(a) After the commissioner’s initial determination of supplemental income benefits, the employee must file a statement with the insurance carrier stating:
(1) that the employee has earned less than 80 percent of the employee’s average weekly wage as a direct result of the employee’s impairment;
(2) the amount of wages the employee earned in the filing period provided by Subsection (b); and
(3) that the employee has complied with the requirements adopted under § 408.1415.
(b) The statement required under this section must be filed quarterly on a form and in the manner provided by the commissioner. The commissioner may modify the filing period as appropriate to an individual case.

(c) Failure to file a statement under this section relieves the insurance carrier of liability for supplemental income benefits for the period during which a statement is not filed.