Worker's Compensation

Board of Indiana



















Benefit Termination Disagreement Untitled Document
The purpose of this tool is to allow you, the injured party, to disagree with the employer/carrier's intent to terminate your Worker's Compensation benefits. To proceed, you will need the form (REPORT OF TEMPORARY TOTAL DISABILITY (TTD) / TEMPORARY PARTIAL DISABILITY (TPD) TERMINATION / REDUCTION State Form 38911 (R7 / 8-10)) sent to you by the employer or their insurance carrier. This form will bear, in the upper, right-hand corner, a field labeled "Accident Number" as illustrated below. In addition, we are asking you to supply the last four digits of your social security number to provide verification that the claim in question belongs to you.

 Accident Number:

 Last Four Digits of Social Security Number: