Free WKC-6119.PDF - Wisconsin

SOCIAL SECURITY REVERSE OFFSET WORKSHEET

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/

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Employee: Insurer: Social Sec. No: 1. 2. 3. 4. 5. 6. 7. 8. 9. Initial 80% ACE: Index: $ X

Injury Date: Date of Birth: File Number:

Redetermined 80% ACE: $ Weekly WC before offset: Limit (Higher of 3 or 4): Initial MBA: ___________________

X 12/52 =

$ $ $

X 12/52 =

$ $

Weekly balance to employee: Entitlement date: Effective date of computation: Instructions

Attach copy of the "Request for Social Security Information, WKC-6156." Line 1: Enter 80% of ACE from the "Request for Social Security Information". Do not reduce the ACE to 80%; the figure has already been reduced. Enter the index based on the entitlement date and redetermination chart. Multiply Line 1 by Line 2 to find the redetermined ACE. Multiply the monthly amount by 12/52nds to find the weekly amount. If indexing is not required use same figure as in Line 1. Enter the WC otherwise due. This rate may be for TTD, escalated TTD, TPD, PTD, or PPD. Vocational rehabilitation is not offset. Enter the top limit. This amount will be the higher of Line 3 (redetermined ACE) or the WC rate otherwise payable from Line 4. Enter the initial MBA from the "Request for Social Security Information". Multiply the MBA by 12/52nds to find the weekly amount. Subtract Line 6 from Line 5 to find the weekly balance to employee. This amount is the total amount the insurance carrier is obligated to pay. If this line is greater than Line 4 then no offset can be taken. Enter the entitlement date. Enter the effective date of this computation. This date is the first date that the insurance carrier can take this offset.

Line 2: Line 3:

Line 4:

Line 5:

Line 6:

Line 7:

Line 8: Line 9:

WKC-6119 (R. 02/2002)