Fillable Extended Disability Report Of Extended Disability (State of New Hampshire)

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Extended Disability Report Of Extended Disability (State of New Hampshire)

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File type: PDF

U.S.A. forms for State of New Hampshire

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LAB 500
THE STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
CONCORD, NH 03301
REPORT OF EXTENDED DISABILITY
This form shall be completed by the Insurer or Self-Insurer and filed with the Department on every
case where total disability benefits are anticipated to or have continued for six months as required by
Administrative Rule Lab 509.03 in accordance with RSA 281-A:25.
Claimant
S.S. No.
(First Name)
(Middle Initial)
(Last name)
Address
(No.)
(Street/P.O. Box or RFD No.)
(City/Town)
(State) (Zip Code)
Telephone Number
(Area)
(Number)
Check (
~
):
Male
Female
Age
Education, Select Highest: 1
2 3 4 5 6 7 8 9 10 11 12
1
2 3 4
(Primary)
(Secondary)
(College)
Injury Date
Disability Date
(Mo.)
(Day)
(Year)
(Mo.)
(Day)
(Year)
Nature and Location of Injury
Employer’s Name
Office Address
(No.)
(Street/P.O. Box or RFD No.)
(City/Town)
(State)
(Zip Code)
Telephone Number
Employer’s I.D. #
Carrier Name
Carrier #
Address
Date employer was contacted as to claimant’s return to employment
Employer’s response: Yes
No
(Name of Person Contacted)
If yes, in what capacity
(Date)
(Carrier Representative’s Signature)
74 WCA (7/1989)
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Extended Disability Report Of Extended Disability (State of New Hampshire)

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Completed 21 July 2020

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