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9126113 SSA- POMS: 0152120.080 Illinois Workers' Compensation (WC)- 09i24/2009 Social Security Social Website E Program Operations Manual System (POMS) Effective Dates: 09/24/2009 - Present BASIC (09-08) DI 52120.080 Illinois Workers' Compensation (WC) A. Types Of Illinois WC Payments And Payment Provisions 1. Temporary Total (TT) Disability TT benefits pay 66 2/3 percent of the individual's average weekly wage. The benefits will pay for the duration of the disability or until the worker has returned to work. 2. Temporary Partial (TP) Benefits The TP benefit is 66 2/3 percent of the difference between the average amount the worker would be able to earn in the pre-injury job(s) and the net amount he or she earns in the lightduty job. Permanent Total (PT) WC PT pays 66 2/3 percent of the individual's average weekly wage, subject to minimum and maximum levels. In the State of Illinois an injured individual may receive lifetime PT benefits. Permanent Partial (PP) Disability There are four types of PP benefits. The maximum and minimum payment amounts vary for type. I! i for a complete list of Wage Differential 1/4

9126113 SSA- POMS: Dl 52120.080- Illinois Worlers' COflllOOSatlon (WC)- 0912412009 Wage Differential PP benefits are paid if the individual returns to employment, but a lower wage than the pre-injury employment The payment amount is 66 percent of the reduction in earnings when comparing the new job with the job held prior to injury. NOTE: The receipt of Wage Differential PP WC is an indication that the individual has returned to work and it may be necessary to establish a Work Continuing Disability Review (CDR) to evaluate the work activity. o Schedule of Injuries The "schedule of injuries" refers to a list that assigns a compensable value for each body part o Non-scheduled Injuries If the condition is not listed on the schedule of injuries, but it imposes certain limitations, the employee may be entitled to a percentage of 500 weeks of benefits, based on the loss of the person as a whole. The individual is paid 60 percent of their average weekly wage for the number of weeks determined. NOTE: This language is not adequate to determine lump sum proration. See Dl 52120.080A o Disfigurement An individual who suffers a serious and permanent disfigurement is entitled to a maximum of 162 weeks of benefits at the PPD rate. 5. Vocational Rehabilitation/Maintenance Benefits To qualify for Vocational Rehabilitation and Maintenance Benefits the individual must participate in a rehabilitation program and be unable to return to the pre-injury job. The employer is required to pay for treatment, instruction, and training necessary for the physical, mental, and vocational rehabilitation of the employee. This includes all maintenance costs (money for living expenses) and incidental expenses. The maintenance benefit payment cannot be less than the employee's calculated TT benefit rate. Illinois lump Sum (LS) Considerations Person as a Whole Awards Illinois LS awards may refer to loss of a specific percentage of loss of earnings capacity as use the person as a the whole lim https://secure.ssa.gol6'apps10/poms.nsfllroi0452120080 2/4

9126113 SSA POMS: 0152120.080 Illinois Workers' Compensation (WC) 09/2412009 a lump sum. The order of preference in 521 must be applied. EXAMPLE: An individual is periodic payments of $135.82 prior to a lump sum settlement lump sum settlement papers indicate the $20000.00 LS a 3 percent loss of use of the person as a is no weekly proration rate given in the award. SSA has determined that, rather than multiplying the 500 week limit times percent and prorating the lump sum over 162.5 weeks at the resulting $123.08 per week, we must consider the award as not stating any proration amount and use the prior periodic rate. Future Medical Expenses There is no provision of the Illinois law specifically addressing the issue of future medical expenses. Conversely, there is nothing in the law which prohibits designating part of a lump sum settlement as being for future medical benefits. Under Illinois WC law, an arbitrator (the individual approving any final settlement) has the option of designating a portion of the LS for future medical expenses. If the settlement specifically identifies money to be used for future medical expenses, then the amount specified should be considered an excludable expense. Standard policies apply when determining if the amounts appear to be excessive. See Excludable Expenses: Dl 52150.050.B.2. B. Cost-Of-Living Adjustments( COLA) A COLA is only provided for recipients of PT benefits. To qualify/ the individual's case must have been closed by a decision. Beginning in the second year after the award was issued the recipient will receive an amount from the Commission's Rate Adjustment Fund (RAF) that reflects the increase in the State-wide average weekly wage during the preceding year. These payments are made monthly and are payments made separately and in addition to the regular PT benefit. The monthly payments are adjusted July 15th of each year. These payments should be included when calculating offset Attorney Fees The attorney's fee is typically limited to 20 percent of the compensation recovered. The fee is further capped at to 20 percent of 364 weeks of the maximum TID benefit, unless a hearing is held and the Commission approves additional fees. In cases where the employer made a written offer to the employer, attorney may only charge a fee based upon the amount recovered that is in excess of the initial offer. In these cases more https:l/socure.ssa.go'w'apps10/poms.nsfllnxf0452120080 3/4

9126/13 SSA- POMS: 0152120.080 Illinois Workers' Compensation (WC)- 09/2412009 Retirement Insurance Benefits (RIB) Considerations VerifyingWC If verification cannot be obtained from the disabled individual you may need to contact the Illinois Workers' Compensation Commission. You will likely need authorization from the Number Holder to obtain release of the information. COMMISSION OFFICES Toll-free: within Illinois only 866/352-3033 Chicago: 100 W. Randolph St. #8-200 60601 Collinsville: 1014 Eastport Plaza Dr. 62234 Peoria: 202 N.E. Madison Ave. #201 61602 Rockford: 200 S. Wyman 61101 Springfield: 701 S. Second St. 62704 312/814-6611 618/346-3450 309/671-3019 81 5/987-7292 217/785-7087 TDD: Telecomm. Device for the Deaf 312/814-2959 You can obtain case status information online by visiting: http://www.state.il.us/agency/iic/caseinfo.htm You will need a claim number to enter the online system. F., References http://www.state.il.us/agency/iic/- Illinois Workers' Compensation site Dl 52135.080- Illinois PDB illi on -Illinois Maximum and Minimum WC rate list Prorating a WC/PDB Lump Sum Settlement 52 0 -Considering the RIB Option 521 50 Excludable Expenses To Link to this section - Use this URL: run: 0912412009 https:i/secure.ssa.g ovlapps 1 O/poms.nsfllnxf0452120080 4/4

9112113 SSA- POMS: Dl 52120.140- Missouri Worl<ers' Compensation {WC)- 10105/2012 Social Security Website E Program Operations Manual System (POMS) Effective Dates: 10/05/2012 - Present TN 5 (09-12) DI 52120.140 Missouri Workers' Compensation (WC) The Missouri (MO) Department of Labor and Industrial Relations, Division of Workers' Compensation (DWC) handles WC cases. Private carriers provide WC in the majority of cases, but some employers can self-insure. A. Types OfWC Payments And Payment Provisions The Missouri Revised Statutes, Chapter 287 covers WC payments. A! I periodic payments are subject to the state maximum amounts. In addition, there is a state minimum amount of $40 per week for temporary total (TT), permanent partial (PP), and permanent total (Pn when the injury occurred on or after 09/28/1981. Once started, they cannot stop temporary partial (TP), Tl or PT WC without notifying the beneficiary and affording him or her of their right to protest. MO pays TP: when the doctor releases an individual to return to work with light duty or modified duty restrictions; two-thirds of the difference between the individual's average earnings before and after the injury; and far a maximum of 100 weeks. Temporary Total (TT) 1 https://secure.ssa.go\fapps10/poms.nsf/lnxl0452120140 119

9112/13 SSA- POMS: 0152120.140- Missouri Warlers' Compensation (WC)- 10/05/2012 TT payments are based on: two-thirds of individual's gross average weekly An individual can receive TI payments up 400 Permanent Total (PT) PT payments are based on: two-thirds of individual's gross average weekly wage. An individual can receive PT payments for the duration of the disability or the individual may receive a lump-sum settlement. PP paid as Scheduled Awards: in addition to TT or TP benefits, upon the termination of TI or TP benefits, and not reduced for any TI or TP paid. PP has a lower state maximum amount than TP, Tf 1 and PT. Award amounts are based on twothirds of an individual's gross average weekly wage for a certain number of weeks, and paid as lump sum payments. PP for specific loss: A formula (referred to as a 'schedule') converts disabilities into a number of weeks of we based on the body part injured. Loss of an arm at the shoulder, for instance, yields 232 weeks of WC. In addition, the percentage of disability assigned to the injured body part determines the amount of PP paid, 116 weeks of we, PP for a 50 percent loss of the use of an arm. Disfigurement: Missouri pays additional PP for serious and permanent disfigurement to the head, neck, hands, or arms. The maximum period awarded is 40 weeks. Non-scheduled injuries: For permanent partial injuries other than those specified in the statutory schedule of losses, or for the body as a whole, the maximum period awarded is 400 weeks. Second Injury Fund (SIF) payments and 1 ) F https://secure.ssa.go'v1apps10/poms.nsfllnxl0452120140 219

9112113 SSA- POMS: Dl 52120.140- Missouri Workers' CornpellSation (WC}- 1010512012 uninsured employers, DWC can make types of payments to injured individuals from the SIF. All payments are offsettable except the physical rehabilitation payments. a. payments compensate an individual when a current work-related injury combined a prior disability an combined disability. The basic concept is the whole is greater than the sum of For example, if an individual has a 1 5 percent from the prior injury, and his combined disability is now 40 percent the SIF pays for the increased disability. The SIF benefit amount varies from case to case. An individual must have a permanent pre-existing disability to be eligible for these benefits. b. Physical rehabilitation payments: For serious injuries, the DWC can authorize weekly payments of $40 from the SIF while the individual receives physical (not vocational) rehabilitation services. These payments are in addition to any other WC paid and generally issued for up to 20 weeks. In certain circumstances, a special order from the DWC can extend that period of rehabilitation. These payments are not offsettable. c. Second job wage loss benefits: This WC benefit only applies to injuries that occur after 08/28/1998 and may be available to an employee who works at two or more jobs. When an employee has a work-related injury from his or her "first job" and is physically unable to work at his or her other job(s) due to that injury, the employee may claim additional benefits from the SIF for the loss of wages from the "second job." Commuted awards (287.530) The DWC or the Commission whose primary duty is the administration of the Department of Labor and Industrial Relations can commute periodic PP or PT and redeem them by the employer's payment of a lump sum that DWC sometimes uses to purchase an annuity. Commutation is a departure from the normal method of payment and it is only allowable when unusual circumstances warrant it and is in the best interest of the injured individual. Compromise settlements and Any agreement to settle or compromise a claim for WC is valid only if approved by a state administrative law judge (AU) or the Commission. MO generally pays settlements as a lump sum payment The following are standard compromise settlement facts: Missouri law passed in 07/1998 allows proration of PP and PT lump sum settlements over the expected life of the injured individual. SSA determined we can apply the proration effective on or after 07/1998 but not retroactively, unless a settlement made before then prorated specified in the approved and becomes we use. https:/lsecure.ssagoldapps10/poms.nsf/lnx10452120140 3!9

9112/13 SSA- POMS: 0152120.140- Missouri Workers' Compensation (WC)- 10/0512012 SSA must consider and use the most advantageous method of lump sum proration in calculating offset by applying rules 521 The settlement decisions on a Form WC -G-11 for Compromise Settlement) that does not include language regarding a proration amount Generally, MO specifies the proration amount on a usually titled "Addendum to Settlement" or "Additional Comments." Sometimes, the second page does not include the AU's signature or a date. However, the state AUs advises us to (if the documents are prepared the same day) treat the "Social Security language" on the second page attached to the settlement document as part of the original settlement Therefore, accept these additional documents as part of the original settlement unless it is obvious that the court prepared the document later. SSA should rely only on the terms specified in the original documents in prorating lump sum awards. Disregard any SUBSEQUENT language appending the award documents or incorporated by the claimant's attorney even when a state AU signed it When a lump sum settlement requires both the carrier and SIF to pay their part of the settlement as lump sums payments, COMBINE the amounts and treat as a single lump sum for offset computation purposes. See also: For instructions on stipulation of compromise settlements see 01 52120.140 B. Cost-Of-Living Adjustments (COLA) Missouri does not give COLAs on WC payments, so there is no need for a yearly diary. Attorney Fees Attorneys are entitled to reasonable fees and expenses, as determined by the state AU. Fees for claimants are limited to percent by policy. Retirement Insurance Benefit (RIB) Considerations Missouri does not offset WC for receipt of RIB. Time Limitations For Filing Claims owe must claims within: or her last we payment; https://secure.ssa.go\dapps10/poms.nsf/lnxf0452120140 4/9

9112/13 SSA- POMS: Dl 52120.140- Missouri Worl<ars' Compensation - 10/0512012 years date of injury or the we payment made, if the employer did timely report the injury or illness to the Division. Requests To Verify WC Payment Amounts 1. Initial request for WC information The DWC requires the injured individual to sign our request or provide another written signed statement giving permission to release WC information. The preferred request form is an SSA- 1709 (Request for Workers' Compensation/Public Disability Benefit Information). ~ Requests for information requirements The SSA-1709 must contain the following information to avoid return of the form without the information requested: SSN, signature of injured worker authorizing consent to release information, we claim number/ date of injury, and employer/s name, for which we are seeking WC information (if the employer's name is unknown, indicate "employer unknown~~ on the SSA-1709). NOTE: There can be rare instances where we cannot obtain the number holder's (NH's) signature, (e.g. the NH is deceased, retro Disability Insurance Benefits (DIB) is payable, and WC verification from SIF is necessary. The surviving spouse signs the SSA-1709). DWC will consider each SSA-1709 signed by someone, other than the injured worker, on a case-by-case basis. Contact the Kansas City Regional Office WC analyst or the Mid America Program Service Center WC analyst and explain the case specifics so they can directly contact the DWC. The we analyst will then question what documentation the owe needs in order to accept a signature other than the injured worker. Required consent obtained Take the following actions when you obtain required consent: Show "Missouri Compensation, ATTN: Customer Unit" in the htlps://secure.ssa.gov!apps10/poms.nsf/lnxf0452120140 5/9

9112/13 SSA- POMS: 0152120.140- Missouri Workers' Compensation (WC) -10/0512012 Complete the rest of the front of the form and include your return fax number in the "RETURN TO" block; the SSA-1709 to the at fax number 573 18. If consent is on a separate document Write your signature in the "Signature of SSA Official" block of the SSA-1709. Write "see attached consent statement" in the claimant signature block. Fax the SSA-1709 and any accompanying release to the state at fax number 573-526- 4718. Expect a reply within one or two business days. Direct any questions to the Customer Service Unit at 1-800-775-2667. Note that the DWC may not have complete information from the WC carrier, so attempt to obtain verification from the carrier before contacting the Division. NOTE: Missouri DWC considers settlement documents open public records; therefore, they will release copies of settlement documents without consent Other records Missouri considers as open public records include: awards issued after contested hearings before an AU, a claim for compensation, or minute sheets. DWC returns request Occasionally the DWC returns an SSA-1709 accompanied by a signed consent with a cover letter explaining the consent requirement and does not provide any further information. The cover letter provides contact information and a phone number for a DWC technician. Since we did obtain consent for release of the information, call the person indicated on the cover letter to resolve these issues individually on a case-by-case basis. Settlement document request Because the WC settlement documents are open public records, the DWC will release copies of settlement documents without consent You can get a copy of a settlement without consent but cannot get information about any WC payments made prior to the settlement (unless that information is in the settlement document itself). NOTE: The document copies provided will not have the individual's Social Security number N) due Missouri sure a of name as well as N. https:/lsecure.ssa.g ovlapps 1 0/poms.nsf/lnx/0452120140 619

9112/13 SSA- POMS: 0152120.140- Missouri Workers' Compensation (WC) -10/0512012 Requests for Sl F information Use Form SSA-1709 to request verification of SIF payments from the Missouri DWC. a. Obtaining SIF information The request may authorize the DWC to disclose II any and all" settlements, awards, and Form WC-2-2 (Notice of Commencement/Termination of Compensation) in its possession. The DWC suggested using the phrase ("any and all"). The signed SSA-1709 gives the DWC the authorization to release all information on benefit payments relating to any employer(s), SIF, settlements, and awards. Requests for information on SIF claim must include: the injury number, date of injury, date the award was issued, and the date the settlement was approved by an AU. c. Address for SIF requests to the DWC Mail or fax requests to: Missouri Division of WC Attn: Second Injury Fund Payment Information Request POBox 58 Jefferson City fv10 65 702 The fax number is (573) 526-4778 Stipulation of Compromise Settlements If the DWC file contains a Stipulation of Compromise Settlement, it will reflect: information relating to medical costs paid, TT disability benefits paid, PP disability amounts the employer or insurer would pay to the injured worker. Also refer comprom1se In 52 this section. a https://secure.ssa.govfapps10/poms.nsfllrm'0452120140 7/9

9112/13 SSA- POMS: 0152120.140- Missouri Workers' Compensation {WC)- 10105/2012 Compromise Settlement agreement or award. NOTE: DWC staff cannot offer clarification or advice on any of the information within agreements or For any additional of WC or Public Disability Benefit (PDB) or needed the injured worker first, then outside sources such as: the worker! s attorney, employer, insurance carrier! the courts! or any Federal, State, or local governments. Also refer to instructions on other sources of verification in 1.001 F. The Missouri courts generally get involved at the appellate level A worker can appeal the DWC s award to the Commission, the Missouri Court of Appeals, and finally to the Missouri Supreme Court The DWC provides SSA with court decisions where applicable. MOWCForms 1. Form WC-2-2 - Notice Commencement/Termination Compensation One of the following sources can complete the form: a self-insured or self-administered employer, insurance company, or third-party administrator. The injured employee receives a copy of this form. Form WC-G-11 -Stipulation The injured worker completes this form for approval of a settlement agreement Form WC-11 0-03-12 - The following information explains this two-page form: a. The first page is a visual chart showing the number of weeks of PP that is payable for certain injuries. a htlps://secure.ssa.go\h'apps10/poms.nsfllmd0452120140 819

9/12/13 SSA- POMS: 0152120.140- Missouri Workers' Compensation (WC)- 10105/2012 Reference Links Workers' Compensation website. Department of Labor and Industrial Relations, Division of n n To Link to this section -Use this URL: Dl52120.140 Missouri Workers' Compensation (WC) Batch run: Rev:J0/0512012 https://secure.ssa.govfapps10/poms.nsf/lnxf0452120140 9/9