CERTIFICATE AUTHORIZING RELEASE
OF BENEFIT INFORMATION,
WCB-6
Filing Requirements
The employer or insurer (which can sometimes be one and the same) may use the Certificate Authorizing Release of Benefit Information to request information about payments made to an injured employee for one of the following:
- Old-age insurance under the United States Social Security Act, 42 United States Code, §§301 to 1397f.
- An employer-funded self-insurance plan.
- An employer-funded wage continuation plan.
- An employer-funded disability insurance policy.
- An employer established or maintained pension plan or program.
The employer/insurer must complete Part I and have the injured employee complete Part II (release of information) before submitting the form to the Social Security Administration or other party who provides one of the above-listed employee benefit plans for completion of Part III.
Distribution
The Employment Status Report is a three-part form that is to be distributed as follows:
Copy 1 to the Employee.
Copy 2 to the Insurer.
Copy 3 to the Employer.
The Board does not receive a copy of this report.
INSTRUCTIONS FOR COMPLETING CERTIFICATE AUTHORIZING
RELEASE OF BENEFIT INFORMATION, WCB-6
Part I Employer/Insurer Completes Boxes 1 Through 17
- 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 Certificate of Discontinuance or Reduction of Compensation, 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 of 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 insurer, self‑insured, or third‑party administrator.
- 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 the city of the employee’s mailing address.
- State
Enter the state of the employee’s mailing address.
- Zip
Enter the zip code of the employee’s mailing address.
- Home Phone Number
Enter the 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.
Part II Employee Completes This Section
I, _____________________, authorize the above-named employer/insurer to obtain written information indicating the nature and amount of benefits I received or am receiving from the following:
Enter your name on the line provided.
Enter the city, state and zip code of the mailing address for the benefit plan on the third line.
_________________________ _______________
Employee Signature Date
Sign your name on the first line and enter the date that you signed this form on the second
line.
Part III Social Security Administration or Employee Benefit Plan Completes This
Section
- Effective Date of Eligibility
Enter the date that the employee listed in Part I first became eligible for payments through the benefit plan listed in Part II.
- Current Gross Monthly Amount
Enter the gross amount of the monthly benefit that the employee is currently being paid. If benefits are not paid monthly, enter the amount of the benefit currently being paid and the frequency of that payment (weekly, biweekly, etc.).
- Percentage of Employee Benefit Plan Paid By Employer (If Applicable)
Enter the percentage of the premium paid for this benefit plan that was paid by the employer listed in Part I.
- Are Benefits from This Employee Benefit Plan Subject to Reduction Based on Receipt of Workers’ Compensation Benefits? If Yes, Explain Below Under Comments.
If this benefit plan provides for an offset of benefits payable when the employee also receives workers’ compensation benefits, enter “yes.” Otherwise, enter “no.” If an offset is allowed, explain how the offset is calculated and applied in the “Comments” area provided.
- Comments
Use this area to enter any additional information, explanations or clarifications.
Authorized Representative
- Signature & Title of Authorized Representative
The person who completes Part III of this form must sign this line. Also enter the title of the person whose signature appears in this box.
- Telephone Number
Enter the telephone number, including area code, of the person listed in box 6 (Part III).
- Date Sent: ___/___/____
MM DD YYYY
Enter the date (month, day, year) that this form is sent back to the requesting party.
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