MCS Screens

WC/PDB

WORKERS’ COMPENSATION/PUBLIC DISABILITY BENEFITS SELECTION MENU

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1	C	COMM WORKERS’ COMPENSATION/PUBLIC DISABILITY BENEFITS SELECTION MENU WPMU TZW	0
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l
4	u
5	m	[ WC/PDB INJURY/ SOURCE OF WC/PDB CLAIM NUMBER INJURY/ SSSSSS
6	n	[ CLAIM ILLNESS COMPENSATION ILLNESS
7	*	[ DATE STATE
8	o	| 1 SSSSSSSS SS SSSSSSSSSSSSSSSSSSSSSSSS SS X
9	n	| 2 SSSSSSSS SS SSSSSSSSSSSSSSSSSSSSSSSS SS X
10	e	| 3 SSSSSSSS SS SSSSSSSSSSSSSSSSSSSSSSSS SS X
11		| 4 SSSSSSSS SS SSSSSSSSSSSSSSSSSSSSSSSS SS X
12	r
13	e
14	s	WC/PDB CLAIM 1 SCREENS: SSSS SSSS SSSS SSSS SSSS SSSS
15	e	WC/PDB CLAIM 2 SCREENS: SSSS SSSS SSSS SSSS SSSS SSSS
16	r	WC/PDB CLAIM 3 SCREENS: SSSS SSSS SSSS SSSS SSSS SSSS
17	v	WC/PDB CLAIM 4 SCREENS: SSSS SSSS SSSS SSSS SSSS SSSS
18	e
19	d	ADD NEW OCCURRENCE (Y/N): X
20
21
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		***********************APPLICATION ERROR MESSAGE******************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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WC/PDB

WC/PDB CLAIM DATA

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1	C	COMM WC/PDB CLAIM DATA WPCL TZW	1
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l	*INJURY/ILLNESS DATE (MMDDCCYY): 99999999 *SOURCE OF COMPENSATION: XX
4	u	*WC/PDB CLAIM NUMBER: XXXXXXXXXXXXXXXXXXXXXXXX INJURY/ILLNESS STATE: XX
5	m
6	n	*PERIODIC PAYMENTS AWARDED (Y/N): X *LUMP SUM AWARDED (Y/N): X
7	*	*WC/PDB CLAIM PENDING (Y/N): X *CLAIM DENIED (Y/N): X
8	o	*APPEAL PENDING (Y/N): X IF YES, EXPECTED DECISION DATE (MMDDCCYY): 99999999
9	n	INTEND TO FILE (Y/N): X
10	e	WILL BE DELETED FROM THIS INJURY – CONTINUE (Y/N): X
11		*REVERSE JURISDICTION INVOLVED (Y/N): X
12	r	IF YES, START (MMDDCCYY): 99999999 STOP (MMCCYY): 999999
13	e
14	s	DO THE PDB’S MEET THE COVERED SERVICE EXCLUSION (Y/N): X
15	e	COVERED EARNINGS PERCENTAGE: 999
16	r	DO YOU NEED TO MANUALLY ENTER A HIGHER ACE (Y/N): X
17	v	IF YES, MANUAL 100 PERCENT ACE: 99999
18	e	SELECT METHOD USED: 9
19	d	1=HIGH 1 2=HIGH 5 3=AVERAGE MONTHLY WAGE.
20		DELETE THIS CLAIM (Y/N): N
21		THIS OCCURRENCE OF DATA WILL BE DELETED FROM CLIENT AND MBR-CONTINUE (Y/N): X
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		**************************APPLICATION ERROR MESSAGE***************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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WC/PDB

WC/PDB CLAIM DATA EMPLOYER/PAYER NAME AND ADDRESS

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1	C	COMM WC/PDB CLAIM DATA EMPLOYER/PAYER NAME AND ADDRESS WPAD TZW	2
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l	INJURY/ILLNESS DATE: SSSSSSSS SOURCE OF COMPENSATION: SS
4	u	WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS INJURY/ILLNESS STATE: SS
5	m
6	n
7	*	EMPLOYER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
8	o	ADDRESS 1: XXXXXXXXXXXXXXXXXXXXXX ADDRESS 2: XXXXXXXXXXXXXXXXXXXXXX
9	n	ADDRESS 3: XXXXXXXXXXXXXXXXXXXXXX ADDRESS 4: XXXXXXXXXXXXXXXXXXXXXX
10	e	CITY: XXXXXXXXXXXXXXXXXXXXXX STATE: XX ZIP: 99999
11		CONTACT: XXXXXXXXXXXXXXXXXXXXXXXXXX PHONE: XXXXXXXXXXXX EXTENSION: 9999
12	r	E-MAIL: XXXXXXXXXXXXXXXXXXXXXXXXXXXX FAX: XXXXXXXXXXXX
13	e
14	s
15	e	PAYER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXX
16	r	ADDRESS 1: XXXXXXXXXXXXXXXXXXXXXX ADDRESS 2: XXXXXXXXXXXXXXXXXXXXXX
17	v	ADDRESS 3: XXXXXXXXXXXXXXXXXXXXXX ADDRESS 4: XXXXXXXXXXXXXXXXXXXXXX
18	e	CITY: XXXXXXXXXXXXXXXXXXXXXX STATE: XX ZIP: 99999
19	d	CONTACT: XXXXXXXXXXXXXXXXXXXXXXXXXX PHONE: XXXXXXXXXXXX EXTENSION: 9999
20		E-MAIL: XXXXXXXXXXXXXXXXXXXXXXXXXXXX FAX: XXXXXXXXXXXX
21
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		**************************APPLICATION ERROR MESSAGE***************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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WC/PDB

WC/PDB PERIODIC PAYMENTS

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1	C	COMM WC/PDB PERIODIC PAYMENTS WPPR TZW	3
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l	INJURY/ILLNESS DATE: SSSSSSSS SOURCE OF COMPENSATION: SS
4	u	WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS INJURY/ILLNESS STATE: SS
5	m
6	n	[ *START STOP *PERIODIC *FREQ TYPE OF *PAYMENT
7	*	[ (MMDDCCYY) (MMDDCCYY) AMOUNT PAYMENT PROOF (Y/N)
8	o	| 99999999 99999999 99999.99 X XX X
9	n	| 99999999 99999999 99999.99 X XX X
10	e	| 99999999 99999999 99999.99 X XX X
11		| 99999999 99999999 99999.99 X XX X
12	r	| 99999999 99999999 99999.99 X XX X
13	e	| 99999999 99999999 99999.99 X XX X
14	s	| 99999999 99999999 99999.99 X XX X
15	e	| 99999999 99999999 99999.99 X XX X
16	r
17	v	IF PERIODIC PAYMENTS ARE TO BEGIN AGAIN, EXPECTED DATE (MMDDCCYY): 99999999
18	e	ARE ONGOING PERIODIC EXPENSES INVOLVED (Y/N): X
19	d	ARE ONE-TIME EXCLUDABLE EXPENSES FROM PERIODIC PAYMENTS INVOLVED (Y/N): X
20		EXPENSES WILL BE DELETED FROM THIS INJURY - CONTINUE (Y/N): X
21		MORE PERIODIC PAYMENTS (Y/N): X
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		**************************APPLICATION ERROR MESSAGE***************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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WC/PDB

WC/PDB PERIODIC PAYMENTS ONGOING EXPENSES

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1	C	COMM WC/PDB PERIODIC PAYMENTS ONGOING EXPENSES WPOX TZW	4
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l	INJURY/ILLNESS DATE: SSSSSSSS SOURCE OF COMPENSATION: SS
4	u	WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS INJURY/ILLNESS STATE: SS
5	m
6	n
7	*	[ START STOP PERIODIC FREQ TYPE OF ONGOING ONGOING PROOF
8	o	[ (MMDDCCYY) (MMDDCCYY) AMOUNT PAYMENT EXPENSES PERCENT (Y/N)
9	n	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
10	e	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
11		| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
12	r	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
13	e	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
14	s	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
15	e	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
16	r	| SSSSSSSS SSSSSSSS SSSSSSS S SS 99999.99 999 X
17	v
18	e
19	d	IF PERIODIC PAYMENTS ARE TO BEGIN AGAIN, EXPECTED DATE (MMDDCCYY): PPPPPPPP
20
21		MORE PERIODIC PAYMENTS (Y/N): X
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		**************************APPLICATION ERROR MESSAGE***************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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WC/PDB

ONE-TIME ONLY EXCLUDABLE EXPENSES FOR PERIODIC PAYMENTS

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1	C	COMM ONE-TIME ONLY EXCLUDABLE EXPENSES FOR PERIODIC PAYMENTS WPEX TZW	5
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l	INJURY/ILLNESS DATE: SSSSSSSS SOURCE OF COMPENSATION: SS
4	u	WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS INJURY/ILLNESS STATE: SS
5	m
6	n
7	*
8	o
9	n	ONE-TIME EXCLUDABLE ATTORNEY EXPENSES: 9999999.99 PROOF (Y/N): X
10	e
11		ONE-TIME EXCLUDABLE MEDICAL EXPENSES: 9999999.99 PROOF (Y/N): X
12	r
13	e	ONE-TIME EXCLUDABLE RELATED EXPENSES: 9999999.99 PROOF (Y/N): X
14	s
15	e
16	r	*SPECIFIED EXPENSE PERIOD START DATE (MMDDCCYY): 99999999
17	v
18	e
19	d
20
21
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		**************************APPLICATION ERROR MESSAGE***************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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WC/PDB

WC/PDB LUMP SUM AWARD DATA

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1	C	COMM WC/PDB LUMP SUM AWARD DATA WPLS TZW	6
2	0	NUMBER HOLDER SSN: SSS-SS-SSSS NUMBER HOLDER NAME: SSSSS SSSSSSSSSS
3	l	INJURY/ILLNESS DATE: SSSSSSSS SOURCE OF COMPENSATION: SS
4	u	WC/PDB CLAIM NUMBER: SSSSSSSSSSSSSSSSSSSSSSSS INJURY/ILLNESS STATE: SS
5	m
6	n
7	*	*LUMP SUM AMOUNT: 9999999.99 *PROOF (Y/N): X
8	o	*LUMP SUM START DATE (MMDDCCYY): 99999999
9	n	*RATE AT WHICH LUMP SUM IS TO BE PRORATED: 99999.99
10	e	*FREQUENCY FOR LUMP SUM PRORATION: X
11		TYPE OF PAYMENT: XX
12	r
13	e	EXCLUDABLE ATTORNEY EXPENSES: 9999999.99 PROOF (Y/N): X
14	s	EXCLUDABLE MEDICAL EXPENSES: 9999999.99 PROOF (Y/N): X
15	e	EXCLUDABLE RELATED EXPENSES: 9999999.99 PROOF (Y/N): X
16	r	SPECIAL AMOUNTS TO BE DEDUCTED FROM LUMP SUM: 9999999.99 PROOF (Y/N): X
17	v
18	e	IF DESIRED, SELECT PRORATION METHOD TO BE USED IN COMPUTATION: 9
19	d	1=METHOD A 2=METHOD B 3=METHOD C.
20
21
22		PF1 HELP AVAILABLE TRANSFER TO: XXXX
23		**************************APPLICATION ERROR MESSAGE***************************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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