Free untitled - Minnesota


File Size: 57.4 kB
Pages: 2
Date: May 23, 2008
File Format: PDF
State: Minnesota
Category: Workers Compensation
Word Count: 406 Words, 2,982 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.mn.gov/WC/PDF/RS05.pdf

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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: