Notice Of Intention To Claim Reimbursement From The Second Injury Fund
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Department of Labor and Industry
Notice of Intention to Claim
Special Compensation Fund
Reimbursement From the
PO Box 64229
R S 0 5
St. Paul, MN 55164-0229
Second Injury Fund
(651) 284-5045 or 1-800-342-5354
DO NOT USE THIS SPACE
Fax: (651) 215-9099
PRINT IN INK or TYPE YOUR RESPONSES
ALL DATES MUST BE ENTERED in MM/DD/YYYY
WID or SSN
DATE OF INJURY
EMPLOYEE NAME
INSURER/SELF-INSURER
EMPLOYER NAME
INSURER/ ADDRESS
INSURER CLAIM NUMBER
CITY
STATE
ZIP CODE
ATTACH COPY OF ACCEPTED REGISTRATION OR DOCUMENTATION OF AUTOMATIC REGISTRATION
1. Nature of registered condition
2. Dates of previous work-related injuries, if any
3. Nature of subsequent injury causing disability for which reimbursement is being claimed
4. The insurer is claiming that this disability is (check one):
a.
more serious because of the registered condition (substantially greater) M.S. § 176.131, subd. 1.
b.
caused by the registered condition (except for) M.S. § 176.131, subd. 2.
ATTACH MEDICAL REPORTS TO SUPPORT THE ITEM CHECKED ABOVE
COMPLETE THE REHABILITATION AND WORK STATUS REPORT ON THE BACK OF THIS FORM
Name of Preparer
Date
TPA Name
Phone No. (include area code & ext.)
Address
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.
SPECIAL COMPENSATION FUND OFFICE USE ONLY
Claim APPROVED on __________________ by _______________________________________________________________
Deductibles
26 weeks and $1,000
52 weeks and $2,000; apportionment under M.S. § 176.131, subd.1(a)
52 weeks and $2,000
No deductibles
Other: _________________________________________________________________________________________________
Claim REJECTED on __________________ by _______________________________________________________________
Deductibles
No registration found
Documentation of automatic registration not attached
Notice was filed late
Medical reports to support claim not attached
Other: _________________________________________________________________________________________________
(over)
MN RS05 (9/15)
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