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This payment is based on the amount of money you are earning after your injury. O Your doctor released you to return to work with modified duty.Complete the first section as appropriate for temporary disability indemnity payments. Employees who miss work due to an onthejob injury or illness may receive payment for lost wages. This is known as an indemnity benefit. If a notice has been issued stating that no further action is planned at the time, but indemnity benefits are continuing, then the case is considered open. How Are Indemnity Benefits Paid? Form nameVersion dateNotesAffidavit of Significant Financial Hardship (AS01)June 2018Legislative changesDisability Status Report (DS01)September 2012Employee's Claim Petition (EC04)June 2018Legislative changes CA. Change in Benefit. Amount. The claim administrator is reporting a change in the amount of weekly indemnity benefits paid to the claimant. CB.
