Form 14-0147 — Payment Activity Report for Compromise Settlement With Self-Represented Claimants

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NAME

Payment Activity Report (PAR) for Compromise Settlement With Self-Represented Claimant

NUMBER

14-0147

EFFECTIVE

December 2023

OVERVIEW

This form is used to as a Payment Activity Report (PAR) to be filed with a proposed compromise settlement involving a self-represented claimant.

INSTRUCTIONS

To complete this form:

1. In Section A, provide the complete names and addresses of the insurance carrier, employer, and employer.
2. In Section B, provide the information concerning any changes in payment status or any comments pertinent to the handling of the claim.
3. In Section C, provide the information relating to the rate calculation.
4. In Section D, indicate whether:
   • The PAR is a Commencement of Payment Notice.
   • The PAR is a Denial of Liability.
   • Benefits are not being paid and the reason.
5. In Section E, provide the requested information to report the benefits paid to date, and to indicate whether an "Interim Report" (disability benefits are continuing; enter the estimated completion date) or "Final Report" (disability benefits have been terminate; enter the date of last payment) is being filed. You may attach a separate sheet if necessary.
6. Identify the person who prepared the PAR and the date on which it was prepared.