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Interim Status Report
I S 0 3

PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.

DO NOT USE THIS SPACE DATE OF INJURY

WID or SSN

EMPLOYEE

EMPLOYER

EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

INSURER CLAIM NUMBER

THE FORM MUST BE SUBMITTED ANNUALLY ON ALL CLAIMS OF CONTINUING DISABILITY, SUPPLEMENTARY OR DEPENDENCY BENEFITS. Please provide additional information on the Benefit Addendum (BA01). Temporary Total* Permanent Total* Balance Carried Forward FROM THROUGH WEEKS RATE *TOTAL

TOTAL: Temporary Partial Balance Carried Forward

TOTAL: Permanent Partial Permanent Partial Disability ___________% Injuries on or after 10/01/95 Impairment Compensation (injuries 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) _______________________ [part of body] (injuries before 01/01/1984) TOTAL: *These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of Supplementary Benefits.

MN IS03 (5/08)

(over)

FROM Retraining Benefits Balance Carried Forward

THROUGH

WEEKS

RATE

TOTAL

TOTAL: Dependency Benefits Balance Carried Forward

TOTAL: Supplementary Benefits* Balance Carried Forward

TOTAL: Social Security Benefits or Other Government Benefits* Name of Program: FROM THROUGH PER WEEK Retirement Disability

*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of Supplementary Benefits. Attorney Fees Paid Attorney Fees Still Withheld

Interest Paid Lump Sum Payment Under Award or Order Total Compensation Paid to Employee Total Dependency Benefits Paid (Please attached copy of worksheet) CLAIM REPRESENTATIVE NAME

Attorney Fees Reimbursed to Employee M.S. 176.081, subd. 7 INSURER/SELF-INSURER/TPA

ADDRESS

PHONE NUMBER (include area code)

CITY

STATE

ZIP CODE

DATE SERVED

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
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.