"Quarterly Expenditure Report Form" - Montana

Quarterly Expenditure Report Form is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on October 9, 2019;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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EXPENDITURE REPORT
WORKERS’ COMPENSATION REGULATION BUREAU
Mail: PO Box 8011 Helena, MT 59604-8011
Street: 1805 Prospect Ave Helena, MT 59601
Phone: (406) 444-6543
Fax: (406) 444-4140
Email:
WCRegBureauQER@mt.gov
Instructions:
General Instructions can be found at the bottom of this report or on our
website at
Quarterly Expenditure Reports
under Workers’ Compensation Regulations Bureau,
Insurance Compliance, and Quarterly Expenditure Reports.
Insurer Name: _________________________________________
DLI#:___________
For the Quarter Ending __________________________________
Compensation __________________________________
Medical __________________________________
Miscellaneous __________________________________
Total __________________________________
Medical in excess of $200,000 per claim
_____________________________________
Report Submitted by:
Reporting Office Name ___________________________________________________
Title/Department ________________________________________________________
Mailing Address _________________________________________________________
City __________________________________ State____________ Zip_____________
Telephone _____________________________________ Ext _____________________
E-mail Address __________________________________________________________
Typed Contact Name _____________________________________________________
Signature ______________________________________________________________
Montana Quarterly Expenditure Form – Revised 10/09/2019
EXPENDITURE REPORT
WORKERS’ COMPENSATION REGULATION BUREAU
Mail: PO Box 8011 Helena, MT 59604-8011
Street: 1805 Prospect Ave Helena, MT 59601
Phone: (406) 444-6543
Fax: (406) 444-4140
Email:
WCRegBureauQER@mt.gov
Instructions:
General Instructions can be found at the bottom of this report or on our
website at
Quarterly Expenditure Reports
under Workers’ Compensation Regulations Bureau,
Insurance Compliance, and Quarterly Expenditure Reports.
Insurer Name: _________________________________________
DLI#:___________
For the Quarter Ending __________________________________
Compensation __________________________________
Medical __________________________________
Miscellaneous __________________________________
Total __________________________________
Medical in excess of $200,000 per claim
_____________________________________
Report Submitted by:
Reporting Office Name ___________________________________________________
Title/Department ________________________________________________________
Mailing Address _________________________________________________________
City __________________________________ State____________ Zip_____________
Telephone _____________________________________ Ext _____________________
E-mail Address __________________________________________________________
Typed Contact Name _____________________________________________________
Signature ______________________________________________________________
Montana Quarterly Expenditure Form – Revised 10/09/2019
Montana Workers’ Compensation Expenditure Report General Instructions
The purpose of the expenditure report is to gather the workers’ compensation costs that are paid
to claimants and/or on behalf of the claimants during the quarter. The costs are broken down
into three categories: (1) compensation benefits paid, (2) medical benefits paid, and (3)
miscellaneous benefits paid. Every insurer is required to file the expenditure report with the
department (MCA 39-71-306). The reported amounts are gross paid amounts and may not be
less than zero.
The DLI Insurer # is the number assigned to the insurer by the Department of Labor & Industry
(DLI).
Reproduce the expenditure report as needed. The format may not be altered. Submit separate
reports for each insurer. A report must be submitted if there are $0 expenditures. Reports must
be received within 15 days of the end of the quarter. (Quarters end September 30, December 31,
March 31 and June 30.) Penalties up to $1,000 may be assessed for late reports (MCA 39-71-
306(2)). Each report must be signed. Reports may be sent to the department by either regular
mail, by facsimile, or by email.
COMPENSATION includes all indemnity payments made for the quarter, including indemnity
benefits paid under a rehabilitation plan.
MEDICAL includes all hospital, medical, surgical, physical therapy, etc. made for the quarter,
including any amounts reimbursable to the insurer under deductible policies.
MISCELLANEOUS may not include any indemnity or medical benefits. Miscellaneous may
include attorney fees, rehabilitation services, rehabilitation expenses such as books and tuition,
auxiliary rehabilitation, independent medical examinations requested by the insurer, burial
expenses, travel expenses, or various other miscellaneous costs paid to or on behalf of the
claimant that do not constitute a compensation or medical benefit. Reporting amounts under
Miscellaneous is required.
MEDICAL IN EXCESS of $200,000 PER CLAIM is excluded from the annual assessment.
Report excess payments over cumulative threshold amount of $200,000 per claim paid in this
quarter. Example: Payments per one claim 1st quarter is $250,000, 2nd quarter $25,000. 1st
quarter report medical $250,000, medical in excess $50,000. 2nd quarter report medical
$25,000, medical in excess $25,000.
Montana Quarterly Expenditure Form – Revised 10/09/2019
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