INSTRUCTIONS FOR COMPLETING
THE
TWCC-6

The TWCC-6, Supplemental Report of Injury, is used to provide information about an injured employee's return to work, additional lost time (or lost time that was not initially indicated on the TWCC-1), change in weekly earnings, or termination.  The two basic sections of the TWCC-6 are the Employee information and the Employer information.

PART 1 - EMPLOYEE INFORMATION

Blocks 1-4 - Self explanatory; however, use the address where the employee will receive mail in the event that contact needs to be made with the employee.

Area between Blocks 4 and 5 - Check the appropriate block and not the additional blocks to be completed based upon the block that you check.  If the employee returned to work, complete blocks 5 a or 5b, 6 and 7.  If additional days lost, blocks 5b and 7; if change in weekly earnings, blocks 5a or 5b, 7, and 8; and if terminated, blocks 5aor 5b, 7, and 9.

Instructions below are for all the blocks.  Use the note above and on the form to determine which blocks to complete.

Block 5a - If initial filing of the TWCC-6, enter the first day of lost time.

Block 5b - Is this is a second or subsequest filing of the TWCC-6, enter the first lost day due to the injury for this filing of this TWCC-6 only.

Block 6 - Enter the date of return to work and check the appropriate blocks about their return to work.

Block 7 - Enter the weekly and hourly earnings at the time of this TWCC-6 report.  Check the appropriate blocks.

Block 8 - Enter the number of hours working weekly at the time of this TWCC-6, then check the appropriate blocks.

Block 9 - If terminated, check the appropriate block and enter the date.

Block 9a - Self-explanatory.

Block 10 - The date the eight days of disability began - if applicable.  This is used to determine the repayment time for the exclusionary period of wages if the lost time was not consecutive or indicated on the TWCC-1.

Block 11 - If injured employee died subsequent to the TWCC-1 filing, enter the date.

Block 12 - Self explanatory.

PART 2 EMPLOYER INFORMATION

Block 13 - 15 - Self explanatory - enter unit information.

Block 16 - Enter "Self-Insured."

Block 17 - Information on the person completing the form - be sure to indicate if completing the form as the injured person or as the employer. THIS CANNOT BE THE INJURED EMPLOYEE!