SCHEDULE OF DEPENDENT(S) AND FILING
STATUS STATEMENT, WCB-2A
For injuries occurring on or after January 1, 1993, the employer or insurer (which can sometimes be one and the same) must file a Schedule of Dependent(s) and Filing Status Statement with the Workers' Compensation Board within 30 days after the employer's notice or knowledge of a claim for compensation (box 28 of the first Memorandum of Payment, WCB‑3, or box 20 of the Notice of Controversy, WCB‑9). NOTE: The Schedule of Dependent(s) and Filing Status Statement should be attached to the Wage Statement before mailing to the Workers' Compensation Board.
The Schedule of Dependent(s) and Filing Status Statement is a four‑part form. The distribution is as follows:
Copy 1 to the Workers’ Compensation Board.
Copy 2 to the Employee.
Copy 3 to the Insurer.
Copy 4 to the Employer.
INSTRUCTIONS FOR COMPLETING SCHEDULE OF DEPENDENT(S)
AND FILING STATUS STATEMENT, WCB-2A
Boxes 1 through 17 are completed by the employer/insurer
- Insurer File Number
This box is provided for use by the insurer. If the insurer file number is known at the time of filing the Schedule of Dependent(s) and Filing Status Statement, enter it here. The Board will record it for reference.
- Employer Name
Enter the employer name as it was entered in box 10 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
- Employer Mailing Address and Phone Number
Enter the address where the employer receives mail. Also enter the employer’s phone number, including area code.
- Insurer Name
Enter the name of the employer’s workers’ compensation insurance company. If the employer is self-insured or group self-insured, indicate this and provide the name of the third-party administrator if there is one.
- Insurer Mailing Address
Enter the insurer, self-insured, or third-party administrator’s mailing address.
Social Security Number
Enter the employee's social security number.
- WCB File Number
If the preparer knows this number, enter it here. Doing so will speed up processing this form.
- Employee Last Name
Enter the employee's last name as entered in box 27 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
- First Name
Enter the employee's first name as entered in box 28 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
- M.I.
Enter the employee's middle initial as entered in box 29 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
- Address – Number and Street
Enter employee's mailing address.
- City
Enter city of employee's mailing address.
- State
Enter state of employee's mailing address.
- Zip
Enter zip code of employee's mailing address.
- Home Phone Number
Enter employee's home telephone number, including area code.
- Date of Injury
Enter the date of injury. This date should be the same as box 42 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
- Description of Injury
Enter a complete description of the injury.
Boxes 18 through 21 are completed by the employee.
- Federal Tax Filing Status
The employee checks the appropriate box based on the employee's Federal Income Tax Return. The filing status is determined according to IRS regulations for the year preceding the injury.
- Dependent(s)
List all members of the employee's household whom the employee is able to claim as dependents on the Federal Income Tax Return. The Board will accept this form without the social security number(s) of dependent(s).
- Employee Signature
The employee signs this section of the form. This information is for use by the employer/insurer. The Board will accept unsigned forms completed by the employer/insurer if the employee refuses to complete this section
- Date
The employee enters the date this section was prepared.
NOTE: If the employee fails to (timely) complete boxes 18 through 21, then the employer/insurer can complete these boxes, based on any known filing status and dependent information. If the filing status and dependent information is unknown, we recommend a filing of “single with no dependents”. The employer/insurer must document that the employee was contacted and failed to (timely) complete this section.
Upon receipt of the employee’s version of the form, a copy should be forwarded to the Board along with any corresponding corrections (if applicable). The newly established weekly compensation rate is effective from the employee’s date of injury.
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