Annual Claim For Reimbursement From Secondary Injury Fund {AR04}

Annual Claim for Reimbursement from the Second Injury Fund PRINT IN INK or TYPE YOUR RESPONSES ALL DATES MUST BE ENTERED in MM/DD/YYYY A0 R4 FOR SCF USE ONLY WID or SSN EMPLOYEE NAME EMPLOYER NAME DATE OF INJURY INSURER/SELF-INSURER (Reimbursement Payable To) ADDRESS INSURER CLAIM NUMBER CITY STATE ZIP CODE Claim status A. AA. B. First claim for this case First and last claim as a result of full, final and complete settlement Continuing - Attach EVIDENCE of contact with employee during the time period claimed which SUPPORTS ELIGIBILITY for benefits claimed (i.e., status check confirming employee remains disabled, medical and/or rehabilitation reports from the time period claimed, etc.). Final Claim for this case. Reason: 1) Returned to work on: _______________________ 2) Death of employee on: _______________________ ATTACH DEATH CERTIFICATE 3) Closed by settlement 4) Other: Explain: C. Mail or fax completed copy to: In Person: Department of Labor & Industry Special Compensation Fund 443 Lafayette Road N. St. Paul, MN 55155-4301 Mailing Address: Department of Labor & Industry Special Compensation Fund PO Box 64229 St. Paul, MN 55164-0029 Fax: (651) 215-9099 YOU MUST COMPLETE THE BACK SIDE OF THIS FORM. Name of Preparer Company Name (if different from above) Address E-mail address Date Phone No. (include area code & ext.) Fax No. (include area code) 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. (over) MN AR04 (9/15) American LegalNet, Inc. www.FormsWorkFlow.com MEDICAL AND REHABILITATION EXPENSE DETAIL Attach detailed description/itemization of rehabilitation and/or medical expenses. Include the dates of service, dates paid, amounts paid and names of providers. (Computerized printouts are sufficient if they include all required information.) These medical expenses do NOT exceed DO exceed permissible limits set for medical services in Minnesota Rules Chapter 5221. If the medical fee schedule has not been applied to any bills for medical services, ATTACH A COPY OF THE BILL SHOWING THE CPT CODE. DATES for which you are requesting reimbursement 1. a. Medical and rehabilitation expenses claimed this period b. Less deductible to this date of injury SUBTOTAL c. Percent apportioned (Attach proof of apportionment if claiming for the first time) SUBTOTAL d. Lump sum amount to be reimbursed e. TOTAL Medical and Rehabilitation expenses claimed $ % through INDEMNITY EXPENSE DETAIL Complete an Interim Status Report for the period covered by this claim. Transfer the information from the Interim Status Report. DATES for which you are requesting reimbursement 2. a. Temporary Partial Benefits paid Retraining Benefits paid Temporary Total Benefits paid Permanent Total Benefits paid SUBTOTAL b. Less deductible to this date of injury SUBTOTAL c. Percent apportioned (Attach proof of apportionment if claiming for the first time) SUBTOTAL d. Permanent Partial, Impairment Compensation, Economic Recovery claimed (circle type of permanency paid) e. Lump sum to be reimbursed f. TOTAL indemnity reimbursement claimed $ $ % through 3. TOTAL reimbursement claimed (1e + 2f) SPECIAL COMPENSATION FUND USE ONLY Indemnity Amount Approved Medical Amount Approved Amount Adjusted Total Approved Paid by Vendor Number $ $ $ $ Adjustment Code Approved by Date Approved Date Paid Batch Number American LegalNet, Inc. www.FormsWorkFlow.com