Form Mn Ac03 - Annual Claim For Reimbursement Of Supplementary Benefits

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Annual Claim for Reimbursement of
Reset
Supplementary Benefits
A C 0 3
FOR SCF USE ONLY
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 (Reimbursement Payable To)
EMPLOYER NAME
ADDRESS
INSURER CLAIM NUMBER
CITY
STATE
ZIP CODE
Claim status
A.
First claim for this case
AA.
First and last claim as a result of full, final and complete settlement
B.
Continuing - Attach EVIDENCE of contact with employee during the time period claimed which SUPPORTS
ELIGIBILITY for benefits claimed (i.e., status check confirming employee remains disabled, medical
and/or rehabilitation reports from the time period claimed, etc.).
C.
Final Claim for this case. Reason:
1) Returned to work on: _______________________
2) Death of employee on: _______________________ ATTACH DEATH CERTIFICATE
3) Closed by settlement
Explain:
4) Other:
Mail or fax completed copy to:
In Person:
Mailing Address:
Fax:
Department of Labor & Industry
Department of Labor & Industry
(651) 215-9099
Special Compensation Fund
Special Compensation Fund
443 Lafayette Road N.
PO Box 64229
St. Paul, MN 55155-4301
St. Paul, MN 55164-0029
YOU MUST COMPLETE THE BACK SIDE OF THIS FORM.
Name of Preparer
E-mail address
Date
Company Name (if different from above)
Phone No. (include area code & ext.)
Address
Fax No. (include area code)
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.
(over)
MN AC03 (9/15)

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