Form 106 - Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period

This form is filed by insurance carriers only if they paid weekly benefits within 14 calendar days of receipt of the First Report of Injury/Death (Form 101), or a claim for weekly benefits on an Employee's Claim Form(Form 110). At least seven calendar days written notice must be given to the Employee of the intent to stop or modify payments, unless based on the actual income of the employee.

Print Insurer's Notification Of Termination Or Modification Of Weekly Compensation  form.