Injured workers use this form to request temporary total disability benefits, providing information about employment and benefits received during the time of disability. You must complete this form every time you make a request for an initial period of temporary total compensation or an extension of an existing period of temporary total compensation.
It's also your responsibility to secure supporting medical documentation from your treating provider for the requested period of disability using the Physician's Report of Work Ability (MEDCO-14) or equivalent documentation that includes information such as physical capabilities and limitations, maximum medical improvement, vocational rehabilitation and the dates of disability being certified, including an estimated or actual return-to-work date.
- Whether application is for a new period of compensation or an extension
- If application is for a new period, the date injured worker became disabled
- Provider(s) treating injured worker for this claim
- Occupation at the time of injury/disease
- Whether injured worker has a job to return to
- Whether injured worker is currently working
- Whether injured worker has previously worked during the period of disability
- Barriers preventing injured worker from returning to work
- Whether injured worker would consider participating in vocational rehabilitation
- Benefits/Earnings received or requested during the period of disability
If you have all the required information on hand, simply click the start button to begin.
Also, there's a how-to video to walk you through completing the form. Simply click the play button to watch.