Montana Workers' Compensation Subsequent Report Form

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Montana Workers' Compensation Subsequent Report
(1) CLAIMANT NAME
(2) SOCIAL SECURITY NUMBER
(3)DATE OF INJURY
( Last, First, , M. I. )
CCYYMMDD
(4)AGREEMENT TO COMPENSATE
(5) DATE DISABILITY BEGAN
(6) PRE-EXISTING DISABILITY
(7) DATE OF
(CHOOSE ONE)
DN 56
REPRESENTATION
WITHOUT LIABILITY OR PLACE UNDER 39-71-608 (W)
YES
NO
CCYYMMDD
ACCEPTED
(L)
(8) RTW QUALIFIER
(9) DATE OF RETURN OR RELEASE TO WORK
CCYYMMDD
1
RTW WITHOUT RESTRICTIONS 5
RELEASED RTW WITHOUT RESTRICTIONS
(CHOOSE ONE)
2
RTW WITH RESTRICTIONS 6
RELEASED RTW WITH RESTRICTIONS
2
WIDOW
6
MOTHER OR FATHER
(10) DATE OF DEATH
(11) NUMBER OF DEPENDENTS
(12) DEATH DEPENDENT
PAYEE RELATIONSHIP
3
WIDOWER
7
INVALID CHILD OVER 18
(CHOOSE ALL THAT APPLY)
CCYYMMDD
4
SON OR DAUGHTER NO.__
9
OTHER
5
BROTHER OR SISTER NO.__
(13) DATE OF MMI
BODY PART CODE
(14) PERMANENT IMPAIRMENT
%
CCYYMMDD
PERMANENT IMPAIRMENT %
15) DATE PROCESSED
(16) MAINTENANCE TYPE CODE
(17) MAINTENANCE TYPE CODE DATE
(CHOOSE ONE)
CCYYMMDD
IP
SA
FN
CO
UR
CCYYMMDD
(18) CLAIM STATUS
19) THIRD PARTY ADMINISTRATOR FEIN
(20) THIRD PARTY ADMINISTRATOR NAME
DN 9
(CHOOSE ONE)
(
OPEN (O)
REOPEN (R)
CLOSED (C)
REOPEN/CLOSE (X)
(21) CLAIM TYPE
22) Claim ADMINISTRATOR CARRIER CLAIM NUMBER
DN15
(CHOOSE ONE)
(
INJURY (I)
OCCUPATIONAL DISEASE
23) PRE INJURY WEEKLY WAGE
(24) CALCULATED WEEKLY COMPENSATION AMOUNT (TTD rate)
(
$
COMPENSATION PAYMENTS
(26) LATE REASON
(27) BENEFIT
(28) AMOUNT
(29) NET WEEKLY
(30) PAYMENT
(31) PAYMENT
(32) WEEKS
(33) DAYS PAID
CODE
TYPE
PAID
AMOUNT
COVERS PERIOD
COVERS PERIOD
PAID
TO DATE
START DATE
THROUGH
CCYYMMDD
DATE
CCYYMMDD
$
$
$
$
$
$
$
$
$
$
BENEFIT ADJUSTMENTS (made to weekly comp rate)
(34) BENEFIT ADJUSTMENT
(35) BENEFIT AMOUNT
(36) START DATE
(34) BENEFIT ADJUSTMENT
(35) BENEFIT AMOUNT
(36) START DATE
CCYYMMDD
CCYYMMDD
CODE
WEEKLY ADJUSTMENT
CODE
WEEKLY ADJUSTMENT
/
/
Num.
Alpha
Num.
Alpha
DN93
/
$
/
$
/
$
/
$
/
$
/
$
OTHER BENEFIT TYPE CODES/REDUCED EARNINGS AMOUNT
(37)
(38)
(37)
(38)
(37)
(38)
(37)
(38)
Code
Amount
Code
Amount
Code
Amount
Code
Amount
300
$
370
$
420
$
810
$
330
$
380
$
820
$
350
$
390
$
830
$
360
$
400
$
840
$
ERD-992(rev. 4-2000) LW

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