If a completed Workers’ Annual Report of Income form (Form 110-A) is not returned by the anniversary date of the award for unscheduled permanent disability benefits, the carrier or self-insured employer must notify the injured worker by Notice of Intent to Suspend (Form 110-B) that benefits will be suspended unless the report of earnings is received within 30 days.

If a completed Notice of Intent to Suspend (Form 110-B) is not received at the end of 30 days, the carrier or self-insured employer can suspend the injured worker’s benefits for failure to submit the required Annual Report of Income.  When the Annual Report of Income is received by the carrier or self-insured employer, the injured worker’s benefits are to be reinstated effective as of the date of receipt.

This form is made available for use on this website but is not filed with the Commission.  Carefully follow the directions on the form and return it as instructed.

IMPORTANT:  Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one-half years in prison, a fifty thousand dollar fine and forfeiture of benefits.

An injured worker may not leave the state for a period exceeding two weeks, (15 days or more), while the need for active medical treatment continues, without the written approval of the Commission.  This form may be used to request approval to leave the state. It must be completed in its entirety including the reason for the request. Failure to state the reason for the request may cause a delay in processing.

The Commission will issue an award either approving or disapproving the request to leave the state.   If approved, the effective date which grants permission for the injured worker to leave the state is the date on which the injured worker filed this request.