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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
Notice of Intention to Claim Reimbursement From the Second Injury Fund
PRINT IN INK or TYPE your responses All dates must be entered in MM/DD/YYYY
R S 0 5
DO NOT USE THIS SPACE
WID or SSN
DATE OF INJURY
EMPLOYEE NAME
INSURER/SELF-INSURER
EMPLOYER NAME
INSURER/ ADDRESS
INSURER CLAIM NUMBER
CITY
STATE
ZIP CODE
ATTACH COPY OF ACCEPTED REGISTRATION OR DOCUMENTATION OF AUTOMATIC REGISTRATION 2. Dates of previous work-related injuries, if any 1. Nature of registered condition
3. Nature of subsequent injury causing disability for which reimbursement is being claimed
4. The insurer is claiming that this disability is (check one): a. more serious because of the registered condition (substantially greater) M.S. § 176.131, subd. 1. b. caused by the registered condition (except for) M.S. § 176.131, subd. 2. ATTACH MEDICAL REPORTS TO SUPPORT THE ITEM CHECKED ABOVE COMPLETE THE REHABILITATION AND WORK STATUS REPORT ON THE BACK OF THIS FORM
Name of Preparer Date
TPA Name
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.
CLAIMS SERVICES AND INVESTIGATIONS OFFICE USE ONLY Claim APPROVED on ____________________ by _______________________________________________________ Deductibles 26 weeks and $1,000 52 weeks and $2,000 52 weeks and $2,000; apportionment under M.S. § 176.131, subd. 1(a) No deductibles
Other: ______________________________________________________________________________________________ Claim REJECTED on ____________________ by _______________________________________________________ Deductibles No Registration found Notice was filed late Documentation of automatic registration not attached Medical reports to support claim not attached
Other: ______________________________________________________________________________________________
MN RS05 (5/08)
VOCATIONAL REHABILITATION AND WORK STATUS REPORT 1. Has the employee returned to work? Yes No Yes No
Do temporary partial benefits continue to be paid?
2. Has this case been referred for vocational rehabilitation? Yes No (Complete #3) Reason:
Disability Status Report filed requesting rehabilitation waiver
3. Current status (check ALL that apply): a. Plan in progress, R-2 submitted b. On-The-Job Training Plan approved and in progress c. Retraining approved and in progress d. Rehabilitation closed, R-8 submitted (check one below): 1. Employee returned to work 2. Employee retired 3. Employee died 4. Rehabilitation discontinued by settlement, mediation, arbitration or order 5. Other Explain: