB
WC/PDB
WC/PDB
WC/PDB

CLAIM
CLAIM
CLAIM
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1 SCREENS: SSSS SSSS
2 SCREENS: SSSS SSSS
3 SCREENS: SSSS SSSS
4 SCREENS: SSSS SSSS

ADD NEW OCCURRENCE

(Y/N) :

SSSS
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https://www.rocis.gov/rocis/dolDownloadDocument?documentID=285231 &version=O

11/29/2011

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Page 20f7

WCIPDB COMMON SCREENS MATRIX
WC/PDB

WC/PDB CLAIM DATA
LnNo 0
1
1 C
2
3
4
5
6
7

8
9
10

0
L
U
M
N
*
0

N
E

11

12
13

14
15
16
17
18
19
20
21
22

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7
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COMM
WC/PDB CLAIM DATA
WPCL
1
TZW
NUMBER HOLDER SSN: SSS-SS SSSS
NUMBER HOLDER NAME: SSSSS ssssssssss
*INJURY/ILLNESS DATE (MMDDCCYY) : 99999999
*SOURCE OF COMPENSATION: XX
*WC/PDB CLAIM NUMBER: XXXXXXXX~XXXXXXXXXXXXXXX
INJURY/ILLNESS STATE: XX

*PERIODIC PAYMENTS AWARDED (YIN) : ~
*LUMP SUM AWARDED (YIN) : ~
*WC/PDB CLAIM PENDING (YIN) : ~
*CLAIM DENIED (YIN) : ~
*APPEAL PENDING (YIN) ; ~ IF YE S, EXPECTED DECISION DATE (MMDDCCYY) ; 99999999
INTEND TO FILE (YIN) ; ~
WILL BE DELETED FROM THIS INJURY - CONTINUE (YIN) ; ~
*REVERSE JURISDICTION INVOLVED (YIN) : ~
IF YES, START (MMDDCCYY) : 99999999
STOP (MMCCYY) ; 9~.2~
DO THE PDB'S MEET THE COVERED SERVICE EXCLUSION (YIN) : ~
COVERED EARNINGS PERCENTAGE: 999
DO YOU NEED TO MANUALLY ENTER A HIGHER ACE (YIN) : ~
IF YES, MANUAL 100 PERCENT ACE: 9_.9999
SELECT METHOD USED: ~
l=HIGH 1
2=HIGH 5
3=AVERAGE MONTHLY WAGE.
DELETE THIS CLAIM (YIN) : !:!
THIS OCCURRENCE OF DATA WILL BE DELETED FROM CLIENT AND MBR-CONTINUE (YIN) :
PFI HELP AVAILABLE
TRANSFER TO:
XXXX
**************************APPLICATION ERROR

~

MESSAGE***************************

24

**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

SCREEN FR
MSOM

https:/lwww.rocis. gov/rocisldolDownloadDocument?documentID=285231 &version=O

11/29/2011

I

Page 3 of7

WCIPDB COMMON SCREENS MATRIX
WC/PDB
WC/PDB CLAIM DATA EMPLOYER/PAYER NAME AND ADDRESS
LnNo 0
1
1 C
2
3
4
5
6
7

0
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8

0

7
7
6
1
2
3
4
5
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WPAD
2
COMM
WC/PDB CLAIM DATA EMPLOYER/PAYER NAME AND ADDRESS
TZW
NUMBER HOLDER SSN: SSS-SS-SSSS
NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
INJURY/ILLNESS DATE: SSSSSSSS
SOURCE OF COMPENSATION: SS
WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS
INJURY/ILLNESS STATE: SS

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EMPLOYER NAME: ~)~XXXXXXXXXX~XXXXXXXXX)\:XXXXXXX
ADDRESS 1 : 2':XXXXXXXXXX~~XXXXXXXXX ADDRESS 2 :
XxXXXXXXXXXXX~XXXXXXXX

9
10

N
E

11

12
13

14
15
16
17
18
19
20
21
22

R
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ADDRESS 3 : XXXXXXXXXXXXXXXXXXXXXX ADDRESS 4 :
CITY: ~XXXXXXXXX~XXXXXXXXXXX
STATE:
CONTACT: XXXXXXXXXXXXXXXX~~XXXXXXXX
PHONE:
E-MAIL: XXXXXXX~XXXXXXXXXXXXXXXXXXXX FAX:

XXXXXXXXXXXXXXXXXXXXXX
ZIP: 99999
XX
XXX;;{XXXXXXXX EXTENSION: ~'t~
XXXl;X:XXXXXX)\:

PAYER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXX
ADDRESS 1 : XXXXXXXXXXXXXXXXXXXXXX ADDRESS 2 :
XXXXXXXXXXXXXXXXXXXXXX
ADDRESS 3 : XXXXXXXXXXXXXXXXXX~XXX ADDRESS 4 :
CITY: XXXXXXXXXXXXXXXXXXXXXX
STATE:
CONTACT: XXXXXXXXXXXXXXXXXXXXXXXXXX
PHONE:
E-MAIL: XXXXXXXXXXXXXXXXXXXXXXXXXXXX
FAX:

XXXXXXXXXXXXX:XXXXXXXXX
XX
ZIP: ~. .9~
XXXXXXXXXXXX EXTENSION:
XX",XXXXXXXXX

PF1 HELP AVAILABLE
XXX X

9999

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23

**************************APPLICATION ERROR
MESSAGE***************************

24

************** (LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

SCREEN FR

MSOM

https:/Iwww.rocis.gov/rocis/do/DownloadDocument?documentID=285231 &version=O

11129/2011

I

Page 4 of7

WCIPDB COMMON SCREENS MATRIX
WC/PDB

Wc/PDB PERIODIC PAYMENTS
LnNo 0
1
1 C
2

0

3
4
5
6

L
U
M
N

7

*

8

0

9
10

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E

11
12

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13
14

E
S

15
16
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20

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WPPR
3
COMM
WC/PDB PERIODIC PAYMENTS
TZW
NUMBER HOLDER SSN: SSS-SS-SSSS
NUMBER HOLDER NAME: SSSSS
SSSSSSSSSS
SOURCE OF COMPENSATION: SS
INJURY/ILLNESS DATE: SSSSSSSS
INJURY/ILLNESS STATE: SS
WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS
[ *START
*PAYMENT
[ (MMDDCCYY)
(Y/N)
I 99999999
X
I 99999999
I 99999999
X
I 99999999
I 99999999
X
I 99999999
I 99999999
X
I 99999999

*FREQ

TYPE OF

STOP

*PERIODIC

(MMDDCCYY)

AMOUNT

99999999

99999.99

X

XX

99999999
99999999

99999.99
99999.99

X
X

XX
XX

X

99999999
99999999

99999.99
99999.99

X
X

XX
XX

X

99999999
99999999

99999.99
99999.99

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X

xx

X

99999999

99999.99

X

XX

PAYMENT

PROOF

XX
X

IF PERIODIC PAYMENTS ARE TO BEGIN AGAIN, EXPECTED DATE (MMDDCCYY) : 99999999
ARE ONGOING PERIODIC EXPENSES INVOLVED (Y /N) : X
ARE ONE-TIME EXCLUDABLE EXPENSES FROM PERIODIC PAYMENTS INVOLVED (Y /N) : X
EXPENSES WILL BE DELETED FROM THIS INJURY - CONTINUE (Y /N) : X
MORE PERIODIC PAYMENTS (Y /N) : X
PFI HELP AVAILABLE
TRANSFER TO:
XXX X
**************************APPLICATION ERROR
MESSAGE***************************

24

************** (LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

SCREEN FR
MSOM

https:llwww.rocis.gov/rocis/dolDownloadDocument?documentID=28 5231 &version=O

11129/2011

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Page 5 of7

WC/PDB COMMON SCREENS MATRIX

WC/PDB
WC/PDB PERIODIC PAYMENTS ONGOING EXPENSES
LnNo 0
1
1 C
2

0

3
4
5
6
7

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10

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11

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7 81
1
2
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COMM
WC/PDB PERIODIC PAYMENTS ONGOING EXPENSES
WPOX
4
TZW
NUMBER HOLDER SSN: SSS-SS-SSSS
NUMBER HOLDER NAME: SSSSS
SSSSSSSSSS
INJURY/ILLNESS DATE: SSSSSSSS
SOURCE OF COMPENSATION: SS
WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS
INJURY/ILLNESS STATE: SS

[ START
PROOF
[ (MMDDCCYY)
(Y/N)
I ssssssss
I ssssssss
X
I ssssssss
I ssssssss
X
I SSSSSSSS

~-

14
15

S
E

16
17
18
19

R
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I ssssssss
I SSSSSSSS

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20
21
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ssssssss

TYPE OF

ONGOING

ONGOING

PAYMENT

EXPENSES

PERCENT

S
S

SS
SS

99999.99

999

~9fl9.

~

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SSSSSSS

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ssssssss

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ssssssss
ssssssss

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99999.99

999
999

~

ssssssss

SSSSSSS

S

SS

.99 9 99.99

999

~

STOP

PERIODIC

(MMDDCCYY)

AMOUNT

ssssssss
ssssssss

SSSSSSS
SSSSSSS

SSSSSSSS

ssssssss

FREQ

IF PERIODIC PAYMENTS ARE TO BEGIN AGAIN,
PPPPPPPP

EXPECTED DATE

99

~

X

(MMDDCCYY) :

23

MORE PERIODIC PAYMENTS (Y/N) : X
PF1 HELP AVAILABLE
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24

**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

TRANSFER TO:

MESSAGE***************************

SCREENFR

MSOM

https:llwww.rocis.govIrocis/dolDownloadDocument?documentID=285231 &version=O

11129/2011

I

Page 6 of7

WCIPDB COMMON SCREENS MATRIX
WC/PDB
ONE-TIME ONLY EXCLUDABLE EXPENSES FOR PERIODIC PAYMENTS
i

LnNo

n

1

C

2

0

3 L
4 U
5 1M
6 N
7 *
8 0
9 N
10 E
11

12
13
14
15
16
17
18
19
20
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1
2
3.
4
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WPEX
COMM
ONE-TIME ONLY EXCLUDABLE EXPENSES FOR PERIODIC PAYMENTS
5
TZW
NUMBER HOLDER NAME: SSSSS
NUMBER HOLDER SSN: SSS SS-SSSS
SSSSSSSSSS
INJURY/ILLNESS DATE: SSSSSSSS
SOURCE OF COMPENSATION: SS
WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS
INJURY/ILLNESS STATE: SS

ONE-TIME EXCLUDABLE ATTORNEY EXPENSES:

9999999.99

PROOF (YIN) :

~

ONE-TIME EXCLUDABLE MEDICAL EXPENSES:

99999~~.99

PROOF (YIN) :

~

ONE-TIME EXCLUDABLE RELATED EXPENSES:

9999999.99

PROOF (YIN) :

~

*SPECIFIED EXPENSE PERIOD START DATE

(MMDDCCYY) :

PF1 HELP AVAILABLE

99999999

TRANSFER TO: XXX X

**************************APPLICATION ERROR

MESSAGE***************************

**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

SCREENFR

MSOM

htlps:llwww.rocis.gov/rocis/dolDownloadDocument?documentID=285231&version=0

11/29/2011

I

WCfPDB COMMON SCREENS MATRIX

Page 70f7

WC/PDB

WC/PDB LUMP SUM AWARD DATA
LnNo 0
1
1 C
2

0

3
4
5

L
U
M
N

6

7

*

8

0

9
10

N
E

11

12
13

14
15
16

17
18
19
20
21
22

R
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R
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7
1
7
4
6
2
3
5
234567890123456789012345678901234567890123456789012345678901234567890123456789
COMM
WC/PDB LUMP SUM AWARD DATA
WPLS
TZW
NUMBER HOLDER SSN: SSS-SS-SSSS
NUMBER HOLDER NAME: SSSSS
SSSSSSSSSS
INJURY/ILLNESS DATE: SSSSSSSS
SOURCE OF COMPENSATION: SS
WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS
INJURY/ILLNESS STATE: SS

*LUMP SUM AMOUNT: ~~Jl3~!L,~
*LUMP SUM START DATE (MMDDCCYY) : il9999~JlJl
*RATE AT WHICH LUMP SUM IS TO BE PRORATED:
*FREQUENCY FOR LUMP SUM PRORATION: ~
TYPE OF PAYMENT: ~~

*PROOF

(YIN) :

~

(YIN) :
(yiN) ;

~

6

~Jl39~~

EXCLUDABLE ATTORNEY EXPENSES: 9~~Jl..~~~
EXCLUDABLE MEDICAL EXPENSES; 9.~~ 9 9iL,JJ.~
EXCLUDABLE RELATED EXPENSES: 9..t3.~JL<:L..~
SPECIAL AMOUNTS TO BE DEDUCTED FROM LUMP SUM:

PROOF
PROOF
PROOF
9993Jt~.!..~

(YIN) :

~
~

PROOF

IF DESIRED, SELECT PRORATION METHOD TO BE USED IN COMPUTATION;
I=METHOD A
2=METHOD B
3=METHOD C.

PFI HELP AVAILABLE

~I

(YIN) ;

~

~

TRANSFER TO:

~~XX

23

**************************APPLICATION ERROR
MESSAGE***************************

24

* * * * * * * * * * * * * * (L I NE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

SCREENFR

MSOM

https:/Iwww.rocis.gov/rocis/dolDownloadDocument?documentID=285231 & version=O

11/29/2011

I