Free untitled - Minnesota

Mail completed copy to: Department of Labor and Industry Claims Services and Investigations PO Box 64229 St. Paul, MN 55164-0229 (651) 284-5045 or 1-800-342-5354 (DIAL-DLI) Fax: (651) 284-5733

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Annual Claim for Reimbursement of Supplementary Benefits
PRINT IN INK or TYPE your responses All dates must be entered in MM/DD/YYYY
A C 0 3

FOR CSI USE ONLY

WID or SSN

DATE OF INJURY

EMPLOYEE NAME

INSURER/SELF-INSURER (Reimbursement Payable To)

EMPLOYER NAME

ADDRESS

INSURER CLAIM NUMBER

CITY

STATE

ZIP CODE

Claim status A. AA. B. First claim for this case First and last claim as a result of full, final and complete settlement Continuing - Attach EVIDENCE of contact with employee during the time period claimed which SUPPORTS ELIGIBILITY for benefits claimed (i.e., status check confirming employee remains disabled, medical and/or rehabilitation reports from the time period claimed, etc.). Final Claim for this case. Reason: 1) Returned to work on: _______________________ 2) Death of employee on: _______________________ ATTACH DEATH CERTIFICATE 3) Closed by settlement 4) Other: Explain:

C.

YOU MUST COMPLETE THE BACK SIDE OF THIS FORM.
Name of Preparer Date

Company Name (if different from above)

Phone No. (include area code & ext.)

Address

ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

MN AC03 (5/08)

(1) Specify TTD or PTD Number of Weeks

(2) Weekly Comp Rate

(3) Government Benefits* Weekly Soc Security Weekly other

(4) SUBTOTAL Col 2 - 3

From

Through

(5) Max. (ROUNDED) supp. benefit minus Col 4

(6)

(7) Net supp benefits Col 5 ­ 6

TOTAL Col 1 X 7

5% Offset

Date of Birth ______________________________

Retirement Disability

TOTAL

*ATTACH EVIDENCE OF GOVERNMENT DISABILITY BENEFIT CHANGES IF OTHER THAN STANDARD COST OF LIVING ADJUSTMENTS.
CLAIMS SERVICES AND INVESTIGATIONS USE ONLY Total Amount Claimed Amount Adjusted Amount Approved Approved by Paid by Date Approved Date Paid Vendor Number Batch Number Adjustment Code

Addendum to Annual Claim for Reimbursement of Supplementary Benefits EMPLOYEE NAME WID or SSN DATE OF INJURY

(1) Specify TTD or PTD Number of Weeks

(2) Weekly Comp Rate

(3) Government Benefits* Weekly Soc Security Weekly other

(4) SUBTOTAL Col 2 - 3

From

Through

(5) Max. (ROUNDED) supp. benefit minus Col 4

(6)

(7) Net supp benefits Col 5 ­ 6

TOTAL Col 1 X 7

5% Offset

Date of Birth ______________________________

Retirement Disability

TOTAL