Minnesota > Workers Comp
Notice Of Intention To Claim Reimbursement From Second Injury Fund RS05 - Minnesota
| Notice Of Intention To Claim Reimbursement From Second Injury Fund Form. This is a Minnesota form and can be used in Workers Comp . |
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Mail completed copy to: Notice of Intention to Claim Department of Labor and Industry Special Compensation Fund Reimbursement From the RS 0 5 443 Lafayette Road North St. Paul, MN 55155 Second Injury Fund (651) 284-5045 or Please PRINT OR TYPE your responses DO NOT USE THIS SPACE 1-800-342-5354 (DIAL-DLI) All dates must be entered in MM/DD/YYYY Fax: (651) 284-5733 SOCIAL SECURITY NUMBER 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 1. Nature of registered condition 2. Dates of previous work-related injuries, if any 3. Nature of subsequent injury causing dis ability 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 ST ATUS 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, RECEIV ES WORKERS COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTIN G, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. SPECIAL COMPENSATION FU ND OFFICE USE ONLY Claim APPROVED on ____________________ by _______________________________________________________ Deductibles 26 weeks and $1,000 52 weeks and $2,000; apportionment under M.S. 176.131, subd. 1(a) 52 weeks and $2,000 No deductibles Other: ______________________________________________________________________________________________ Claim REJECTED on ____________________ by _______________________________________________________ Deductibles No Registration found Documentation of automatic registration not attached Notice was filed late Medical reports to support claim not attached Other: ______________________________________________________________________________________________ MN RS05 (8/03) <<<<<<<<<********>>>>>>>>>>>>> 2 VOCATIONAL REHABILITATION AND WORK STATUS REPORT 1. Has the employee returned to work? Yes No Do temporary partial benefits continue to be paid? Yes No 2. Has this case been referred for vocational rehabilitation? Yes (Complete #3) No 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:
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