Section 7 Forms

Overview of Forms
Most of the forms that the department has created are required by statute and rule and are necessary to all of the users of the workers’ compensation system. They are kept as up-to-date and user-friendly as possible. All parties must use the required forms to report information, including payments made on claims. The department uses the information to verify the accuracy and timeliness of payments, and for statistical purposes. Besides the obvious data (compensation rate, periods of lost time, etc.), the forms include instructions to the employee that are extremely important. For instance, the forms tell employees about their time limits for requesting a discontinuance conference or the statute of limitations on contesting a primary denial of liability. The timely filing of these forms is important for several reasons: • • • • Filing of the FROI starts the statute of limitations. Employees are informed of their rights and benefits quickly. Parties will avoid getting requests from the department for additional claim information. Parties can avoid penalties for late filing.

Note: If a claim does not involve any claimed disability beyond the waiting period and doesn’t include possible PPD, the statute does NOT require that it be reported to the department. Requirements for filing subsequent documents apply to this type of claim ONLY if the FROI has already been (perhaps mistakenly) sent to the department.

First Report of Injury (FROI)
The FROI is the reporting document for all work-related injury claims. It provides basic information necessary to start the claim. Deaths and serious injuries must be reported to the department within 48 hours. This can be done via telephone, facsimile, or electronic transmission, to be followed by the FROI. For all other injuries, where claimed disability exceeds three calendar days, the employer must get the FROI to their insurance company within 10 days of the first day of disability or the date they were aware of disability, whichever is later. Likewise, the insurance company must file the FROI with the department within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later. For self-insured employers, the FROI must be filed with the department within 14 days of the first day of disability or the date the employer was aware of
Basic Adjusters’ Training Guide MN Department of Labor and Industry July 2007 7-1

Forms

disability, whichever is later. The employee must be given a copy of the FROI along with the employee information sheet. Employees are not responsible for completing the FROI. The form should be completed accurately, completely, legibly, and timely by the employer. Again, it is very important that the FROI be submitted timely to avoid unnecessary penalties. More information regarding penalties for late filing of the FROI can be found in the Section 5.

July 2007 7-2

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4305 (651) 284-5030

First Report of Injury
See Instructions on Reverse Side PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. 2. OSHA Case #
F R 0 1

1. EMPLOYEE SOCIAL SECURITY #

DO NOT USE THIS SPACE
5. Time employee began work on date of injury 7. Gender 8. Marital Status 10. Home phone # M F

3. DATE OF CLAIMED INJURY 4. Time of injury 6. EMPLOYEE Name (last, first, middle)

am pm

am pm Married Unmarried 11. Date of birth

9. Home Address

City

State

Zip Code

12. Occupation

13. Regular department

14. Date hired

15. Average weekly wage

16. Rate per hour

17. Hours per day

18. Days per week

19. Employment Status 21. Apprentice

Full time Seasonal

Part time Volunteer No

20. Weekly value of:

Meals

Lodging

2 Income

nd

Yes

22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: “Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”

23. What was the injury or illness (include the part(s) of body)? Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.

25. Did injury occur on employer’s premises? Yes No If no, indicate name and address of place of occurrence

26. Date of first day of any lost time

27. Employer paid for lost time on day of injury (DOI) Yes No No lost time on DOI

28. Date employer notified of injury

29. Date employer notified of lost time

30. Return to work date

31. Date of death

32. TREATING PHYSICIAN (name, address, and phone)

33. HOSPITAL/CLINIC (name and address) (if any)

34. Emergency Room Visit Yes 35. Overnight in-patient Yes No No

36. EMPLOYER Legal name

37. EMPLOYER DBA name (if different)

38. Mailing address

39. Employer FEIN

40. Unemployment ID#

City

State

Zip Code

41. Employer’s contact name and phone #

42. Physical address (if different)

43. Witness (name and phone)

City

State

Zip Code

44. NAICS code

45. Date form completed

46. INSURER name

51. CLAIMS ADMIN COMPANY (CA) name (check one)

Insurer TPA

47. Insured legal name

52. CA address

48. Policy # or self-insured certificate #

City

State

Zip Code

49. Insurer FEIN

50. Date insurer received notice

53. CA FEIN

54. Claim #

MN FR01 (02/06)

Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)

GENERAL INSTRUCTIONS TO THE EMPLOYER Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a workrelated injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary. If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-2845731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence. Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employee’s local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department’s web site at www.doli.state.mn.us. Employees are not responsible for completing this form. SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM • • • • • • • • • • • Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301. Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved. Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. Item 28: Fill in the date you first became aware of the injury or illness. Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury. Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to work, fill in the date and notify your insurer if the employee misses time due to this injury after that date. Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on Employer ID Number under Business. Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are both assigned by the Minnesota Unemployment Insurance Program (651-296-6141). Items 46-54: Your insurer or claims administrator will complete this information. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn. Stat. § 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department. • Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public selfinsured company or group. • Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number. • Item 49: Fill in the insurer’s Federal Employment ID number (FEIN) number. • Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the “Insurer” or “TPA” box. • Item 53-54: Fill in the claims administrator’s FEIN and claim number. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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.

Minnesota workers’ compensation system employee information sheet
What does workers’ compensation pay for?
• Medical care for the work injury, as long as it is reasonable and necessary • Wage-loss benefits for part of your lost income (there is a three-calendar-day waiting period before these benefits start) • Benefits for permanent damage or loss of function of a body part • Benefits to your spouse and/or dependents if you die of a work injury • Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer

How are workers’ compensation benefits paid?
Your workers’ compensation benefits are paid by an insurance company or your employer, if your employer is selfinsured. State law sets the benefit levels. Please note: pursuant to statute, the insurer can obtain medical information specific to your work injury without your authorization. If the insurer accepts your claim for wage loss benefits and you have been disabled for more than three calendar days: • The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating your claim is accepted. • The insurer must start paying wage-loss benefits within 14 days of the date your employer knows about your work injury and lost wages. The insurer must pay benefits on time. Wage-loss benefits are paid at the same intervals as your work paychecks. If the insurer denies your claim for wage loss benefits: • The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating it is denying primary liability for your claim. The form must clearly explain the facts and reasons why the insurer believes your injury or illness did not result from your work. • If you disagree with the denial, you should talk with the insurance claims adjuster who is handling your claim. Your employer’s insurance company can answer most questions about your claim. Insurer name: Phone :

• If you are not satisfied with the response you receive from the insurer and still disagree with the denial, you should contact the Department of Labor and Industry at one of the numbers listed below to see what to do next. If you have other questions or need more help, call the Minnesota Department of Labor and Industry Workers’ Compensation Hotline: Twin Cities and Southern Minnesota: Duluth and Northern Minnesota: (651) 284-5005 or 1-800-342-5354; TTY (651) 297-4198 (218) 733-7810 or 1-800-365-4584

Your call will be answered by experienced workers’ compensation specialists, who will provide instant, accurate information and assistance. Additional workers’ compensation information is available on the department’s Web site at: www.doli.state.mn.us
Your employer is required by law to give you this information. This material can be made available in different formats, such as large print, Braille or on audiotape, by calling the numbers printed above.
Updated April 2003 (format-change only). This form may be copied or reproduced electronically. Do not file this form with the department.

Forms

Notice of Insurer’s Primary Liability Determination (NOPLD)
Time Requirements
For injuries with claimed disability extending more than three calendar days, the insurer must make a determination regarding liability within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later. This means insurer must pay or deny a claim within 14 days. Failure to pay or deny within 14 days can result in penalties. More information regarding penalties for late payments and late denials are discussed in the Section 5. The NOPLD form is used to notify the employee (or heirs/dependents of an employee), the employer, and the department of the insurer’s position regarding primary liability on the claim, including specific details of the accepted or denied claim. It is important to remember that this form could be completed several different times on the same claim to reflect changes in the insurer’s position or changes in the specific details of the claim. These subsequent filings of the form would be considered amended NOPLD forms. In addition, this form outlines the employee’s rights and responsibilities. The department uses the information supplied on the form to review for timely and accurate compliance with the statutes and rules, for statistical data, and to publish a legislatively mandated annual report about the promptness of insurers’ first actions on claims.

Reasons to File
The NOPLD must be filed at least once whenever a FROI has been filed - NO EXCEPTIONS. It is used to report: • • • the first payment of wage loss benefits; acceptance of liability, but denial of initial wage loss benefits; a denial of primary liability.

The NOPLD can be required more than once for some claims. For instance: • • When the insurer initially denies primary liability, but later accepts liability. When the insurer initially accepts a claim and pays wage loss benefits, but later denies primary liability within 60 days pursuant to Minnesota Statutes §176.221, Subd. 1. When the insurer accepts a claim on which there are no wage loss benefits initially paid, but later pays wage loss benefits voluntarily.

Note: This form is not to be used to report a resumption of wage-loss payments after they have been previously discontinued. The Notice of Benefit Reinstatement form is used for this purpose.
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Forms

When to File
• • When making payment, the form should be filed at the time the initial payment is made. When denying primary liability or denying partial liability (for the initial claimed disability), the form must be filed within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later.

How to Complete the Form
The boxes (in the upper left-hand corner on the front of the form) containing claim identifying information must be fully completed each time the form is filed. The boxes containing the dates of lost time, notice, and initial return to work, and the average weekly wage must be completed, if applicable, each time the form is filed, regardless of the liability determination. Note: If the employee initially returns to work before the insurer sends this form to the department, (e.g. initial claimed disability was within the waiting period) and there is a subsequent period of disability, they must fill in the first date of the period of subsequent disability and the date the employer was notified of this new period. • • Check Box 1, 2, or 3. Only one box should be checked. Check Box 1 to report acceptance of liability for the claim and payment wage loss benefits. Complete all fields in this section. • Check any additional box in this section as needed (i.e. full wage continuation, fatality, etc.).

Note: If the insurer indicates that the employer paid “full wages,” they must still file a Notice of Intention to Discontinue (NOID) form at the appropriate time showing the date of return to work or other reason for discontinuance, and the payment data on the back of the form as required by Minnesota Statutes §176.221, Subd. 9 • Check Box 2 to report acceptance of liability for the claim, but without payment of wage loss benefits (a partial denial). Also check one of the boxes, “A”, “B”, or “C”. • Choose “A” if the employee did not have any days of claimed disability or if the claimed disability did not exceed the waiting period. To help clarify possible waiting period questions, explain employee’s work schedule if not Monday through Friday. Choose “B” if this is a TPD-only claim and are accepting liability but are unable to make payment because there is not sufficient wage loss verification to determine the any amount due. The NOPLD must be filed again at the time TPD payment is made.
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Choose “C” to deny payment for the claimed disability for any other reason. The specific facts forming and the legal basis for the reason for the denial must be stated clearly in the space provided.

Check Box 3 to report a denial of primary liability for the claim. Specify whether it is the injury or the death (or both) that is being denied. The specific facts and legal basis for the reason for the denial must be stated clearly in the space provided. Fill in the claim representative’s name and phone number, and the date the form is being served on the parties. No signature is required, but it is important to note that the name and phone number, including extension, must be for the person who actually made the primary liability determination, not for the person who is filling out the form (if different).

Basic Adjusters’ Training Guide MN Department of Labor and Industry

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July 2007 7-6

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Notice of Insurer’s Primary Liability Determination
See instructions on reverse side. Enter dates in MM/DD/YYYY format.
N L 0 1

Amended
SOCIAL SECURITY NUMBER DATE OF INJURY DATE OF DEATH (if applicable)

DO NOT USE THIS SPACE

EMPLOYEE

EMPLOYER

INSURER/SELF-INSURER/TPA

INSURER CLAIM NUMBER

First date of lost time

Date employer notified of this lost time

Initial date of return to work

Average weekly wage at date of injury

If the initial return to work was followed by a new period of lost time, complete the following information: First date of new Date employer period of lost time: ____________________________________________ notified of this lost time: ________________________________

1. Your claim is ACCEPTED and wage loss benefits will be paid.
Benefit type: Date of payment Temporary Total (TTD) Amount of payment Temporary Partial (TPD) Permanent Total (PTD) Dependency (DEP) Compensation rate

Time period covered with this payment Date from Date through __

Any ongoing payments will be made on ____________________ (day of week) at________________________(weekly, biweekly, etc.) intervals.

Full wage continuation by the employer under M.S. § 176.221, subd. 9.
Check all that apply

TPD payment made according to the wage loss verification received by the insurer on __________________________(date). Fatality with dependents. Payment is being made according to dependent information, which must be ATTACHED. Fatality with no dependents. Payment is being made to the estate or the Special Compensation Fund.

2. Your claim is ACCEPTED. However, wage loss benefits will not be paid at this time for the following reason: A. Injury did not cause lost time from work beyond the three calendar day waiting period. If employee’s work schedule is not Monday through Friday, explain: _______________________________________________________________________
Check only one

B. Verification of reduced wages for TPD has not been received from the employee or employer. C. Other reason (include legal and factual basis):

3. Primary liability is DENIED for the claimed work related Reason for denial (include legal and factual basis):

injury and/or

death. (Check one or both)

NAME OF THE PERSON MAKING THIS DETERMINATION (print)

PHONE NUMBER

EXTENSION

DATE SERVED (must be completed)

MN NL01 (12/05)

Distribution: Workers’ Compensation Division, Employer, Insurer, Employee/Heirs and Dependents

INSTRUCTIONS TO EMPLOYEE/HEIRS AND DEPENDENTS PLEASE KEEP A COPY OF THIS NOTICE FOR YOUR RECORDS General Information This liability determination is the opinion of the insurer. If the claim has been denied, this opinion may not be final. If you have questions about any of the information on this form, you should first contact the person making this determination (see name and phone number on the front side of this form). If you still have questions, contact the Department of Labor and Industry (DLI), Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you (listed below). For the hearing impaired, please call our Telecommunication Device for the Deaf (TDD) at (651) 297-4198. If there are problems with your claim, there are several options available to resolve them informally. Minnesota Department of Labor and Industry 5 North Third Avenue West, Suite 400 Duluth, MN 55802-1614 Telephone: (218) 733-7810 1-800-365-4584 Minnesota Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155-4301 Telephone: (651) 284-5030 1-800-342-5354

Time Limitations If the injury claim has been denied, you may lose your right to benefits if you do not commence legal proceedings within three years after your employer/insurer filed a written report of your claimed injury with DLI, not to exceed six years after the date of the claimed injury. If you have an occupational disease, you have three years to begin legal proceedings from the date you learned that the cause of the disease might be work related and the disease first caused disability. If the death claim has been denied, you may lose your right to benefits if you do not commence legal proceedings within three years after the employer/insurer filed the written notice of death with DLI, except that: 1) For claims where the employer/insurer did not pay benefits for the injury, commencement of legal proceedings cannot exceed six years from the date of injury resulting in the death. 2) For claims where the employer/insurer did pay benefits for the injury, commencement of legal proceedings cannot exceed six years from the date of death. In very rare circumstances, there may be exceptions to the time limits noted above. Vocational Rehabilitation If the insurer is denying primary liability for your claim and you disagree, cannot return to your former employment, and would like vocational rehabilitation assistance, contact DLI, Vocational Rehabilitation Unit at (651) 284-5038. Instructions to Insurer/Claims Administrator 1. If the claim is a fatality with dependents and payment is being made, attach dependent information. 2. The reason for a denial must be clear and specific, and state a legal and factual basis in language which is easily understood. If the reason for a denial is based on medical information, attach medical reports or summary of any health care provider contacts that support your reason for denial. 3. This form may be filed more than once if your liability determination changes. (Examples: when you initially deny primary liability, but later accept liability; when you initially accept a claim and pay wage loss benefits, but later deny primary liability within 60 days pursuant to M.S. § 176.221, subd 1; when you accept liability, but are unable to pay TPD benefits until verification of wage loss is received, but later issue the first TPD check.) 4. If you file this form more than once, check the Amended box in the upper left-hand corner for each subsequent filing. 5. Do not use this form to reinstate benefits. Use the Notice of Benefit Reinstatement (NOBR) form. 6. If you indicate that the employer paid “full wage,” you must also file a Notice of Intention to Discontinue (NOID) at the appropriate time showing the date of return to work or other reason for discontinuance and the payment data on the back of the form as required by M.S. § 176.221, subd. 9. 7. The date served must be completed each time you file this form. 8. The boxes (in the upper left-hand corner on the front of the form) containing claim identifying information must be fully completed each time you file the form. The boxes containing the dates of lost time, notice, and initial return to work, and the average weekly wage must also be completed, if applicable, each time you file the form, regardless of your liability determination. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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.

Forms

Notice of Intention to Discontinue Workers’ Compensation Benefits (NOID)
The purpose of the NOID form is to notify the employee of a reduction or discontinuance of wage-loss benefits, the amount of benefits paid on the claim, and their right to an administrative conference. It must be served on parties as noted on the form. The department uses the form to review for compliance with the statute and rules, to verify calculation of benefits, and for statistical data. Always attach an “Employee’s Request for Administrative Conference” form to the employee’s copy.

Reasons to File
To discontinue or reduce TTD, TPD, or PTD: 1) 2) 3) when the employee returns to work at full wage; when the employee returns to work at reduced wage; or for reasons other than a return to work.

When to File
• • Within 14 days of the date the insurer receives notice that the employee has returned to work (# 1 or 2 above). At the time of discontinuance for reasons other than return to work (#3 above). This includes situations where the insurer is discontinuing benefits when they are denying primary liability and it is more than 60 days from the first day of disability or the date the employer was aware of disability, whichever is later.

Note: In most situations, payment must be made through the date of service of the NOID when reason #3 is being used. Statutory Language 176.238 Notice of Discontinuance of Compensation. (1995) Subd. 2. Continuance of employer’s liability; suspension. (a) Discontinuance because of return to work. If the reason for the discontinuance is that the employee has returned to work, temporary total compensation may be discontinued effective the day the employee returned to work. Written notice shall be served on the employee and filed with the division within 14 days of the date the insurer or self-insured employer has notice that the employee has returned to work.

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(b) Discontinuance for reasons other than return to work. If the reason for the discontinuance is for other than that the employee has returned to work, the liability of the employer to make payments of compensation continues until the copy of the notice and reports have been filed with the division. When the division has received a copy of the notice of discontinuance, the statement of facts and available medical reports, the duty of the employer to pay compensation is suspended, except as provided in the following subdivisions and in section 176.239. 176.239 Administrative Decision Concerning Discontinuance of Compensation. (1995) Subd. 3. Payment through date of discontinuance conference. If a notice of discontinuance has been served and filed due to the employee’s return to work, and the employee requests a conference, the employer is not obligated to reinstate or otherwise pay temporary total, temporary partial, or permanent total compensation unless so ordered by the commissioner. When an administrative conference is conducted under circumstances in which the employee has not returned to work, compensation shall be paid through the date of the administrative conference unless: (a) the employee has returned to work since the notice was filed; (b) the employee fails to appear at the scheduled administrative conference; or (c) due to unusual circumstances or pursuant to the rules of the division, the commissioner orders otherwise.

How to Complete the Form
Front Page • • Check one box for type of benefit being discontinued (TTD, TPD, or PTD). Check one box for reason for discontinuance. • • • #1 for return to work at full wage #2 for return to work at reduced wage #3 other - supply specific reason and supporting documentation

Back Page • TTD/PTD, TPD, and Retraining benefits: • • Use the format provided on the form — from, through, weeks, rate, total. Each period of TTD/PTD should be listed separately on the form (or an attached worksheet if there is not enough room on the form). A break in continuous dates of TTD/PTD or a change in the weekly payment rate constitutes a start of a separate period of disability.
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Each period of TPD should be listed separately on the form (or an attached worksheet if there is not enough room on the form). A break in continuous dates of TPD constitutes a start of a separate period of disability.

Permanent Partial Disability: • • Enter the percent of PPD. Check the appropriate box for the date of injury and type of benefit being paid - PPD, IC, or ERC. Enter the weeks, rate if applicable, and total.

• •

Attorney Fee Expenses: • Enter the amounts on the appropriate lines.

Note: When withheld fees are paid, remove them from the “withheld” line. • Totals: • Enter the amounts on the appropriate lines.

Note: The starred items on the form should not be shown with attorneys fees deducted from the totals. Benefit totals shown on the form for these items should always include amounts withheld or paid for attorney fees. • Fill in the claim representative’s name and phone number, and the date the form is being served on the parties. No signature is required.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

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July 2007 7-10

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Notice of Intention to Discontinue Workers’ Compensation Benefits
Enter dates in MM/DD/YYYY format.

N D 0 1

DO NOT USE THIS SPACE DATE OF INJURY EMPLOYER

SOCIAL SECURITY NUMBER EMPLOYEE

EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

INSURER CLAIM NUMBER

Your benefits for (check one) TEMPORARY TOTAL TEMPORARY PARTIAL disability are being discontinued for one of the following reasons: 1. 2. You have returned to work on You have returned to work on Temporary partial between your wage of 3. will $ will not

PERMANENT TOTAL

(date) at full wage. (date) at reduced hours or wages. be paid. Temporary partial is usually based on the difference at the time of the injury and your current weekly wage. (date)

Reasons other than return to work. Payment will be made through Give reasons and facts below. (Appropriate medical reports must be attached).

Reasonable medical expenses and any permanent partial disability due will still be paid, unless your claim has been denied. INSTRUCTIONS TO EMPLOYEE – THIS REQUIRES YOUR IMMEDIATE ATTENTION You are responsible for reviewing this form to make sure that you have been properly paid the benefits due you. YOU DO NOT NEED TO TAKE ANY ACTION IF YOU BELIEVE THAT YOU HAVE RECEIVED ALL BENEFITS DUE OR THAT THE REDUCTION OF BENEFITS IS PROPER. If Box 1 or 2 is checked above and you believe that your benefits should be reinstated due to an occurrence during the initial 14 calendar days after your return to work, you may request a conference. Your request must be received by the Workers’ Compensation Division within 30 calendar days after the date that you returned to work. If Box 3 is checked above and you think the reason for stopping your benefits is incorrect, or you disagree with the proposed discontinuance, you may request a conference. Your request must be received within 12 calendar days after this notice is received by the Workers’ Compensation Division. TO REQUEST A CONFERENCE, YOU MUST MAIL OR DELIVER THE ATTACHED FORM TO THE WORKERS’ COMPENSATION DIVISION SO THAT IT IS RECEIVED WITHIN THE ABOVE TIME LIMITS. TELEPHONE REQUESTS WILL ALSO BE ACCEPTED AT (612) 349-2513 OR 1-800-342-5354. The conference will be scheduled within 10 calendar days of the date your request is received by the Division. You, your employer, and the insurer will be invited to attend. You are not required to bring an attorney, but may bring one if you wish. You should bring to the conference any current reports and return-to-work restrictions, if available. You may instead file an Objection to Discontinuance with the Division. This is a formal procedure before a compensation judge which takes longer than the administrative conference process and usually requires an attorney. If you do this, your benefits will stop on the date stated in this notice and will not be paid during the time you wait for the hearing.

MN ND01 (11/05)

(over)

If the insurer is denying primary liability for your claim and you disagree with the denial, cannot return to your former employment and would like vocational rehabilitation assistance, contact the Department of Labor and Industry, Vocational Rehabilitation Unit at (651) 284-5038. If you have questions about your benefits, you should first contact the claim representative whose telephone number is at the bottom of the page. Be sure to provide that person with any additional information you have to support your claim. If you still have questions, contact the Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you. Minnesota Department of Labor and Industry 5 North Third Avenue West, Suite 400 443 Lafayette Road North Duluth, MN 55802-1614 St. Paul, MN 55155-4301 Telephone: (218) 733-7810 Telephone: (651) 284-5030 1-800-365-4584 1-800-342-5354 This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

THE FOLLOWING BENEFITS HAVE BEEN PAID Temporary Total Disability or Permanent Total Disability

FROM

THROUGH

WEEKS

RATE

*TOTAL

Benefit Addendum Attached Temporary Partial Disability Retraining Benefits Permanent Partial Disability ___________% Injuries on or after 10/01/95 Impairment Compensation (injuries 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) _______________________ [part of body] (injuries before 01/01/1984) Attorney Fees/Expenses M.S. 176.081, subd. 1 & 3 Paid M.S. 176.081, subd. 1 & 3 Still Withheld Heaton Fees Paid Roraff Fees Paid M.S. 176.191 Paid Other Fees Paid Costs & Disbursements Paid INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME Benefit Totals *Lump sum Payment Under Award or Order Attorney Fees Reimbursed to Employee (M.S. 176.081, subd. 7) Interest Paid *TOTAL COMPENSATION PAID *Total Supplementary Benefits Total Medical Expenses Paid to Date

ADDRESS

PHONE NUMBER (include area code)

CITY

STATE

ZIP CODE

DATE SERVED ON EMPLOYEE

DATE SERVED ON ATTORNEY

*Include attorney fees in these totals.

Distribution: Workers’ Compensation Division, Employer, Employee, Insurer

Employee’s Request for Administrative Conference Minn. Stat. § 176.239, subd. 2
PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format.

E Q

0 5

DO NOT USE THIS SPACE DATE OF INJURY

SOCIAL SECURITY NUMBER

EMPLOYEE

EMPLOYER

EMPLOYEE ADDRESS

THIS REQUIRES YOUR IMMEDIATE ATTENTION
STATE ZIP CODE
Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

CITY

INSURER CLAIM NUMBER

INSURER/SELF-INSURER/TPA

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.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. INSTRUCTIONS TO EMPLOYEE

DO NOT COMPLETE THIS FORM IF YOU AGREE THAT YOUR WEEKLY WORKERS’ COMPENSATION BENEFITS MAY BE STOPPED OR CHANGED. HOWEVER, IF YOU DISAGREE THAT YOUR BENEFITS MAY BE STOPPED OR CHANGED, YOU MAY BE ENTITLED TO AN ADMINISTRATIVE CONFERENCE. At the conference, a decision can be made about your right to further weekly benefits. TO REQUEST A CONFERENCE, MAIL OR DELIVER THIS COMPLETED FORM TO: DEPARTMENT OF LABOR AND INDUSTRY WORKERS’ COMPENSATION DIVISION 443 LAFAYETTE ROAD NORTH ST PAUL, MN 55155-4301 Requests will also be accepted by telephone. Call (612) 349-2513 or 1-800-342-5354 TIME LIMIT TO REQUEST A CONFERENCE IF BOX 1 OR 2 is checked on the Notice of Intention to Discontinue Workers’ Compensation Benefits, your request for a conference must be received by the Workers’ Compensation Division WITHIN 30 DAYS AFTER YOU RETURNED TO WORK. IF BOX 3 is checked on the Notice of Intention to Discontinue Workers’ Compensation Benefits, your request for a conference must be received WITHIN 12 DAYS AFTER A COPY OF THE NOTICE OF INTENTION TO DISCONTINUE WORKERS’ COMPENSATION BENEFITS IS RECEIVED BY THE WORKERS’ COMPENSATION DIVISION. EMPLOYEE’S REQUEST FOR ADMINISTRATIVE CONFERENCE 1. 2. BOX (check one) 1 2 3 is checked on the Notice of Intention to Discontinue Workers’ Compensation Benefits.

My weekly benefits should not be changed/stopped because:

(attach separate sheet if more room is needed)

EMPLOYEE SIGNATURE

EMPLOYEE PHONE # (include area code)

DATE

ATTORNEY (if you have one)

ATTORNEY #

ATTORNEY PHONE # (include area code)

QRC (if you have one)

MN EQ05 (12/05)

QUESTIONS: Call (651) 284-5032 Toll free within Minnesota 1-800-342-5354

ASK FOR BENEFIT MANAGEMENT AND RESOLUTION

Forms

Notice of Benefit Reinstatement (NOBR)
The purpose of the NOBR form is to report payments to the department when there is a resumption in payments of wage-loss benefits after they have been previously discontinued. It is also used to report other specific benefit payment changes on the claim. The department uses this form to review for compliance with the statute and rules, and for statistical data.

Reasons to File
• • • To report a resumption of benefits, either voluntarily or pursuant to an order, after an NOID has been filed. To report a change of wage loss benefits being paid from TPD to TTD. To report a change from full wage continuation by the employer to insurer-paid benefits.

Note: This form is not to be used to report the initial payment of wage loss benefits. The NOPLD form is used for this purpose.

When to File
• The form should be filed at the time of the payment.

How to Complete the Form
• • • • • Fill in all information in the top section. Fill in all fields of the next section (date of new payment, amount, etc.) Check Box 1-4, only one box should be checked and fill in all the requested information in that box. The pre-injury wage information section needs to be completed only if the information differs from prior submissions. Otherwise, it can be left blank. Fill in the claim representative’s name and phone number, and the date this form is being sent. No signature is required.

Note: The insurer is not required to send a copy of this form to the employee or employer, but you may wish to use it to notify them as well as the department.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-11

Forms

July 2007 7-12

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Notice of Benefit Reinstatement
Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format.

N C 0 1

DO NOT USE THIS SPACE DATE OF DEATH (if applicable)

SOCIAL SECURITY NUMBER DATE OF INJURY

EMPLOYEE

EMPLOYER

INSURER/SELF-INSURER-TPA

INSURER CLAIM NUMBER

THIS IS NOTIFICATION THAT WORKERS’ COMPENSATION BENEFITS HAVE BEEN REINSTATED. Date of new payment Amount of payment Type of benefit TTD PTD TPD DEP Time period covered with this payment Date from Date through Compensation rate

Insurer: Check appropriate box and enter data information: 1. Payment resumed voluntarily. First date of new period of time lost: Date of notice to employer of new period of time lost:

2. Payment resumed pursuant to order served and filed on M.S. § 176.239 decision OR Other decision (OAH, WCCA, or Supreme Court)

3. TPD changed to TTD effective

4. Full wage continuation changed to TTD effective Please provide the following pre-injury wage information ONLY if it differs from prior submissions: Average Weekly Wage Weekly value of: Meals Lodging 2nd income

Straight time: Rate per hour Hours per day Days per week 26 week earnings Total days worked in last 26 weeks Total weeks worked in last 26 weeks

IF OVERTIME IS PAID OR IF EMPLOYEE IS IRREGULARLY SCHEDULED, ATTACH A 26 WEEK WAGE STATEMENT.

CLAIM REPRESENTATIVE NAME

PHONE # (include area code)

DATE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
MN NC01 (8/04) Distribution: Workers’ Compensation Division, Insurer

Forms

Notice of Benefit Payment (NOBP)
The purpose of the NOBP form is two-fold. It is used: 1) to notify the employee about payment(s) of PPD benefits and how those PPD benefits are paid; and to notify the employee of a final benefit payment according to an award, decision, or order.

2)

In addition, this form supplies the employee with a summary total of all benefits that have been paid or withheld on the claim. The department uses the form to review for compliance with the statute and rules, to verify calculation of benefits, and for statistical data.

Reasons to File
• • • • When paying PPD in a lump sum. When making the first payment of periodic PPD benefits. When paying under an award, order or administrative decision. When making the final payment of periodic PPD.

When to File
• The form should be filed at the time the payment is made.

How to Complete the Form
Front Page Check the box for PPD or final payment. PPD • • • • Enter the percent of PPD. Enter the rule number(s) from the PPD schedule, the name of doctor, and the date of medical report. Attach the medical report giving the PPD rating. Check the box if this is a preliminary payment. For injuries on or after October 1, 1995 • Enter the amount per week, beginning date, number of weeks, and total amount to be paid.
July 2007 7-13

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Forms

For injuries between January 1, 1984 and September 30, 1995 • Lump sum IC - Indicate the dollar amount, date paid, and weeks of eligibility for Monitoring Period Compensation. Periodic IC or ERC - Check box for type of benefit and enter the amount per week, beginning date, and number of weeks.

Final Payment • • Check the appropriate box A through D. Indicate the date of the decision, award, or prior NOBP.

Back Page • TTD/PTD, TPD, and Retraining benefits: • • Use the format provided on the form — from, through, weeks, rate, total. Each period of TTD/PTD should be listed separately on the form (or an attached worksheet if there is not enough room on the form). A break in continuous dates of TTD/PTD or a change in the weekly payment rate constitutes a start of a separate period of disability. Each period of TPD should be listed separately on the form (or an attached worksheet if there is not enough room on the form). A break in continuous dates of TPD constitutes a start of a separate period of disability.

Permanent Partial Disability: • • Enter the percent of PPD. Check the appropriate box for the date of injury and type of benefit being paid - PPD, IC, or ERC. Enter the weeks, rate if applicable, and total.

• •

Attorney Fee Expenses: • Enter the amounts on the appropriate lines.

Note: When withheld fees are paid, remove them from the “withheld” line. • Totals: • Enter the amounts on the appropriate lines.

July 2007 7-14

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Forms

Note: The starred items on the form should not be shown with attorneys fees deducted from the totals. Benefit totals shown on the form for these items should always include amounts withheld or paid for attorney fees. • Fill in the claim representative’s name and phone number, and the date the form is being served on the parties. No signature is required.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-15

Forms

July 2007 7-16

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Notice of Benefit Payment
N B 0 1

Enter dates in MM/DD/YYYY format.

DO NOT USE THIS SPACE DATE OF INJURY EMPLOYER

SOCIAL SECURITY NUMBER EMPLOYEE

EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

INSURER CLAIM NUMBER

THE FOLLOWING PERMANENT PARTIAL DISABILITY BENEFIT WILL BE PAID TO YOU: % of whole body according to Minnesota Workers’ Compensation Permanent Partial Disability Schedule number(s) The rating is based on the attached medical report of Dr. dated

This payment is based on the preliminary rating. If your final disability rating is higher, further payments will be made. For injuries on or after 10/01/1995 payment will be made at (date) for a total of $ $ per week beginning on weeks and a total amount of $

For injuries on or after 10/01/2000 a total lump sum payment of will be made as requested by the employee.

, rather than weekly payments

For injuries between 01/01/1984 and 09/30/1995 payment will be made as follows: $ Impairment compensation will be paid in a lump sum on (date). weeks of the day your returned to work,

(if you are laid off from your job for economic reasons within

you may be entitled to monitoring period compensation, in addition to Impairment Compensation.) Periodic impairment compensation or of $ per week beginning on Periodic economic recovery compensation (date) will be paid for up to weeks. If you

return to work before this number of weeks, you will receive the balance due in a lump sum after working 30 days. 26 weeks economic recovery compensation (M.S. § 176.101, subd. 3t) of per week will be paid beginning on (date). $

YOUR FINAL PAYMENT OF BENEFITS WAS

$ WILL BE

FOR ISSUED ON (DATE) ACCORDING TO:

A. B. . C. D.

An award on agreement of the parties dated A prior Notice of Benefit Payment for periodic payment of permanent partial disability dated An administrative decision under M.S. § 176.239 dated A judge’s decision and order dated

MN NB01 (12/05)

(over)

INSTRUCTIONS TO EMPLOYEE You are responsible for reviewing this form to make sure that you have been properly paid the benefits due you. YOU DO NOT NEED TO TAKE ANY ACTION IF YOU BELIEVE THAT YOU HAVE RECEIVED ALL BENEFITS DUE YOU OR THAT THE REDUCTION OF BENEFITS IS PROPER. If you have questions about your benefits, you should first contact the claim representative whose telephone number is at the bottom of the page. Be sure to provide that person with any additional information you have to support your claim. If you still have questions, contact the Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you. Minnesota Department of Labor and Industry 5 North Third Avenue West, Suite 400 443 Lafayette Road North Duluth, MN 55802-1614 St. Paul, MN 55155-4301 Telephone: (218) 733-7810 Telephone: (651) 284-5030 1-800-365-4584 1-800-342-5354 This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

THE FOLLOWING BENEFITS HAVE BEEN PAID Temporary Total Disability or Permanent Total Disability

FROM

THROUGH

WEEKS

RATE

*TOTAL

Benefit Addendum Attached Temporary Partial Disability Retraining Benefits Permanent Partial Disability ___________% Injuries on or after 10/01/95 Impairment Compensation (injuries 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) _______________________ [part of body] (injuries before 01/01/1984) Attorney Fees/Expenses M.S. 176.081, subd. 1 & 3 Paid M.S. 176.081, subd. 1 & 3 Still Withheld Heaton Fees Paid Roraff Fees Paid M.S. 176.191 Paid Other Fees Paid Costs & Disbursements Paid INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME Benefit Totals *Lump sum Payment Under Award or Order Attorney Fees Reimbursed to Employee (M.S. 176.081, subd. 7) Interest Paid *TOTAL COMPENSATION PAID *Total Supplementary Benefits Total Medical Expenses Paid to Date

ADDRESS

PHONE NUMBER (include area code)

CITY

STATE

ZIP CODE

DATE SERVED ON EMPLOYEE

DATE SERVED ON ATTORNEY

*Include attorney fees in these totals.

Distribution: Workers’ Compensation Division, Employer, Employee, Insurer

Forms

Interim Status Report (ISR)
The purpose of the ISR form is to notify the department of continuing compensation payments on longer-term claims. Consider filing the forms on the anniversary date of the injury to avoid calculation errors. The department uses the information supplied on the form to verify calculation of benefits and for statistical data.

Reasons and When to File
• Annually on all claims with ongoing payments and/or supplementary benefits.

How to Complete the Form
Front Page • Temporary Total and Permanent Total disability: • • • Check the appropriate box. Enter the balance carried forward from the last ISR or NOID filed. Enter each separate new period of TTD/PTD paid (attach a worksheet if there is not enough room on the form). A break in continuous dates of TTD/PTD or a change in the weekly payment rate constitutes a start of a separate period of disability.

Temporary Partial disability: • • Enter the balance carried forward from the last ISR or NOID filed. Enter each separate new period of TPD paid (attach a worksheet if there is not enough room on the form). A break in continuous dates of TPD constitutes a start of a separate period of disability. (Do not itemize each week of TPD.)

Permanent Partial disability: • • Enter the percent of PPD. Check the appropriate box for the date of injury and type of benefit being paid - PPD, IC, or ERC. Enter the weeks, rate if applicable, and total.

Back Page • Retraining and Dependency benefits:
July 2007 7-17

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Forms

• •

Enter the dates, weeks, rate, and total.

Social Security/Government benefits: • • • Check retirement or disability. Enter the name of the program. Enter the dates and the amount per week.

Supplementary benefits: • Enter the dates, weeks, rate, and total.

Attorney fees: • Enter the amounts on the appropriate lines.

Note: When withheld fees are paid, please remove them from the “withheld” line. • Total: • Enter the amounts on the appropriate lines.

July 2007 7-18

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Interim Status Report
I S 0 3

Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format.

DO NOT USE THIS SPACE DATE OF INJURY

SOCIAL SECURITY NUMBER

EMPLOYEE

EMPLOYER

EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

INSURER CLAIM NUMBER

THE FORM MUST BE SUBMITTED ANNUALLY ON ALL CLAIMS OF CONTINUING DISABILITY, SUPPLEMENTARY OR DEPENDENCY BENEFITS. Please provide additional information on the Benefit Addendum (BA01).

Temporary Total*

Permanent Total* Balance Carried Forward

FROM

THROUGH

WEEKS

RATE

*TOTAL

TOTAL: Temporary Partial Balance Carried Forward

TOTAL: Permanent Partial Permanent Partial Disability ___________% Injuries on or after 10/01/95 Impairment Compensation (injuries 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) _______________________ [part of body] (injuries before 01/01/1984) TOTAL: *These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of Supplementary Benefits.
MN IS03 (8/04) (over)

FROM Retraining Benefits Balance Carried Forward

THROUGH

WEEKS

RATE

TOTAL

TOTAL: Dependency Benefits Balance Carried Forward

TOTAL: Supplementary Benefits* Balance Carried Forward

TOTAL: Social Security Benefits or Other Government Benefits* Name of Program: FROM THROUGH PER WEEK Retirement Disability

*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of Supplementary Benefits. Attorney Fees Paid Attorney Fees Still Withheld Interest Paid Lump Sum Payment Under Award or Order Total Compensation Paid to Employee Total Dependency Benefits Paid (Please attached copy of worksheet) CLAIM REPRESENTATIVE NAME

Attorney Fees Reimbursed to Employee M.S. 176.081, subd. 7 INSURER/SELF-INSURER/TPA

ADDRESS

PHONE NUMBER (include area code)

CITY

STATE

ZIP CODE

DATE SERVED

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

Forms

Notice of File Closing
The purpose of this form is to notify the department that the insurer’s file is about to be closed. Although filing of this form is not required by statute or rule, the voluntary use of it often avoids requests from the department to the insurer after their file has been closed and shipped to off-site storage. The department uses the receipt of the form as a trigger to perform a final audit of the file for compliance with the statute and rules.

Reasons to File
• To notify department staff that the insurer is closing a file.

When to File
• At the time the insurer determines their file can be closed. Be sure that all required documents have been sent to the department before filing this form.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-19

Forms

July 2007 7-20

Basic Adjusters’ Training Guide MN Department of Labor and Industry

N F 0 1

DO NOT USE THIS SPACE

Notice of File Closing
Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format.

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE

EMPLOYER

INSURER CLAIM NUMBER

THIS IS TO NOTIFY YOUR OFFICE THAT ALL PAYMENTS AND OTHER ACTIVITIES HAVE BEEN COMPLETED ON THIS FILE. AS A RESULT, WE ARE NOW CLOSING IT ON OUR SYSTEM.

CLAIM REPRESENTATIVE NAME

DATE

ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

PHONE NUMBER (include area code)

Send completed form to:

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4317

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1 800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

MN NF01 (8/04)

Forms

Health Care Provider Report (HCPR)
The purpose of the HCPR form is to request required medical information that is critical to proper administration of the claim. When requesting this information from a health care provider, a party must complete the general information section (at the top of the form) identifying the employee, the employer, and the insurer. Also, they must specify all items to be answered by the health care provider. The health care provider must respond on this report form or in a narrative report that contains the same information within 10 calendar days of the request. The health care provider is not reimbursed for providing the information on this form. If the report indicates that the employee has reached MMI, the insurer must serve the report on the employee (see MMI in Section 1 for more information). If the report indicates a preliminary or final permanent partial disability rating, it must be filed with the department.

Report of Work Ability (RWA)
A health care provider treating an employee who alleges a work related injury must complete a RWA within 10 days of a request for a RWA from the insurer. In addition, the primary health care provider must provide a RWA to the employee at the following intervals (Minnesota Rules Part 5221.0410, Subp. 6): • • • every visit if visits are less frequent than one every two weeks; or every two weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner; or at expiration of the end date or review date specified in previous RWA.

The RWA must either be on the prescribed form or in a report that contains the same information. The health care provider must provide the RWA to the employee and place a copy in the medical record. It is not necessary to file the RWA with the department unless the report is the basis for a discontinuance or needed to resolve a dispute.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-21

Forms

July 2007 7-22

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Health Care Provider Report
See Instructions on Reverse Side
(WHEN COMPLETED RETURN TO REQUESTER)
Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format.
H C 0 1

DO NOT USE THIS SPACE DATE OF INJURY

SOCIAL SECURITY NUMBER

EMPLOYEE

EMPLOYER

INSURER/SELF-INSURER/TPA

INSURER CLAIM NUMBER

INSURER ADDRESS

CITY

STATE

ZIP CODE

REQUESTER must specify all items to be completed by health care provider. HEALTH CARE PROVIDER TO COMPLETE ITEMS REQUESTED ABOVE 1. 2. Date of first examination for this injury by this office Diagnosis (include all ICD-9-CM codes):

Items:

MMI (#9)

PPD (#10)

3.

History of injury or disease given by employee:

4. 5.

In your opinion (as substantiated by the history and physical examination) was the injury or disease caused, aggravated or accelerated by the employee’s alleged employment activity or environment? No Yes Is there evidence of pre-existing or other conditions that affect this disability? No Yes If yes, describe:

6.

Is further treatment of this injury or referral to another doctor planned?

No

Yes

If yes, describe:

7.

Has surgery been performed?

No

Yes

If yes, date and describe:

8. 9.

Attach the most recent Report of Work Ability. Date of Report: Has the employee reached maximum medical improvement? (If yes, complete item #10) (See definition on back) No Yes Date reached:

No Yes Too early to determine 10. Has the employee sustained any permanent partial disability from the injury? The permanent partial disability is % of the whole body. This rating is based on Minn. Rules: 5223. 5223.
NAME

% %

5223. 5223.
SIGNATURE DEGREE

% %

ADDRESS

STATE

LICENSE #/REGISTRATION #

CITY
N

STATE

ZIP CODE

PHONE # (include area code)

DATE SIGNED

MN HC01 (8/04)

NOTICE TO EMPLOYEE: SERVICE OF THIS REPORT OF MAXIMUM MEDICAL IMPROVEMENT (SEE DEFINITION IN INSTRUCTIONS FOR ITEM 9) MAY HAVE AN IMPACT ON YOUR TEMPORARY TOTAL DISABILITY WAGE LOSS BENEFITS. IF THE INSURER PROPOSES TO STOP YOUR BENEFITS, A NOTICE OF INTENTION TO DISCONTINUE BENEFITS SHOULD BE SENT TO YOU. IF YOU HAVE ANY QUESTIONS CONCERNING YOUR BENEFITS OR MAXIMUM MEDICAL IMPROVEMENT, YOU MAY CALL THE CLAIM REPRESENTATIVE OR THE DEPARTMENT OF LABOR AND INDUSTRY, WORKERS’ COMPENSATION DIVISION AT (651) 284-5030 OR 1-800-342-5354. INSTRUCTIONS TO THE INSURER AND HEALTH CARE PROVIDER Within ten (10) calendar days of receipt of a request for information on the Health Care Provider Report from an employer, insurer, or the commissioner, a health care provider must respond on the report form or in a narrative report that contains the same information. (Minn. Rules 5221.0410, subp. 2) A. The employer, insurer, or Commissioner may request required medical information on the Health Care Provider Report form.

• • • •

The requester must complete the general information identifying the employee, employer, and insurer. The requester must specify all items to be answered by the health care provider. For those injuries that are required to be reported to the Division, the self-insured employer or insurer must file reports with the Division. (M.S. § 176.231, subd. 1 and Minn. Rules 5221.0410, subp. 5 and subp. 8) The self-insured employer or insurer must serve the report of maximum medical improvement (MMI) on the employee. (M.S. § 176.101, subd. 1(j) and Minn. Rules 5221.0410, subp. 3)

B.

Instructions to the Health Care Provider for completing the Health Care Provider Report:

• • • • •

Items 1 - 5: Fill in all information as required. Item 6: Indicate if further treatment or referral is planned. Describe the treatment plan (e.g., continue medication, refer to physical therapy, refer to a specialist, perform surgery). Item 7: State if surgery has been performed. If yes, fill in the date performed and describe the procedure. Item 8: Attach the most recent Report of Work Ability. (Minn. Rules 5221.0410, subp. 6) Item 9: Indicate if the employee has reached MMI. If yes, fill in the date MMI was reached. At MMI, permanent partial disability (PPD) must be reported (item 10). (M.S. § 176.011, subd. 25 and Minn. Rules 5221.0410, subp. 3) MAXIMUM MEDICAL IMPROVEMENT means “The date after which no further significant recovery from or significant lasting improvement to a personal injury can reasonably be anticipated, based upon reasonable medical probability, irrespective and regardless of subjective complaints of pain.”

Item 10: The health care provider must render an opinion of PPD when ascertainable, but no later than the date of MMI. (M.S. § 176.011, subd. 25 and Minn. Rules 5221.0410, subp. 4) Indicate if the employee sustained PPD from this injury. Check one of the three boxes (too early to determine, no, yes). If yes, specify any applicable category of the PPD schedule in effect for the employee’s date of injury. Report any zero ratings.

• •

Identify the health care provider completing the report by name, professional degree, license or registration number, address, and phone number. The health care provider must sign and date the report.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

Report of Work Ability
See Instructions of Reverse Side
R W 0 1

Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. This form must be provided to the employee. (Minn. Rules 5221.0410,l subd. 6)

DO NOT USE THIS SPACE

NOTICE TO EMPLOYEE: YOU MUST PROMPTLY PROVIDE A COPY OF THIS REPORT TO YOUR EMPLOYER OR WORKERS’ COMPENSATION INSURER, AND QUALIFIED REHABILITATION CONSULTANT IF YOU HAVE ONE. SOCIAL SECURITY NUMBER DATE OF INJURY

EMPLOYEE

EMPLOYER

INSURER/SELF-INSURER-TPA

INSURER CLAIM NUMBER

Date of most recent examination by this office Select the appropriate option(s) below and fill in the applicable dates. 1. 2. Employee is able to work without restrictions as of Employee is able to work with restrictions, from The restrictions are: (date) (date) to (date)

3.

Employee is unable to work from as needed OR SIGNATURE

(date)

to

(date)

The next scheduled visit is: NAME (Type or Print)

DEGREE

ADDRESS

STATE

LICENSE #/REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

DATE SIGNED

MN RW01(9/04)

INSTRUCTIONS FOR COMPLETING REPORT OF WORK ABILITY Each health care provider directing the course of treatment for an employee who alleges to have incurred an injury on the job must complete a Report of Work Ability within 10 days of a request for a Report of Work Ability from the insurer, or at the applicable interval (Minn. Rules 5221.0410, subp. 6): 1. every visit if visits are less frequent that one every two weeks; 2. every 2 weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner; and 3. upon expiration of the ending or review date of the restrictions specified in a previous Report of Work Ability. The Report of Work Ability must either be on this form or in a report that contains the same information. The Report of Work Ability must: • • • Identify the employee by name, social security number, and date of injury. Identify the employer at the time of the employee’s claimed work injury. If known, identify the workers’ compensation insurer at the time of the claimed injury, or the workers’ compensation thirdparty administrator. Also indicate this workers’ compensation payer’s claim number. Indicate the date of the most recent examination by this office. The Report of Work Ability should be completed based on this evaluation. Identify the appropriate option which best describes the employee’s current ability to work by checking box 1, 2, or 3. 1. If the employee is able to work without restrictions, fill in the beginning date. 2. If the employee is able to work with restrictions, fill in the date any restriction of work activity is to begin and the anticipated ending or review date. Describe any restrictions in functional terms (e.g., employee can lift up to 20 pounds, 15 times per hour; should have 10 minute break every hour). 3. If the employee is unable to work at all, fill in the date the restriction of work activity is to begin and the anticipated ending or review date. • • Indicate the date of the next scheduled visit or indicate that additional visits will be scheduled as needed. Identify the health care provider completing the report by name, professional degree, license or registration number, address and phone number. Include the signature of the health care provider and date of the report.

The health care provider must provide the Report of Work Ability to the employee and place a copy in the medical record. If you have questions, please call the claim representative or the Department of Labor and Industry, Workers’ Compensation Division at (651) 284-5030 or 1-800-342-5354. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

Forms

Disability Status Report (DSR)
To ensure that a rehabilitation consultation is provided when necessary, Minnesota Rules Part 5220.0110, Subp. 7 requires that the insurer send the employee a DSR and file a copy with the department, when any of the following occur: • • • within 14 calendar days of knowledge that the employee’s TTD is likely to exceed 13 cumulative weeks; or within 90 calendar days of the date of injury when the employee has not returned to work following a work injury; or within 14 calendar days after receiving a request for a rehabilitation consultation, whichever is earlier.

In addition, a DSR must be filed within 14 calendar days of expiration of an approved waiver of rehabilitation services. An insurer who files a DSR must refer the employee for a rehabilitation consultation or request a waiver of rehabilitation services. A rehabilitation waiver is granted when the employer documents that the otherwise qualified employee will return to suitable gainful employment with the date-of-injury employer within 90 calendar days after the request for the waiver is filed. The waiver shall not be effective more than 90 calendar days after the waiver is granted. If the insurer is requesting a waiver, please note the Instructions to Insurer on the back of the prescribed DSR form. Documentation that the employee will return to suitable gainful employment is satisfied by submitting a written offer of suitable gainful employment, signed by the employer, that is within the treating doctor’s restrictions and to which the employee will return within 90 calendar days after the waiver is filed. The department reviews all requests for waivers and notifies the insurer whether a waiver is granted or denied. If the department grants a waiver, it is only effective until 90 calendar days after the waiver is granted. A waiver of consultation and rehabilitation services may not be renewed. If a waiver is not granted, the insurer must provide a rehabilitation consultation. When referring an employee to a QRC for a consultation, the insurer must send a copy of the DSR, the FROI, and the treating physician’s RWA to the QRC prior to the consultation. If the insurer does not refer the employee for such a consultation, the department will order a consultation by the department’s Vocational Rehabilitation unit or by the employee’s choice of QRC.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-23

Forms

July 2007 7-24

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Disability Status Report
Filed as required by Minn. Rules 5220.0110, subp. 7
D S 0 1

Enter dates in MM/DD/YYYY format.

DO NOT USE THIS SPACE 1. SOCIAL SECURITY NUMBER 2. DATE OF INJURY

3. EMPLOYEE NAME

4. EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

5. EMPLOYEE PHONE #

6. EMPLOYER

7. EMPLOYER CONTACT PERSON

8. PHONE #

9. INSURER/SELF-INSURER/TPA

12. TITLE OF JOB AT DATE OF INJURY

10. INSURER ADDRESS

13. AVERAGE WEEKLY WAGE AT DATE OF INJURY STATE ZIP CODE 15. NUMBER OF DAYS OF DISABILITY

14. JOB AT DATE OF INJURY FULL TIME PART TIME 16. IS THE EMPLOYEE CURRENTLY WORKING? YES NO

CITY

11. INSURER CLAIM NUMBER

17. WILL THE DISABILITY LIKELY EXTEND BEYOND 13 WEEKS? (see instructions on back) YES NO

18. REASON FOR FILING THE DISABILITY STATUS REPORT: (Check A or B) Was a consultation requested? Insurer A. Employer
NO YES

If yes, consultation requested by: (date of request)

Employee on

The employee is being referred for a rehabilitation consultation. (Insurer must send a copy of this Disability Status Report, the First Report of Injury, and the treating physician’s Report of Work Ability to the QRC before the rehabilitation consultation.) Name of QRC

B.

A waiver of the rehabilitation consultation is being requested. (An offer of suitable gainful employment signed by the date-of-injury employer and the Report of Work Ability must be attached.)

Projected return to work date

Name of insurer representative completing form

Phone number

Extension

Date served on employee

MN DS01 (12/05)

Distribution: Workers’ Compensation Division, Employee

Instructions to Insurer The Disability Status Report (DSR) is used to notify parties that you are either referring the injured worker for a rehabilitation consultation or requesting a waiver of the consultation. The DSR, with a Report of Work Ability (RWA), must be mailed to the injured worker and filed with the Department of Labor and Industry: • Within 14 calendar days of knowledge that the employee’s temporary total disability is likely to exceed 13 cumulative weeks; or • Within 90 calendar days of the date of injury when the employee has not returned to work following a work injury; or • Within 14 calendar days after receiving a request for a rehabilitation consultation, whichever is earlier; or • Within 14 calendar days of expiration of an approved waiver of rehabilitation services. To Refer for a Rehabilitation Consultation: If you are referring the injured worker for a rehabilitation consultation, check Box 18A. Send a copy of the DSR form, the First Report of Injury and the treating physician’s Report of Work Ability to the QRC prior to the consultation. Fill in the name of the QRC on the form and indicate which party requested the consultation. If the employee requested the consultation, fill in the date of the request. To Request a Waiver of a Rehabilitation Consultation: M.S. § 176.102, subd. 4 and Minn. Rules 5220.0110 and 5220.0120 provide that the commissioner may grant a waiver of a rehabilitation consultation to an otherwise qualified employee if there is documentation that the employee will return to suitable gainful employment with the date-of-injury employer within 90 calendar days after the request for waiver is filed. A waiver will not be granted unless documentation is submitted that a suitable job offer within the treating doctor’s restrictions has been made. If you are requesting a waiver, check Box 18B and attach the following documentation: • Report of Work Ability or other medical report with the same information from the treating doctor which indicates that the employee will be released to return to work within 90 calendar days after the request for waiver is filed and specifying the employee’s work restrictions in functional terms. • Written offer of suitable gainful employment signed by the employer that is within the treating doctor’s restrictions to which the employee will return within the timeframe indicated above. Include one of the following: • If the employer is offering the employee his/her date-of-injury job, any modifications of the job to accommodate the employee’s restrictions must be noted. If the written offer of suitable gainful employment (which does not include temporary, light-duty) is for a different job with the date-of-injury employer, the offer must include the job title, job environment, work tasks, weekly wage, physical, mental and educational demands of the job, and/or employer modifications of the job to accommodate the employee’s restrictions.

Instructions to Employee If you do not agree with the insurer’s recommendation for a rehabilitation consultation or a waiver of rehabilitation consultation, you may file a Rehabilitation Request with the Department of Labor and Industry. If you have questions call the Benefit Management and Resolution Unit at 1-800-342-5354 or 651-284-5032.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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.

Forms

Rehabilitation Consultation Report (RCR)
The rehabilitation consultation is a meeting between the employee and a QRC to determine whether the employee is eligible for rehabilitation services. According to Minnesota Rules Part 5220.0100, Subp. 22, an employee is eligible if, because of the effects of an injury or disease, whether or not combined with the effects of a prior injury or disability, the employee: • is permanently precluded or is likely to be permanently precluded from engaging in the employee’s usual and customary occupation or from engaging in the job the employee held at the time of injury; can not reasonably be expected to return to suitable gainful employment with the date-of-injury employer; and can reasonably be expected to return to suitable gainful employment through the provision of rehabilitation services, considering the treating physician’s opinion of the employee’s work ability.

• •

During the consultation, the QRC must disclose any affiliations with the employer or insurer and must discuss the information on the “Rehabilitation Rights and Responsibilities of the Injured Worker” form. To determine the employee’s eligibility for rehabilitation services, the QRC talks not only with the employee, but also the employer and the treating doctor, when necessary. The QRC completes RCR which spells out the likelihood that the employee will return to the pre-injury employer or pre-injury occupation, and gives an assessment of whether or not the employee is a qualified employee for rehabilitation services. This form must be filed with the department within 14 days of the first in-person meeting with the employee. The QRC is required to provide copies of the RCR, a signed Rehabilitation Rights and Responsibilities of the Injured Worker form, and a narrative report explaining the basis for the determination to the employer, the employee, any attorney for the employee, and the insurer (see Minnesota Rules Parts 5220.0130, Subp. 3C(4) and 5220.0100, Subp. 31).

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-25

Forms

July 2007 7-26

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Rehabilitation Consultation Report
Enter dates in MM/DD/YYYY format.

R C 0 1

DO NOT USE THIS SPACE 2. DATE OF INJURY

1. SOCIAL SECURITY NUMBER 3. EMPLOYEE NAME 4. EMPLOYEE ADDRESS CITY 7. EMPLOYER NAME 10. INSURER CLAIM NUMBER 11. INSURER/SELF-INSURER/TPA 12. INSURER ADDRESS CITY 13. CLAIM REPRESENTATIVE 21. Date of rehabilitation consultation

STATE

ZIP CODE

5. EMPLOYEE PHONE NUMBER 6. DATE OF BIRTH 9. PHONE #

8. EMPLOYER CONTACT PERSON 15. QRC NAME 16. QRC FIRM 17. ADDRESS STATE ZIP CODE 14. PHONE # CITY 18. QRC #

STATE

ZIP CODE

19. QRC FIRM # 20. PHONE NUMBER

File this form with the Department of Labor and Industry within 14 days of date of rehabilitation consultation. See Minn. Rule 5220.0130, subp. 3 D. Yes Yes Yes Yes Yes Yes No No No No No No Unknown Unknown Unknown

22. Is the employee receiving assistance from employer in returning to work there? If “NO”, do you recommend such assistance in returning to the date-of-injury employer? 23. In your opinion is the employee expected to return to the date-of-injury employer? 24. In your opinion is the employee expected to return to the date-of-injury occupation? 25. Can the employee be expected to return to suitable gainful employment through rehabilitation services considering the treating physician’s Report of Work Ability? 26. Is the employee eligible for rehabilitation services at this time?

ATTACH A NARRATIVE REPORT EXPLAINING THE BASIS FOR YOUR DETERMINATION 27. QRC Signature Date

QRC: If the employee is eligible for rehabilitation services, a Rehabilitation Plan (R-2) must be developed and implemented within 30 days of the initial meeting and filed with the Department within 45 days of the initial meeting. Employee: If you disagree with or have questions about the information provided on this form, you are encouraged to contact the QRC and insurer to discuss any concerns. If your concerns are not resolved, you may call the Department’s Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354 or request a determination by filing a Rehabilitation Request with the Department. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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 RC01 (12/05)

cc: Employee, Employer, Insurer, and Attorney(s)

Rehabilitation Rights and Responsibilities of the Injured Worker
Enter dates in MM/DD/YYYY format.

I W

0 5

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

The purpose of vocational rehabilitation is to assist you (the injured worker) so that you may return to your former job, to a job related to your former employment, or to a job in another work field. The job should be physically appropriate and produce an economic status as close as possible to that which you would have enjoyed without disability. The first step in this return to work process is a Rehabilitation Consultation with a Qualified Rehabilitation Consultant (QRC) to determine if you qualify for rehabilitation services. If the QRC determines that you are qualified, the next step is the development of a rehabilitation plan. Your QRC will help you develop and implement this plan. Consideration will be given to your former employment, the current labor market and your qualifications, including transferable skills, previous work history, age, education and interests.

YOUR RIGHTS Under the provisions of the Minnesota Workers’ Compensation Law, you (the injured worker) have certain rehabilitation rights. These rights include: • Selection of your own Qualified Rehabilitation Consultant (QRC). The employer/insurer will generally refer you to a QRC. You may choose your own QRC up to 60 days after a written rehabilitation plan is filed with the State. Any further change of QRC must be mutually agreed upon or determined to be in the best interest of the parties by the Commissioner or a compensation judge. When a QRC first meets or writes to contact you, he or she is required to disclose to you in writing, any affiliation or ownership interest between the QRC (or the QRC firm) and your employer/insurer or adjusting company. The QRC is also required to disclose to you and all parties to a case, any affiliation or business referral arrangement between the QRC (or the QRC firm) and any other parties to the case, including attorneys and doctors. If the QRC determines that you are eligible for vocational rehabilitation, a rehabilitation plan, which may include training if needed, will be developed. The rehabilitation services required to carry out the plan will be provided at no cost to you. The right to request a change in your rehabilitation plan. The right to receive a copy of your rehabilitation plan. The right to obtain a copy of any required progress records upon request. The right to request assistance from the Workers’ Compensation Division of the Minnesota Department of Labor and Industry. If you have questions about your rehabilitation plan, call 651-2845032 or 800-342-5354. If there is a dispute about your eligibility for statutory rehabilitation services or the rehabilitation plan, you may file a Rehabilitation Request and the Department may schedule an administrative conference in order to resolve the dispute.
(over)

• •

MN IW05 (12/06)

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME
I W 0 5

YOUR RESPONSIBILITIES In addition to the above rights, you (the injured worker) have certain rehabilitation responsibilities under the workers' compensation law. These responsibilities include the following: • • • You must cooperate with reasonable medical and rehabilitation examinations and evaluations as ordered by the Commissioner. You must make a good faith effort to participate in your rehabilitation plan. Failure to do so may result in suspension or termination of your rehabilitation or monetary benefits. You must advise your QRC and insurance company of your wage, hours, employer and job title when you return to work and when your hours or wages change. This is necessary to accurately calculate your wage loss benefits and to ensure rehabilitation services are appropriate. Failure to accurately report wages earned while receiving workers’ compensation benefits may result in civil or criminal consequences.

The statements below are requested to verify whether you received the documents listed and that the information on this form has been explained to you. You are not required to provide the information requested below or sign this form. Your workers’ compensation benefits will not be affected if you choose not to provide the information or sign the form. This form will be filed with the Minnesota Department of Labor and Industry, and may also be provided to the Office of Administrative Hearings and law enforcement agencies. Employee, check any that apply: The above information has been explained to me and I have been provided with a copy of this form. I have received written notification from the QRC disclosing any affiliation or business referral arrangement the QRC or QRC firm may have with any parties to my case and a written explanation of any affiliation or ownership interest the QRC or QRC firm may have with my employer/insurer, and any other insurer or adjusting company. The QRC has informed me that he/she and the QRC firm have no affiliation or ownership interest or business referral arrangement with any parties to my case or any other insurer or adjusting company.
EMPLOYEE SIGNATURE QRC SIGNATURE QRC NUMBER DATE DATE

PROVIDING THE INFORMATION ON THIS FORM TO THE INJURED WORKER IS REQUIRED BY MINNESOTA STATUTES SECTION 176.102, SUBD. 4C AND MINNESOTA RULES, PART 5220.1803, SUBP. 1 AND 1A. THIS MATERIAL CAN BE MADE AVAILABLE IN DIFFERENT FORMS, SUCH AS LARGE PRINT, BRAILLE OR ON TAPE. REQUEST, CALL (651) 284-5030 OR 1-800-342-5354 (DIAL-DLI)/VOICE OR TDD (651) 297-4198. TO

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.

The QRC must sign and date this form at the first in-person contact with the employee, and must provide a copy to the employee and the insurer. The QRC must also provide a copy of this form to the Department of Labor and Industry. Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5032 1-800-342-5354 (DIAL-DLI)

Forms

R-2 Rehabilitation Plan
The purpose of the plan is to communicate to all parties the vocational goal, the rehabilitation services to be provided, and the projected amounts of time and money needed to achieve the vocational goal. The QRC must complete a proposed plan and send it to the parties within 30 days of the consultation. Upon receipt of the proposed plan, each party must, within 15 days, either sign and return the plan to the QRC or promptly notify the QRC of any objection to the plan and work with the QRC to overcome this objection. If the objection is not resolved, the objecting party must file a Rehabilitation Request form with the department within the 15 days of receipt of the proposed plan. A plan signed by all parties is considered approved upon filing with the department. If a party fails to sign the plan or file a Rehabilitation Request within 15 days, it shall be assumed that the parties are in substantial agreement with the plan’s vocational objective and the rehabilitation services proposed.

R-3 Rehabilitation Plan Amendment
The QRC submits a Rehabilitation Plan Amendment whenever circumstances indicate that the plan’s objectives are not likely to be achieved. The procedure for filing, approval, and requirements follow the same pattern for the plan amendments as for plans.

Plan Progress Report (PPR)
The PPR is used to inform parties of the current status of the plan and provide a current estimate of the plan cost and duration. The PPR must be filed with the department (with copies to parties) within 15 days after six months have passed from the date the plan was filed. If the QRC has filed a plan amendment 15 days before or after the six month time period, it is not necessary to also file the PPR.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-27

Forms

July 2007 7-28

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-2 Rehabilitation Plan
Enter dates in MM/DD/YYYY format.

R E 0 1

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

1. SOCIAL SECURITY NUMBER 3. EMPLOYEE NAME 4. EMPLOYEE ADDRESS CITY 7. EMPLOYER NAME 10. INSURER CLAIM NUMBER 11. INSURER/SELF-INSURER/TPA 12. INSURER ADDRESS CITY 13. CLAIM REPRESENTATIVE 21. Occupation at time of injury

2. DATE OF INJURY

STATE

ZIP CODE

5. EMPLOYEE PHONE NUMBER 6. DATE OF BIRTH 9. PHONE #

8. EMPLOYER CONTACT PERSON 15. QRC NAME 16. QRC FIRM 17. ADDRESS STATE ZIP CODE 14. PHONE NUMBER 22. Pre-injury AWW CITY 18. QRC #

STATE

ZIP CODE

19. QRC FIRM # 20. QRC PHONE NUMBER

25. Highest grade completed (select one) a. No high school diploma or GED

23. Job at date of injury: 24. Employee’s work status

Part time

Full time

b. High school diploma or GED c. Some post secondary course work d. Post secondary vocational/technical program e. Bachelor’s degree f. Master’s, PhD or professional degree Yes No

a. Off work from DOI to start of rehabilitation b. Some work between DOI and start of rehabilitation, not working at start of rehabilitation c. Working at start of rehabilitation

26. Employee may require an interpreter:

27. Date of rehabilitation consultation (start date)

28. Vocation goal a. RTW same employer Comments:

b. RTW different employer

MN RE01 (6/05)

(over)

cc: Employee, Insurer, Attorney(s) or other parties

VOCATIONAL REHABILITATION PLAN SERVICE CATEGORY and CODE (from VRI) DESCRIPTION SERVICE START DATE SERVICE END DATE ESTIMATED DAYS ESTIMATED COST

TOTALS

Employee Comments:

STATEMENT OF EMPLOYER/INSURER RESPONSIBILITY: The employer/insurer understands its responsibility to pay for services reasonably required and to monitor the costs and timelines of the services. M.S. § 176.102, subd. 9 and Minn. Rules 5220.1900, subp. 1g. STATEMENT OF QRC RESPONSIBILITY: I understand that I am responsible for the timely delivery of the above specified services pursuant to M.S. § 176.102 and Minn. Rules 5220.0100-.1900 and agree to conscientiously carry out my professional duties as a Qualified Rehabilitation Consultant in the interest of the employee’s rehabilitation. Should the estimated cost of this plan be exceeded or if additional time is required for completion of the plan, I will notify the Department and the parties by submitting a Rehabilitation Plan Amendment (R-3) in accordance with M.S. § 176.102, subd. 8 and Minn. Rules 5220.0510. STATEMENT OF EMPLOYEE RESPONSIBILITY: I understand that it is my responsibility to cooperate with all parties involved in my rehabilitation and I agree to make a good faith effort to participate in this plan. This includes attendance at scheduled activities and appointments, and adherence to reasonable medical advice. TO THE PARTIES: If you disagree with the plan, you have 15 days from the receipt of the proposed plan to resolve the disagreement or object to the proposed plan. The objection must be filed with the Department on a Rehabilitation Request form. Send a copy of this plan to the employee's treating health care provider if permitted by Minn. Rules 5220.1802, subp. 5 (Minn. Rules 5220.0410, subp. 7). Attach a copy of your initial evaluation report (Minn. Rules 5220.1803, subp. 5).

Employee has read and signed the form “Rights and Responsibilities of the Injured Worker” Employee has read and declined to sign the form “Rights and Responsibilities of the Injured Worker”
Employee Signature Date

Claim Representative Signature

Date

QRC Signature

Date

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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.

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-3 Rehabilitation Plan Amendment
Enter dates in MM/DD/YYYY format.

R P 0 1

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

1. SOCIAL SECURITY NUMBER 3. EMPLOYEE NAME 4. INSURER/SELF-INSURER/TPA 5. INSURER CLAIM NUMBER 6. EMPLOYER NAME

2. DATE OF INJURY 7. QRC NAME 8. ADDRESS CITY 9. QRC # 10. QRC FIRM # STATE ZIP CODE

11. PHONE NUMBER

12. CHANGE OF QRC

13. WITHDRAWAL OF QRC? 14. PROPOSED AMENDMENT/RATIONALE (attach separate sheet as necessary)

Yes Yes

No No

PREVIOUS QRC #

NEW QRC #

15. EMPLOYEE COMMENTS Plan costs to date 16. Costs 17. Plan duration from plan filing date (in weeks) Duration to date + + Expected additional duration to plan completion = Other costs necessary to complete plan = Estimated total duration Estimated total cost

18. Specify any additional rehabilitation services or changes to the current plan that will be required: SERVICE CATEGORY and CODE (from VRI) DESCRIPTION PROJECTED COMPLETION DATE COST

19. Is this form being filed in lieu of a Plan Progress Report? See Minn. Rule 5220.0450, subp. 3.A. 20. Is the employee released to return to work? 21. Current work status: Not working
with

Yes

No
without

If yes, complete #20-22. Medical report date If working, is this a temporary job? Yes No

Yes, restrictions Part time Full time

Yes, restrictions Seasonal layoff

No

Yes No 22. Do barriers to successful completion of the rehabilitation plan exist? If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form. Employee Signature Date Claim Representative Signature QRC Signature Date Date

MN RP01 (8/05)

cc: Employee, Insurer, Attorney(s) or other parties

Instructions to QRC Proposed plan amendment without a change of QRC: The QRC or other parties may propose amendments to current rehabilitation plans. It is the QRC’s responsibility to facilitate discussion of proposed amendments and file the Rehabilitation Plan Amendment (R-3) form when appropriate. Once an amendment has been proposed, the QRC shall provide copies of the R-3 to the employee, insurer, and any attorneys representing the employee or insurer. The QRC shall also send a copy of the R-3 to the date of injury employer if the goal is to return the employee to work with that employer. Proposed plan amendment including a change of QRC: 1. If the employee has the right to change QRC’s without approval per Minn. Rule 5220.0710, subpart 1, the new QRC must file an R-3 with the Department of Labor and Industry within 15 calendar days of receipt of the information transferred by the former QRC. However, it is not necessary to circulate for signatures. Copies must be sent to the parties listed on the form. 2. If approval of a change of QRC is required per Minn. Rule 5220.0710 and the insurer has approved the change, the new QRC must circulate the R-3 for signatures and file with the Department of Labor and Industry within 15 days of obtaining the signatures. 3. If approval of a change of QRC is required and the insurer objects to the change, the insurer should file a Rehabilitation Request form with the Department of Labor and Industry within 15 days of the receipt of the R-3. Proposed plan amendment for withdrawal of QRC when insurer has denied further liability for the injury for which rehabilitation services are being provided: If a claim petition, objection to discontinuance, request for administrative conference, or any other document initiating litigation has been filed on the liability issue, a QRC who elects to withdraw must file the R-3 with the Department of Labor and Industry and send copies to the parties, including a separate copy to the Department’s Vocational Rehabilitation Unit. If no litigation is pending on the liability issue, the QRC may withdraw by filing an R-8 Plan Closure form if permitted by Minn. Rule 5220.0510, subp. 7. Instructions to Other Parties Within 15 days of receiving a proposed amendment: 1. If you agree with the amendment, sign the R-3 and return to the QRC; or 2. If you disagree with the amendment, notify the QRC of your objections and try to work with the QRC to resolve them. If the issues are not resolved, the objecting party must file a Rehabilitation Request with the Department of Labor and Industry within 15 days of the receipt of the R-3. NOTE: If a party fails to sign or object to a proposed amendment within 15 days of receiving the R-3, the amendment is deemed approved.

This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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.

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Plan Progress Report
Enter dates in MM/DD/YYYY format.
P R 0 1

DO NOT USE THIS SPACE

1. DATE OF THIS REPORT 2. SOCIAL SECURITY NUMBER 4. EMPLOYEE NAME 5. EMPLOYEE ADDRESS CITY 6. EMPLOYER NAME 9. INSURER CLAIM NUMBER 10. INSURER/SELF-INSURER/TPA 11. INSURER ADDRESS CITY 12. CLAIM REPRESENTATIVE STATE ZIP CODE STATE ZIP CODE 7. EMPLOYER CONTACT PERSON 14. QRC NAME 15. QRC FIRM 16. ADDRESS CITY 18. QRC FIRM # STATE ZIP CODE 8. PHONE NUMBER 3. DATE OF INJURY

13. PHONE NUMBER 17. QRC #

19. PHONE NUMBER

20. Is the employee released to return to work? 21. Current work status: 22. Is the plan still current? Not working Yes

Yes, Part time No

with restrictions

Yes, restrictions Seasonal layoff

without

Medical report date No If working, is this a temporary job? Yes No

Full time

Plan costs to date 23. Costs 24. Plan duration from plan filing date (in weeks) Duration to date + +

Other costs necessary to complete plan = Expected additional duration to plan completion = Yes No

Estimated total cost

Estimated total duration

25. Do barriers to successful completion of the rehabilitation plan exist?

If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form.

This form is required to be filed 6 months after filing the R-2 (unless an R-3 is filed 15 days before or after 6 months have passed since the R-2 filing date). See Minn. Rules 5220.0450, subp. 3 A. Send copies to the employee, insurer, and attorney(s). Send to the date-of-injury employer if the goal of the rehabilitation plan is to return to work with that employer.
This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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 PR01 (6/05)

Forms

On-the-Job Training
On-the-job training means training while employed at a workplace where the employee receives instruction from an experienced worker and which is likely to result in employment with the on-the-job training employer upon its completion. When an on-the-job training plan is submitted to the department, the department reviews the proposed plan within 30 days of its submission and notifies the parties of plan approval or rejection. The plan approval process is subject to the procedures under Minnesota Rules Part 5220.0410, Subp. 6. The commissioner may make a determination or pursue resolution of disputes regarding the plan consistent with Minnesota Rules Part 5220.0950, Subp. 3.

Retraining
Retraining is training for a new occupation and obtaining the necessary skills to obtain work which produces an economic status as close as possible to what the employee would have enjoyed without disability. Retraining is to be given equal consideration with other rehabilitation services and may be proposed for approval if other considered services are not likely to lead to suitable gainful employment. When the QRC determines retraining to be appropriate, the QRC completes a Retraining Plan describing the recommended course of study and circulates it to the employee, employer, and insurer for their signatures. When the QRC submits a Retraining Plan to the department with all three signatures, the department reviews the plan within a day or two of its submission, notifies the parties of its approval or denial and mails the Proof of Service to all parties with a signed copy of the Retraining Plan. For injuries from October 1, 1995 through September 30, 2000, a request for retraining of an employee must be filed with the department before the insurer has paid 104 weeks of temporary total and/or temporary partial disability benefits. For injuries on or after October 1, 2000, any request for retraining must be filed with the department before 156 weeks of temporary total and/or temporary partial disability benefits have been paid. The insurer must notify the employee in writing of this requirement, and this notice must be given before 80 weeks of temporary total and/or temporary partial benefits have been paid.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-29

Forms

July 2007 7-30

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

On the Job Training Plan
Enter dates in MM/DD/YYYY format.
J A 0 4

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

SOCIAL SECURITY NUMBER EMPLOYEE NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER OJT EMPLOYER NAME OJT EMPLOYER ADDRESS CITY

DATE OF INJURY

OJT JOB TITLE OJT BEGINNING DATE OJT ENDING DATE STATE ZIP CODE OJT PLAN PROGRESS EVALUATION DATE(S)

Does this OJT employer intend to hire the employee upon completion of the OJT?

Yes

No

JOB DESCRIPTION (attach a job analysis, or describe the nature of the work, giving examples of duties)

Job must be within the employee’s physical restrictions. ATTACH MEDICAL REPORT. List the skills the employee will acquire through this training:

List supplies and tools needed during training (itemize costs):

TOTAL COSTS

WEEKLY WAGES AND WORKERS’ COMPENSATION BENEFITS Weekly wages paid by OJT Employer Weekly workers’ compensation benefits paid by Insurer

Start of OJT

End of OJT

MN JA04 (12/05)

(over)

cc: Employee, Insurer, OJT Employer

RATIONALE FOR OJT: see Minn. Rule 5220.0850, subp. 2(N) [NOTE: Justification is required for plans EXCEEDING 6 months: see Minn. Rule 5220.0850, subp. 3]

ACCEPTED PLAN: If all parties are in agreement with (and have signed) this OJT Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0850, subp. 4).
Employee Signature Insurer Representative Signature OJT Employer Signature OJT Trainer Signature QRC Signature QRC Number Print or type name Print or type name Print or type name Print or type name Print or type name Phone number Phone number Phone number Phone number Phone number Date Date Date Date Date

INSTRUCTIONS TO QRC DISPUTED PLAN: To resolve a disputed OJT Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032, and/or file a Rehabilitation Request (see Minn. Rule 5220.0850, subp. 5). DO NOT SUBMIT A DISPUTED PLAN to the Department without attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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. For Department Use Only Approved DLI Representative Signature Reason for denial: Denied Print or type name Phone number Date

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Retraining Plan
Enter dates in MM/DD/YYYY format.
E P 0 4

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

SOCIAL SECURITY NUMBER EMPLOYEE NAME EMPLOYER NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER

DATE OF INJURY

CLAIM REPRESENTATIVE

PHONE NUMBER

Pre-injury job title Occupational goal(s) Certificate/Degree program title School name Program length (weeks)

Pre-injury wage

Current compensation rate

Anticipated wage (from Labor Market Survey) Program start date City, State to Program completion date

ITEMIZED COSTS: * Explain (for example, tutoring, board and lodging) Tuition/Lab/Activity fees Books/Tools Special/Unique costs* Custodial Day Care Travel/Parking Total retraining costs (excluding wage benefits) REQUIRED ATTACHMENTS: Pursuant to Minn. Rule 5220.0750, subp. 2(H), the following items MUST BE ATTACHED. a. Course syllabus/class titles. b. Physical requirements of the job for which the employee is being trained. (On-site job analysis is preferred.) c. Medical information that the training and the occupational goals are within the employee’s restrictions. d. Test results which support course choice. e. Recent labor market survey.
MN EP04 (12/05) (over) cc: Employee, Insurer

RETRAINING RATIONALE: see Minn. Rule 5220.0750, subp. 2(F)

ACCEPTED PLAN: If all parties are in agreement with (and have signed) this Retraining Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0750, subp. 5).
Employee Signature Insurer Representative Signature QRC Signature QRC Number Print or type name Print or type name Print or type name Phone number Phone number Phone number Date Date Date

INSTRUCTIONS TO QRC NOTE: Retraining is limited to 156 weeks. DISPUTED PLAN: To resolve a disputed Retraining Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032 and/or file a Rehabilitation Request (see Minn. Rule 5220.0950). DO NOT SUBMIT A DISPUTED PLAN to the Department without attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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. For Department Use Only Approved DLI Representative Signature Reason for denial: Denied Print or type name Phone number Date

Forms

R-8 Notice of Rehabilitation Plan Closure
When an employee’s rehabilitation plan is completed and closure of rehabilitation services is not disputed, the QRC must file a Notice of Rehabilitation Plan Closure along with a Closure Report summarizing services provided. When the reason for the closure is a return to work, the QRC may not complete and file the closure report until the employee has continued working for at least 30 calendar days following the return to work. This form must be filed with the department, with copies sent to the employee and the insurer. At any time, the insurer or employee may request the closure or suspension of rehabilitation services by filing a “Rehabilitation Request” form. The commissioner or a compensation judge may close rehabilitation services for good cause, including, but not limited to the following reasons: • • • • denial of primary liability lack of medical causation employee is not cooperating with the plan employee is not likely to benefit from further rehabilitation services

Note: An insurer intending to discontinue rehabilitation benefits as well as TTD or TPD benefits must file a “Rehabilitation Request” form in addition to the NOID form.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 7-31

Forms

July 2007 7-32

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-8 Notice of Rehabilitation Plan Closure
Enter dates in MM/DD/YYYY format.

N R 0 1

DO NOT USE THIS SPACE

1. DATE OF REHABILITATION CONSULTATION: (#27 on R-2)

2. SOCIAL SECURITY NUMBER

3. DATE OF INJURY

8. QRC NAME

4. EMPLOYEE NAME 5. DATE-OF-INJURY EMPLOYER

9. ADDRESS CITY STATE ZIP CODE

6. INSURER/SELF-INSURER/TPA

10. QRC NUMBER

11. QRC FIRM #

12. QRC PHONE #

7. INSURER CLAIM NUMBER

13. NAME OF LAST REGISTERED REHAB VENDOR

14. VENDOR #

15. EMPLOYMENT STATUS AT PLAN CLOSURE (check one) a. Employee RTW with DOI employer b. Employee RTW with different employer c. Employee not employed (Skip to item 21) COMPLETE #16-20 IF EMPLOYEE RETURNED TO WORK 16. EMPLOYER AT PLAN CLOSURE

21. REASON FOR REHABILITATION PLAN CLOSURE (check one) (see instructions on back) a. Plan completed (employee returned to suitable gainful employment) b. Award on Stipulation/Mediation c. Commissioner or Compensation Judge Order d. Employee and insurer have agreed to close the plan

17. JOB TITLE AT PLAN CLOSURE

e. Unable to locate employee f. Death of employee g. QRC withdrawal

18. Gross weekly wage at RTW

19. RTW DATE

22. Did employee have an attorney? Yes No

23. PLAN CLOSURE DATE

20. RETURN TO WORK JOB: Same job Modified job Different job

24. Check if services provided: On-the-job training Retraining $ $ $ $ $ $ $

25. Cost of prior QRC Firm services other than placement 26. Cost of current QRC Firm services other than placement 27. Cost of any job placement and job development provided by prior QRC Firm 28. Cost of any job placement and job development provided by current QRC Firm 29. Cost of job placement and job development by Registered Rehabilitation Vendor(s) (including CARF accredited) 30. Cost of other rehabilitation services (retraining, on-the-job training, relocation, testing, etc.) 31. Total cost of rehabilitation services (add 25-30)

By signing this form, I certify that copies of this form and attachments are being sent to the insurer, any attorney(s), the Department of Labor and Industry , and if required to the VRU, and to the employee at the following address: 32. QRC signature 33. Date form completed

EMPLOYEE: IF YOU HAVE QUESTIONS ABOUT THE CLOSURE OF THIS REHABILITATION PLAN, CALL THE DEPARTMENT OF LABOR AND INDUSTRY AT 651-284-5032 OR 1-800-342-5354
MN NR01 (6/05)

Instructions to QRC

The Notice of Rehabilitation Plan Closure (R-8) form must be filed with the Department of Labor and Industry within 30 calendar days of knowledge that: (see Minn. Rules 5220.0510, subps. 7 and 7a) a. the employee has been steadily working at suitable gainful employment for 30 days or more, or the time period provided for in the plan b. the employee’s rehabilitation benefits have been closed out by an award on stipulation or award on mediation c. the commissioner or a compensation judge has ordered that the rehabilitation plan be closed and there has been no timely appeal of that order d. the employee and insurer have agreed to close the rehabilitation plan e. the QRC has been unable to locate the employee following a good faith effort to do so f. the employee has died g. the QRC decides to withdraw after the insurer has provided written notice to the employee, the employee’s attorney, the commissioner, and the QRC that the insurer is denying further liability for the injury for which rehabilitation services are being provided. In this situation, the QRC must file the R-8 and attach a copy of the insurer’s notice of denial, copying appropriate parties, including a separate copy to the Department’s Vocational Rehabilitation Unit. NOTE: This does not apply if a claim petition, objection to discontinuance, request for an administrative conference, or other document initiating litigation has been filed on the liability issue. If one of these documents has been filed and the QRC decides to withdraw, the QRC shall document the withdrawal by filing a Rehabilitation Plan Amendment (R-3). ATTACH A CLOSURE REPORT SUMMARIZING SERVICES PROVIDED. (see Minn. Rule 5220.0510, subp. 7(4)) Send copies of the R-8 to the employee, insurer, and attorney(s). If the insurer is denying further liability, send a separate copy addressed to the Department’s Vocational Rehabilitation Unit.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.

Forms

Medical Request
A Medical Request form is used to request the department’s help in resolving a workers’ compensation dispute that involves medical issues. This form should not be used if the dispute involves rehabilitation, wage loss, or permanency benefits. Parties involved in a medical dispute should try to resolve the dispute themselves prior to filing the request form. They can also call the department’s Workers’ Compensation Hotline for help in resolving the dispute informally. Medical Requests are usually filed by employees or healthcare providers to get approval for payment of a medical service which was denied by the insurer. An insurer may also file such a request to resolve a dispute over treatment. This form is also filed to a request for a change of treating doctor. Be sure to fill out the name of the current treating doctor and the name of the doctor to whom treatment should be switched. If the employee is requesting a change of doctor and the insurer agrees, this form does not need to be filed. Medical Responses are filed within 20 days after the Medical Request is filed. If the dispute involves surgery or medical services exceeding $7,500.00, the request is automatically referred to OAH for a formal hearing. Otherwise, the matter will be set for an administrative conference with a mediator at the department.

Medical Response
If the employee or health care provider has filed a Medical Request form, the insurer must file a Medical Response form with the department and serve copies on the other parties no later than 20 days after service of the Medical Request. Once the department processes both the Medical Request and the Medical Response, a legally binding written decision may be made based on the information submitted on the forms. It is important that the insurer make their response as complete as possible.

Rehabilitation Request
A Rehabilitation Request form is used to request the department’s help in resolving a workers’ compensation dispute that involves rehabilitation issues. This form should not be used if the dispute involves medical, wage loss, or permanency benefits. Parties involved in a rehabilitation dispute should try to resolve the dispute themselves prior to filing the request form. They can also call the department’s Workers’ Compensation Hotline for help in resolving the dispute informally. Typical disputes filed by insurers include requesting that a plan be changed or terminated. For example, the insurer could file a Rehabilitation Request form if the QRC believes the employee should be retrained and they believe it is not
Basic Adjusters’ Training Guide MN Department of Labor and Industry July 2007 7-33

Forms

necessary. If the insurer submits a request to terminate the rehabilitation plan, they must send the employee a Rehabilitation Response form with the employee’s copy of the request.

Rehabilitation Response
If another party has filed a Rehabilitation Request form, the responding party should file a Rehabilitation Response form in a timely manner. The department expedites the processing of all Rehabilitation Requests and will begin to intervene immediately.

Request for Formal Hearing
When a party wishes to appeal a medical or rehabilitation decision and order per Minnesota Statutes §176.106, this form must be filed within 30 days after the decision and order was served on the parties.

Objection to Penalty Assessment
When a party wishes to object to a penalty assessment, this form must be served on the parties and with the department within 30 days after the notice of penalty assessment was served on the parties.

July 2007 7-34

Basic Adjusters’ Training Guide MN Department of Labor and Industry

CHECK BOX IF THIS REQUEST ADDS MEDICAL ISSUES TO A PENDING MEDICAL REQUEST SOCIAL SECURITY NUMBER

Medical Request
Enter dates in MM/DD/YYYY format.

NOTE: Before filing this form, call the workers’ compensation insurer. If that does not resolve the issue, call Workers’ Compensation Benefit Management and Resolution at (651) 284-5032 (or 1-800-342-5354).

M

Q

0 3

DO NOT USE THIS SPACE

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • This form must be filled out completely; otherwise, it may be returned to you. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee’s Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer’s Attorney

Health Care Provider

2. 3.

Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information showing that the dispute resolution process of the certified managed care plan has already been exhausted. MEDICAL ISSUES (check only those that apply) I request: a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets if needed. Itemized bills and supporting medical reports must be attached.) NAME ADDRESS UNPAID BALANCE

b. FROM: TO: c. d. e.

a change of treating doctor: NAME NAME ADDRESS ADDRESS SPECIALTY SPECIALTY

that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting medical reports.) that the employee’s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports. a second opinion or consultation with NAME SPECIALTY

f.

other (explain):

MN MQ03 (12/05)

(over)

IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST. 4. HAS ANYONE OTHER THAN THE WORKERS’ COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO THIS DISPUTE? YES NO If yes, bills were paid by: Medicare NAME employee Veterans Administration Dept. of Human Services (Welfare) other POLICY NUMBER

Social Security Administration ADDRESS

private health insurance

In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.

5.

Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.

6.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys, and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #6 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

Medical Response
Enter dates in MM/DD/YYYY format.

THIS FORM RESPONDS TO ISSUES RAISED ON THE MEDICAL REQUEST FORM THAT WAS SIGNED ON

M

R 0 3

(date)

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. • This form must be filled out completely. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • You must complete this response form and send it to the address on the back of this form within 20 days of the date you received the Medical Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. YES NO

2.

THIS RESPONSE IS BEING COMPLETED BY: Employee’s Insurer/TPA Insurer’s Health Care Employee Employer Attorney Self-insured Attorney Provider The employee has not exhausted the dispute resolution process of the certified managed care plan. The employee may contact at Name of the Certified Managed Care Plan (phone) to initiate this process.

3.

RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I respond to the request for payment of medical or chiropractic bills as follows: (List the health care providers and your response to the specific bill amounts listed on the Request form. Attach extra sheets if needed). HEALTH CARE PROVIDER ALREADY PAID AGREE TO PAY REFUSE TO PAY

b. c. d. e. f.

I I I I

agree agree agree agree

disagree refuse refuse disagree

with the request to change treating doctors. to pay for the requested treatment, surgery or equipment. to reimburse the employee for medical expenses. with the request for a second opinion or consultation.

Response to “Other”:

MN MR03 (12/05)

(over)

YOU MUST COMPLETE # 4 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 4. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers’ Compensation Division file, and the Medical Request form. Specify any applicable treatment parameter(s): Minn. Rule 5221.

5.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #5 on PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

CHECK BOX IF THIS REQUEST ADDS REHABILITATION ISSUES TO A PENDING REHABILITATION REQUEST SOCIAL SECURITY NUMBER

Rehabilitation Request
Enter dates in MM/DD/YYYY format.

NOTE: Before filing this form, call the workers’ compensation insurer. If that does not resolve the issue, call Workers’ Compensation Benefit Management and Resolution Unit at (651) 284-5032 (or 1-800-342-5354).

R Q

0 3

DO NOT USE THIS SPACE

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • This form must be filled out completely; otherwise, it may be returned to you. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • This form may not be used to request wage loss, medical, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee’s Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer’s Attorney

QRC/ Vendor

2.

REHABILITATION ISSUES (check only those that apply) I request: a. b. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions. a change of QRC (qualified rehabilitation consultant): NAME FIRM NAME T O ADDRESS PHONE # (include area code)

NAME F FIRM NAME R O ADDRESS M PHONE # (include area code) c. d. e. f. g. h. i. that the rehabilitation plan be changed. retraining or exploration of retraining. that the rehabilitation plan be terminated. that the rehabilitation plan be suspended.

that the employee’s rehabilitation expenses be reimbursed. Attach itemized bills and supporting documentation. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills. other (explain)

MN RQ03 (11/05)

(over)

3.

Explain the details of your request. Attach all documents, such as medical reports and rehabilitation reports/bills, which support your request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.

4.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

Rehabilitation Response
Enter dates in MM/DD/YYYY format.

THIS FORM RESPONDS TO ISSUES RAISED ON THE REHABILITATION REQUEST FORM WHICH WAS SIGNED ON

R R 0 3

(date)

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. • This form must be filled out completely. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • Insurers must file this form with the Department of Labor and Industry, and serve this form on the other parties, within 10 days after service of the Rehabilitation Request. All others should file this form with the Department of Labor and Industry, and serve it on all parties, within 20 days after service of the Rehabilitation Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS RESPONSE IS BEING COMPLETED BY: Employee’s Insurer/TPA Employee Employer Attorney Self-insured RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I agree disagree with the request for rehabilitation consultation/services. YES NO

Insurer’s Attorney

QRC/ Vendor

2.

IF A QRC IS BEING ASSIGNED, GIVEN NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC. NAME FIRM NAME ADDRESS SELECTED BY

b. c. d. e. f. g. h. i.

I I I I I I I

agree agree agree agree agree agree agree

disagree disagree disagree disagree disagree refuse refuse

with the request to change QRCs. that the rehabilitation plan should be changed. with the request for retraining/exploration of retraining. that the rehabilitation plan should be terminated. that the rehabilitation plan should be suspended. to reimburse the employee for rehabilitation expenses. to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for dispute.

Response to “Other”:

MN RR03 (11/05)

(over)

YOU MUST COMPLETE # 3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers’ Compensation Division file, and the Rehabilitation Request form.

4.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

SOCIAL SECURITY NUMBER

DATE(S) OF CLAIMED INJURY

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 1-800-342-5354 (DIAL-DLI)

R F 0 3

DO NOT USE THIS SPACE

EMPLOYEE VS. EMPLOYER AND INSURER AND ADDITIONAL PARTIES (INCLUDING INTERVENORS)
Please PRINT or TYPE. Enter dates in MM/DD/YYYY format.

Request for Formal Hearing
(under M.S. 176.106 or 176.305)

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

TO THE ABOVE NAMED PARTIES AND THEIR ATTORNEYS: The above-named party, a formal hearing. An administrative decision on the issues was previously issued by: (Name) The decision was served and filed on: specific reason(s) for disputing the decision are as follows: . (date). The specific issues in dispute and the , requests

MN RF03 (10/04)

(over)

Copies of this request have been served on all parties and their attorneys who are listed with addresses and attorney registration numbers as follows: (attach additional sheet if necessary) Employee: Employee Attorney:

Employer:

Employer/Insurer Attorney:

Insurer:

Other Party (Specify):

REQUESTOR SIGNATURE

ATTORNEY FOR PARTY SIGNATURE

REQUESTOR PRINTED NAME

ADDRESS

DATE

CITY

STATE

ZIP CODE

ATTORNEY REGISTRATION #

PHONE # (include area code)

INSTRUCTIONS This form must be served on each party and each party’s attorney, and received by the Department within 30 days after the date the decision was served and filed. Issues and reasons for the request must be specifically listed. For example, a general statement that the prior decision is not in conformity with the Workers’ Compensation Act is not a specific statement of the disputed issues. All requests will be referred to the Office of Administrative Hearings for a formal hearing before a workers’ compensation judge. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) 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.

Minnesota Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155 (651) 284-5030 SOCIAL SECURITY NUMBER DATE OF INJURY

C E 0 0 0 3

EMPLOYEE NAME

PENALTY NUMBER

INSURER’S CLAIM NUMBER

DEPARTMENT OF LABOR AND INDUSTRY WORKERS’ COMPENSATION DIVISION VS. EMPLOYER

OBJECTION TO PENALTY ASSESSMENT
AND

INSURER

Minnesota Rules Part 5220.2870 PENALTY OBJECTION AND HEARING states: “A party to whom notice of assessment has been issued may object to the penalty assessment by filing a written objection with the division on the form prescribed by the commissioner. The objection must also be served on the employee if the penalty is payable to the employee. The objection must be filed and served within 30 days after the date the notice of assessment was served on that party by the division. (emphasis added) The written objection must contain a detailed statement explaining the legal or factual basis for the objection and including any documentation supporting the objection. Upon receipt of a timely objection, unresolved issues shall be referred for a hearing to determine the amount and conditions of any penalty. Objections which are not served and filed within the 30-day objection period must be dismissed by a compensation judge.” The above-named Employer/Insurer objects to the following portion of the Notice of Assessment of Penalty filed in this matter and requests that this matter be set for hearing. 1) Additional award to the Employee (M.S. § 176.225) 2) Payment to the Assigned Risk Safety Account (M.S. § 176.221, subd. 3 or 3a) 3) Penalty for failure to file required report (M.S. § 231, subd. 10) 4) Other, please explain: Detailed statement/documentation to support your objection (M.R. 5220.2870): (Attached additional sheets as necessary.)

Objection to Penalty Assessment filed by:
NAME Employer COMPANY NAME Insurer ADDRESS Attorney CITY TELEPHONE STATE ZIP

Filing party is

Other_____________________________

MN CE0003 (9/03)

PROOF OF SERVICE STATE OF MINNESOTA ss. COUNTY OF ____________

I, ________________________________________________________, being first duly sworn, depose and state that on __________________, 20___, I served a true and correct copy of the enclosed document upon all interested parties to this objection, with postage prepaid, in the United States mail at ____________________, _______________, addressed as follows: (City) (State)

SEND ORIGINAL TO:
Compliance Services Minnesota Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155

SEND COPIES TO:
(Provide Names and Addresses)

Employer (if objection filed by Insurer, or other party):

Other parties (if applicable):

Insurer (if objection filed by Employer, or other party):

Employee (if applicable)

Subscribed and sworn to before me this ____ day of ________________, 20___. ___________________________________ Notary Public ______________________________________________ Signature

Forms

Forms Filing Table
(when to file common forms with the department)
FORM # FORM NAME Indemnity Benefits FR01 First Report of Injury FROI This form must be filed by the insurer if the claim results in the employee’s inability to work for a period of more than three calendar days or results in PPD: • within 14 days of the first day of disability, or the date the employer was aware of the disability, whichever is later; • within 10 days of a request from the department, to complete a substitute filing of this form if the employer is unable or refuses to file this form. This form must also be filed within 21 days upon specific request from the department. This form must be filed by the insurer when, after reviewing the FROI, there appears to be claimed lost time beyond the waiting period. When accepting liability and making payment of wage-loss benefits, this form must be filed whenever the following occurs: • liability is accepted and the initial payment is made for TTD, TPD, or PTD benefits; • liability is accepted for wage-loss benefits and the employer has a full-wage plan; • liability is accepted payment is made on a fatality. The first payment must be made within 14 days of the first day of disability, or the date the employer was aware of the disability, whichever is later. When partially accepting liability but not making payment of wage-loss benefits, this form must be served on the employee and filed the department within 14 days of the first day of the disability or the date the employer was aware of the disability, whichever is later, whenever the following occurs: • liability is accepted but denial of the initial claimed disability is determined; or • liability is accepted for temporary partial benefits and payment will be made in the future, upon receipt of wage-loss information. When denying primary liability, this form must be served on the employee and filed the department within 14 days of the first day of the disability or the date the employer was aware of the disability, whichever is later. This form must also be filed within 21 days upon specific request from the department. NOTE: NOPLDs may be filed multiple times on a claim. This form must be filed by the insurer to reduce or discontinue TTD, TPD, or PTD benefits: • within 14 days of the date the insurer receives notice that the employee has returned to work at full or reduced wages; • at the same time that benefits are reduced or discontinued for reasons other than return to work;
July 2007 7-35

AKA

WHEN TO FILE

NL01

Notice of NOPLD Insurer’s Primary Liability Determination

ND01

Notice of NOID Intention to Discontinue WC Benefits

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Forms

FORM # FORM NAME

AKA

WHEN TO FILE when discontinuing benefits and denying primary liability on a previously accepted claim when it is more than 60 days from the first day of disability or the date the employer was aware of disability, whichever is later. This form must also be filed within 21 days upon specific request from the department. •

NC01

Notice of Benefit NOBR Reinstatement

This form must be filed by the insurer at the time TTD, TPD, or PTD benefits are reinstated, TPD benefits are changed to TTD benefits, or payment of wage continuation by the employer for TTD or TPD is changed to TTD or TPD paid by the insurer. This form must also be filed within 21 days upon specific request from the department. This form must be filed by the insurer at the time the initial and final PPD payments are made or when a final payment is made per award or order. This form must also be filed within 21 days upon specific request from the department. This form must be filed by the insurer annually, for as long as indemnity benefits continue, at one year after the last payment form was filed with the department. This form must also be filed within 21 days upon specific request from the department. This form must be filed by the insurer to discontinue TTD, TPD, or PTD benefits as soon as the insurer learns of the death of the employee. This form must also be filed within 21 days upon specific request from the department. This form must be filed at the time the insurer reduces or stops payment of dependency benefits. This form must also be filed within 21 days upon specific request from the department. This form should only be filed when the insurer needs additional space when filing one of the following forms: NOID, NOBP, ISR, or NOD Death. This form may be filed by the insurer within 14 days of notice to or knowledge by the employer of a new period of TTD that is related to a prior paid claim.

NB01

Notice of Benefit NOBP Payment

IS03

Interim Status Report

ISR

BD02

Notice of Discontinuance of WC Benefits Upon Death of Employee Notice of Discontinuance of Dependency Benefits Benefit Addendum Request for Extension

DB02

BA01

QE03

Medical HC01 Health Care Provider Report HCPR This form is completed by the primary health care provider and must be filed by the insurer when there is a preliminary or final permanent partial disability rating. The completed form may be filed by the insurer when the employee has reached maximum medical improvement. This form must also be filed within 21 days upon specific request from the department. This form must be completed by the primary health care provider every two weeks or at every visit if visits are less frequent and given to the employee (but not filed with the department). The employee provides the RWA to the employer or insurer.
July 2007 7-36 Basic Adjusters’ Training Guide MN Department of Labor and Industry

RW01

Report of Workability

RWA

Forms

FORM # FORM NAME MQ03 MR03 Medical Request Medical Response

AKA

WHEN TO FILE This form may be filed by any party when there is a dispute involving medical issues. This form is filed within 20 days after service of the medical request or within the time period provided by Minnesota Rules Part 5221.6050, Subp. 7. This form must be filed by the insurer within 14 days of knowledge that the TTD will likely exceed 13 weeks or within 90 calendar days of the date of injury when the employee has not returned to work after the injury or within 14 calendar days after receiving a request for a rehabilitation consultation, whichever comes first. This form must also be filed within 21 days upon specific request from the department. This form must be filed by the QRC within 14 days of the first in-person meeting with employee A signed copy of the “Rights and Responsibilities of the Injured Worker” as well as an assessment of whether or not the employee is a qualified employee for rehabilitation services should be filed with the RCR. Needs to be filed with the RCR.

Rehabilitation DS01 Disability Status DSR Report

RC01

Rehabilitation Consultation Report

RCR

IW05

Rights and Responsibilities of the Injured Worker R-2 Rehabilitation Plan R-2

RE01

This form must be filed by the QRC within 45 days of the first in-person contact with employee or within 15 days of circulation of the parties, whichever is earlier. A copy of the QRC’s initial evaluation narrative report must also be filed with the R-2. This form must be filed by the QRC within 15 days of circulation to the parties.

RP01

R-3 Rehabilitation Plan Amendment Plan Progress Report

R-3

PR01

PPR

This form must be filed by the QRC within 15 days after 6 months have passed from date of filing of the rehabilitation plan. An R-3 may be used in lieu of the PPR if filed within the same time period. This form must be filed by the QRC to submit on-the-job training plan for approval. The department shall review the proposed plan within 30 days of its submission and notify the parties of the plan’s approval or rejection. This form must be filed by the QRC to submit a retraining plan for approval. The department shall review the proposed retraining plan within 30 days of its submission and notify the parties of the plan’s approval or denial.

JA04

On the Job Training Plan

OJT

EP04

Retraining Plan

NR01

R-8 Notice of Rehabilitation Plan Closure

R-8

This form must be filed by the QRC within 30 calendar days of knowledge that: 1) the employee has been steadily working at suitable gainful employment for 30 days or more, or the time period provided in the plan. 2) the employee’s rehabilitation benefits have been closed
July 2007 7-37

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Forms

FORM # FORM NAME

AKA

WHEN TO FILE out by an award on stipulation or an award on mediation. 3) the employee and insurer have agreed to close the rehabilitation plan. 4) the QRC has been unable to locate the employee following a good faith effort to do so. 5) the employee has died. 6) the commissioner or a compensation judge has ordered that the rehabilitation plan be closed and there has been no timely appeal of that order. 7) the QRC decides to withdraw after the insurer has provided written notice to the employee, the employee’s attorney, the department, and the QRC that the insurer is denying further liability for the injury for which rehabilitation services are being provided.

RQ03 RR03

Rehabilitation Request Rehabilitation Response

This form may be filed by any party when there is a dispute involving rehabilitation issues. It is recommended that a response be filed within twenty days after receipt of the rehabilitation request. When a party wishes to object to a penalty assessment, this form must be served on the parties and filed with the department within 30 days after the notice of penalty assessment was served on the parties. This form must be filed by the employee’s attorney, prior to filing a medical or rehabilitation request form, to allow the department to certify that a medical or rehabilitation dispute exists. Exception: It is not needed when there is other pending litigation. When a party wishes to appeal a medical or rehabilitation decision and order per Minnesota Statutes §176.106, this form must be filed within 30 days after the decision and order was served on the parties. This form may be filed at the time the insurer determines their file can be closed. Be sure all required documents have been sent to the department before filing this form.

Miscellaneous CE0003 Objection to Penalty Assessment CA0022 Request for Certification of Dispute

RF03

Request for Formal Hearing

NF01

Notice of File Closing

July 2007 7-38

Basic Adjusters’ Training Guide MN Department of Labor and Industry