Minnesota > Workers Comp
Permanent Total Disability Agreement PA04 - Minnesota
| Permanent Total Disability Agreement Form. This is a Minnesota form and can be used in Workers Comp . |
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Mail completed copy to: Permanent Total Disability Department of Labor and Industry Special Compensation Fund Agreement PA 0 4 443 Lafayette Road North (Effective Only for Dates of Injuries Prior to 10/01/1995) St. Paul, MN 55155 Please PRINT OR TYPE your responses (651) 284-5045 or All dates must be entered in MM/DD/YYYY DO NOT USE THIS SPACE 1-800-342-5354 (DIAL-DLI) Fax: (651) 284-5733 SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE NAME EMPLOYEE ADDRESS CITY STATE ZIP CODE INSURER/SELF-INSURER EMPLOYER NAME INSURER ADDRESS INSURER CLAIM NUMBER CITY STATE ZIP CODE 1. Attach any medical reports pertinent to the issue of permanent total disability whether pro or con, that have not been previously filed with the Workers Compensation Division. (see Minn. Rule 5222.0400, subp. 4) The parties are relying primarily upon medical reports by: Health Care Provider(s) Date of report(s) 2. The status of rehabilitation: Continuing Closed Not assigned Attach rehabilitation reports to support this claim. (see Minn. Rule 5222.0400, subp. 5). 3. Total disability benefits have been paid to the employee without substantial interruption since Yes No the proposed date of permanent total dis ability. (see Minn. Rule 5222.0300.A) 4. Date the employee began receiving governm ent disability benefits or government old age Date benefits: (see Minn. Rule 5222.0300.B) 5. The employee is receiving or will receive supplementary benefits after an offset for Yes No government disability benefits or government old age benefits is taken. (see Minn. Rule 5222.0300.C) 6. Has the issue of permanent total disability for the time period proposed been determined in a Yes No judicial or administrative proceeding? (see Minn. Rule 5222.0300.D) 7. Will the offset provision of M.S. 176.101, subd. 4 result in an overpayment of benefits to Yes No the employee? If yes, explain why there is an overpayment, the amount, and how it will be recovered. 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, 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. MN PA04 (8/03) <<<<<<<<<********>>>>>>>>>>>>> 2 WEEKLY BENEFIT CHANGE ANALYSIS Proposed Effective Dates: Permanent Total Disability $25,000 Offset Date Reached Date Supplementary Benefits Payable Before $25,000 Before PTD Date As of PTD Date * * TTD $ PTD $ * * SSDI $ SSDI $ SB $ SB $ Subtotal $ Subtotal $ OPC $ OPC $ TOTAL $ TOTAL $ After $25,000 SB NOT Payable When SB Payable * * PTD $ PTD $ * * SSDI $ SSDI $ SB $ SB $ Subtotal $ Subtotal $ OPC $ OPC $ TOTAL $ TOTAL $ *enter F for full benefit, R for reduced benefit Workers compensation benefits must be coordinated with most government benefits. When a person is receiving more than one form of benefit, either the government benefit or the workers compensation benefit may be reduced. If you are not currently receiving government benefits, your workers compensation benefits may be affected in the future. After a specific waiting period, supplementary benefits will be paid, if necessary, to assure the employees compensation benefits are not less than 65% of the state-wide average weekly wage. If you have questions call the Special Compensation Fund. KEY PTD - permanent total disability TTD - temporary total disability SB - supplementary benefits OPC - overpayment credit SSDI - social security disability income; include old age, PERA, etc. AGREEMENT Based on the information provided, the insurer/employer and employee agree that the employees total disability is permanent as of ____________________ for purposes of the employer/insur er obtaining reimbursement of supplementary benefits under Minn. Rules 5222.0100 to 5222.1000. All parties understand that a substantial error in the information on this form may be basis to vacate the agreement. Employee Signature Phone Date Employee Attorney Signature (If applicable) Phone Date Claim Representative Signature Phone Date Workers Compensation Division Signature Approved Phone Date Rejected Reason rejected:
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