SSA-546 Workers’ Compensation / Public Disability Benefit Questi

Form SSA-546 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0247

WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT QUESTIONNAIRE
NAME OF WORKER

SOCIAL SECURITY NUMBER

1. What type of benefit are you receiving, did you receive or do you expect to receive in connection with your disability?
WORKERS' COMPENSATION:
Workers' Compensation - State (including
occupational disease payments)

PUBLIC DISABILITY BENEFITS:
Civil Service Disability or Federal Employees'
Retirement System (FERS) Disability Benefits

Black Lung Benefits

State Temporary Disability Payments

Longshore and Harbor Workers' Compensation

Federal, State or Local Government Employee
Disability Benefits

Federal Employees' Compensation (FECA- workers'
compensation for Federal employees)

Other:

2. For each benefit checked above, enter the claim number, employer, insurance carrier and date of injury/illness.
TYPE OF BENEFIT

CLAIM NUMBER

EMPLOYER

INSURANCE CARRIER

DATE OF INJURY/
ILLNESS

3. Indicate the State in which you worked when these benefits began or, if workers' compensation is one of the
benefits involved, the State in which the injury occurred.

STATE

4. If you are receiving one of the public disability benefits listed in item 1, were Social Security taxes always paid on your
earnings?
No (If "No," explain. For example, you were a federal, State or local government
Yes
employee whose earnings were not covered or were not always covered by Social
Security.)
5. Indicate the status of your claim for workers' compensation or other public disability benefits. If you are receiving more than
one type of benefit, indicate the status of each claim.
a. Filed for Benefits, or Intend to File but not yet Entitled

d. Currently Receiving Benefits

b. Filed for Benefits, but Claim was Denied

e. Received Payments in the Past but not Presently

c. Claim Denied; Appeal Pending (if appeal is pending,
give date you expect a decision.)

Other (e.g., lump-sum payment)
Explain:

If a., b., or c. is checked, go on to Item 11 (signature block). If d., e., or f. is checked, complete the remainder of the form.
6. How are (or were) those disability payments made?
Weekly

Monthly

Every Two Weeks

Other (Explain):

7. a. List the amount(s) and the period(s) of time for which those disability benefits were made. (if only lump-sum payment was
made, see item 8.)
TYPE OF BENEFIT

AMOUNT

FROM

b. If those payments have stopped, indicate the reason:
Lump-Sum Settlement Pending

Appeal Pending

Permanent Rating Pending

Other (Explain in item 10, "Remarks")

TO

Form SSA-546 (XX-XXXX)

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c. Do you expect those payments to begin again?

Yes

No

If "Yes", When
8. Have you ever received or been awarded a lump-sum settlement (including "compromise and release" or similar type of
settlement)?
Yes (If "Yes", complete item 9)
No
9. Lump-sum payment:
a. Date(s) settlement(s) or award(s) made

b. Gross Amount(s)
$

c. The lump sum represents:
$

per week for

d. The amount shown in 9.b. (Gross amount) includes:
(1) MEDICAL EXPENSES OF
(2) ATTORNEY FEES OF
$

$

weeks beginning
(3) RELATED EXPENSES OF
$

10. Remarks:

IMPORTANT INFORMATION. PLEASE READ THE FOLLOWING CAREFULLY.
I agree to report if I apply for or begin to receive a workers' compensation (including black lung benefits) or a public disability
benefit or the amount that I am receiving changes or stops, or I receive a lump-sum settlement. I understand that such benefits
may affect my Social Security payments or result in an overpayment which I may have to pay back. I have examined all the
information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I
understand that anyone who knowingly makes or causes to be made a false statement or representation of material fact for use
in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect
an initial or continued right to payment, or submits or causes to be submitted any false statement or document knowing the same
to contain any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both,
and may be subject to administrative sanctions.
DATE
TELEPHONE NUMBERS(S) at which you may be contacted during the day
MAILING ADDRESS (Number Street, Apt. No., P.O. Box., Rural Route)
CITY AND STATE

ZIP CODE

Privacy Act Statement
Collection and Use of Personal Information
Section 224 of the Social Security Act, as amended, allows us to collect your information, which we will use to determine the
effect of your worker's compensation or other public disability benefit on your Social Security disability insurance benefits.
Providing this information is voluntary, but not providing all or part of the information may prevent an accurate and timely decision
regarding benefits eligibility. As law permits, we may use and share the information you submit, including with other Federal
agencies, contractors, and others, as outlined in the routine uses within System of Records Notices (SORN) 60-0089 and
60-0090, available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to
establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB)
control number. We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.