North Dakota > Workers Comp
Injured Worker Status Report SFN 10012 - North Dakota
| Injured Worker Status Report Form. This is a North Dakota form and can be used in Workers Comp . |
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INJURED WORKER STATUS REPORT CLAIMS DIVISION SFN 7871 (05/2008) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Injured Worker's Name: Injured Worker's Address: Date: Claim Number: Before any further wage-loss benefits may be paid, you must answer all of the following questions, sign and mail the status report back to Workforce Safety & Insurance (WSI) in the envelope provided. Failure to return this report before the date of your next wage-loss benefit payment date will result in suspension of the wage-loss benefit. You must accurately report work of any kind (voluntary, part-time, or full-time) that you do, whether you are paid or not. You must report any money received from work, activities, or services of any kind, regardless of profit or loss. Failure to report any type of work, wages, or other money received, may be a violation of law. "Work" is defined as physical or mental effort exerted to do or make something for any amount of remuneration, or physical or mental effort exerted to do or make something that a reasonable person would consider commonly done or made for remuneration. 1. During this calendar year, have you gone back to work, or done any type of work, whether for pay or not, that you have not already disclosed on a prior status report? Yes No If yes, please answer the following: A. Type of work performed B. Dates worked C. Name, address, telephone number of person or business you worked for 2. During this calendar year, have you received money from any source other than WSI that you have not already disclosed on a prior status report? Yes No If yes, include with this status report any related pay stubs or pay records, and check the source(s) that apply: Business Venture Farming Hobby Ranching Self-employment Social Security Unemployment Other, please explain: If yes, list name, address, and telephone number of money source, date and amount of money received. 3. 4. If approved for school and/or retraining, are you enrolled and attending your class(es)? Give the date of your last medical appointment and the name of the doctor: Yes No 5. Give the date and time of your next medical appointment and the name of the doctor 6. Has your dependency or marital status changed? If yes, how: Yes No 7. Has your address changed (see above) If yes, please provide current address: Yes No I understand the nature of the questions asked in this status report and further understand that providing false information may be a crime, punishable by substantial fines and imprisonment, or both. By my signature below, I declare the above statements to be complete, true and accurate. Injured Worker's Signature FL214 Date Telephone Number If new telephone number, check box American LegalNet, Inc. www.FormsWorkFlow.com
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