Interim Status Report {IS03}

Interim Status Report Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. I S 0 3 DO NOT USE THIS SPACESOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE EMPLOYER EMPLOYEE ADDRESS CITY STATE ZIP CODE INSURER CLAIM NUMBER THIS FORM MUST BE SUBMITTED ANNUALLY ON ALL CLAIMS OF CONTINUING DISABILITY, SUPPLEMENTARY OR DEPENDENCY BENEFITS. Please provide additional information on the Benefit Addendum (BA01). FROM THROUGH WEEKS RATE TOTAL Temporary Total* Permanent Total* Balance Carried Forward TOTAL: Temporary Partial Balance Carried Forward TOTAL: Permanent Partial Permanent Partial Disability % Injuries on or after 10/01/1995 Impairment Compensation (injuries 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) [part of body] (injuries before 01/01/1984) TOTAL: MN IS03 (7/01) -OVER- <<<<<<<<<********>>>>>>>>>>>>> 2 FROM THROUGH WEEKS RATE TOTALRetraining Benefits Balance Carried Forward TOTAL: Dependency Benefits Balance Carried Forward TOTAL: Supplementary Benefits* Balance Carried Forward TOTAL: Social Security Benefits or Other Government Benefits* Retirement Disability Name of Program: FROM THROUGH PER WEEK*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement ofSupplementary Benefits. Attorney Fees Paid Interest Paid Lump Sum Payment Attorney Fees Still Withheld Under Award or Order Attorney Fees Total Compensation Paid to Em ployee Reimbursed to Employee Total Dependency Benefits Paid M.S. 176.081, subd. 7 (Please attach copy of worksheet) INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME ADDRESS AREA CODE PHONE NUMBER CITY STATE ZIP CODE DATE SERVED This material can be made available in different forms, such as large print, Braille or on a tape, if you call (651) 284-5030 o r1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. 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.