Form Mn Pa04 - Permanent Total Disability Agreement
Download a blank fillable Form Mn Pa04 - Permanent Total Disability Agreement in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Mn Pa04 - Permanent Total Disability Agreement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset
Mail or fax completed copy to:
Permanent Total Disability
Department of Labor and Industry
Agreement
Special Compensation Fund
PO Box 64229
P A 0 4
(Effective Only for Dates of Injuries Prior to 10/01/1995)
St. Paul, MN 55164-0229
(651) 284-5045 or 1-800-342-5354
PRINT IN INK or TYPE YOUR RESPONSES
DO NOT USE THIS SPACE
Fax: (651) 284-5731
ALL DATES MUST BE ENTERED in MM/DD/YYYY
WID or SSN
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
Yes
No
since the proposed date of permanent total disability. (see Minn. Rule 5222.0300.A)
4. Date the employee began receiving government disability benefits or government old
Date
age 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
Yes
No
determined in a 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
Yes
No
to 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 audio. To request, call (651) 284-5032
or 1-800-342-5354 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.
MN PA04 (9/15)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal