Montana Workers' Compensation Subsequent Report Form printable pdf download

MONTANA WORKERS’ COMPENSATION SUBSEQUENT REPORT

(1)

(2)

(3)

AGENCY CLAIM NUMBER DN5

EMPLOYEE NAME (LAST, DN43 FIRST, DN44 MI, DN45)

SOCIAL SECURITY NUMBER DN42

(4) DATE OF INJURY DN31

(5) AGREEMENT TO COMPENSATE DN75

(6) DATE DISABILITY BEGAN DN56

(7) PRE-EXISTING

(8) DATE OF

(CHOOSE ONE)

DISABILITY DN69

REPRESENTATION DN76

WITHOUT LIABILITY OR PLACE UNDER 39-71-

608

YES

WITH LIABILITY

(9) RTW QUALIFIER DN71

(CHOOSE ONE)

(10) DATE OF RETURN OR RELEASE TO WORK

DN72

ACTUAL RTW WITHOUT PHYSICAL RESTRICTIONS

RELEASED RTW WITHOUT PHYISICAL RESTRICTIONS

ACTUAL RTW WITH PHYSICAL RESTRICTIONS

RELEASED RTW WITH PHYSICAL RESTRICTIONS

(11) EMPLOYEE DATE OF

(12) NUMBER OF DEPENDENTS

(13) DEPENDENT PAYEE

WIDOW

MOTHER OR FATHER

DEATH DN57

DN55

RELATIONSHIP DN97

WIDOWER

DISABLED CHILD OVER 18

SON OR DAUGHTER

OTHER

(CHOOSE ALL THAT APPLY)

BROTHER OR SISTER

(14) DATE OF MMI DN70

BODY PART CODE DN83

(15) PERMANENT IMPAIRMENT

PERMANENT IMPAIRMENT% DN84

(16) MAINTENANCE TYPE CODE DN2 (CHOOSE

(17) CLAIM STATUS DN73 (CHOOSE ONE)

(18) CLAIM TYPE DN74 (CHOOSE ONE)

ONE)

OPEN

(O)

REOPEN

(R)

INJURY (I)

OCCUPATIONAL DISEASE (Z)

CLOSED (C)

REOPEN/CLOSED (X)

(19) CLAIM ADMINISTRATOR FEIN DN8

(20) CLAIM ADMINISTRATOR NAME DN9

(21) CLAIM ADMINISTRATOR CLAIM NUMBER DN15

(22) PRE-INJURY WEEKLY WAGE DN62

(23) TEMPORARY TOTAL DISABILITY RATE

COMPENSATION PAYMENTS (CUMULATIVE)

(24) LATE

(25) PAYMENT

(27) NET WEEKLY

(28) PAYMENT

(29) PAYMENT

(26) AMOUNT PAID TO

(30) WEEKS PAID

(31) DAYS PAID

REASON CODE

CODE

AMOUNT

START DATE

END DATE

DATE DN86

DN90

DN91

DN77

DN85

DN87

DN88

DN89

BENEFIT ADJUSTMENTS

(Made to weekly corresponding compensation rate)

(32) PAYMENT

(33) BENEFIT

(34) BENEFIT

(35) START

CODE

ADJUSTMENT

ADJUSTMENT WEEKLY

DATE

DN85

CODE

AMOUNT

DN94

DN92

DN93

Weekly Rate - Benefit Adjustment Weekly Amount DN93 = Net Weekly Amount DN87

PAID TO DATE/REDUCED EARNINGS/RECOVERIES (CUMULATIVE)

(36)

(37)

(38)

(39)

(40)

(41)

(42)

(43)

CODE

AMOUNT DN96

CODE

AMOUNT DN96

CODE

AMOUNT DN96

CODE

AMOUNT DN96

300

380

440

830

DN95

840

330

390

450

DN95

350

400

800

DN95

360

420

810

DN95

370

430

820

DN95

ERD-922 (Rev 02-18-10)

Conditional – Mandatory Based on Event

Mandatory – Fully complete

Montana Workers' Compensation Subsequent Report Form

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