Form MN RS05 "Notice of Intention to Claim Reimbursement From the Second Injury Fund" - Minnesota

What Is Form MN RS05?

This is a legal form that was released by the Minnesota Department of Labor and Industry - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the Minnesota Department of Labor and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MN RS05 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Labor and Industry.

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Download Form MN RS05 "Notice of Intention to Claim Reimbursement From the Second Injury Fund" - Minnesota

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Department of Labor and Industry
Notice of Intention to Claim
Special Compensation Fund
Reimbursement From the
PO Box 64229
R S 0 5
St. Paul, MN 55164-0229
Second Injury Fund
(651) 284-5045 or 1-800-342-5354
DO NOT USE THIS SPACE
Fax: (651) 215-9099
PRINT IN INK or TYPE YOUR RESPONSES
ALL DATES MUST BE ENTERED in MM/DD/YYYY
WID or SSN
DATE OF INJURY
EMPLOYEE NAME
INSURER/SELF-INSURER
EMPLOYER NAME
INSURER/ ADDRESS
INSURER CLAIM NUMBER
CITY
STATE
ZIP CODE
ATTACH COPY OF ACCEPTED REGISTRATION OR DOCUMENTATION OF AUTOMATIC REGISTRATION
1. Nature of registered condition
2. Dates of previous work-related injuries, if any
3. Nature of subsequent injury causing disability for which reimbursement is being claimed
4. The insurer is claiming that this disability is (check one):
a.
more serious because of the registered condition (substantially greater) M.S. § 176.131, subd. 1.
b.
caused by the registered condition (except for) M.S. § 176.131, subd. 2.
ATTACH MEDICAL REPORTS TO SUPPORT THE ITEM CHECKED ABOVE
COMPLETE THE REHABILITATION AND WORK STATUS REPORT ON THE BACK OF THIS FORM
Name of Preparer
Date
TPA Name
Phone No. (include area code & ext.)
Address
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY
MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
SPECIAL COMPENSATION FUND OFFICE USE ONLY
Claim APPROVED on __________________ by _______________________________________________________________
Deductibles
26 weeks and $1,000
52 weeks and $2,000; apportionment under M.S. § 176.131, subd.1(a)
52 weeks and $2,000
No deductibles
Other: _________________________________________________________________________________________________
Claim REJECTED on __________________ by _______________________________________________________________
Deductibles
No registration found
Documentation of automatic registration not attached
Notice was filed late
Medical reports to support claim not attached
Other: _________________________________________________________________________________________________
(over)
MN RS05 (9/15)
Reset
Department of Labor and Industry
Notice of Intention to Claim
Special Compensation Fund
Reimbursement From the
PO Box 64229
R S 0 5
St. Paul, MN 55164-0229
Second Injury Fund
(651) 284-5045 or 1-800-342-5354
DO NOT USE THIS SPACE
Fax: (651) 215-9099
PRINT IN INK or TYPE YOUR RESPONSES
ALL DATES MUST BE ENTERED in MM/DD/YYYY
WID or SSN
DATE OF INJURY
EMPLOYEE NAME
INSURER/SELF-INSURER
EMPLOYER NAME
INSURER/ ADDRESS
INSURER CLAIM NUMBER
CITY
STATE
ZIP CODE
ATTACH COPY OF ACCEPTED REGISTRATION OR DOCUMENTATION OF AUTOMATIC REGISTRATION
1. Nature of registered condition
2. Dates of previous work-related injuries, if any
3. Nature of subsequent injury causing disability for which reimbursement is being claimed
4. The insurer is claiming that this disability is (check one):
a.
more serious because of the registered condition (substantially greater) M.S. § 176.131, subd. 1.
b.
caused by the registered condition (except for) M.S. § 176.131, subd. 2.
ATTACH MEDICAL REPORTS TO SUPPORT THE ITEM CHECKED ABOVE
COMPLETE THE REHABILITATION AND WORK STATUS REPORT ON THE BACK OF THIS FORM
Name of Preparer
Date
TPA Name
Phone No. (include area code & ext.)
Address
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY
MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
SPECIAL COMPENSATION FUND OFFICE USE ONLY
Claim APPROVED on __________________ by _______________________________________________________________
Deductibles
26 weeks and $1,000
52 weeks and $2,000; apportionment under M.S. § 176.131, subd.1(a)
52 weeks and $2,000
No deductibles
Other: _________________________________________________________________________________________________
Claim REJECTED on __________________ by _______________________________________________________________
Deductibles
No registration found
Documentation of automatic registration not attached
Notice was filed late
Medical reports to support claim not attached
Other: _________________________________________________________________________________________________
(over)
MN RS05 (9/15)
VOCATIONAL REHABILITATION AND WORK STATUS REPORT
1. Has the employee returned to work?
Yes
No
Do temporary partial benefits continue to be paid?
Yes
No
2. Has this case been referred for vocational rehabilitation?
Yes
(Complete #3)
No
Reason:
Disability Status Report filed requesting rehabilitation waiver
3. Current status (check ALL that apply):
a. Plan in progress, R-2 submitted
b. On-The-Job Training Plan approved and in progress
c. Retraining approved and in progress
d. Rehabilitation closed, R-8 submitted (check one below):
1. Employee returned to work
2. Employee retired
3. Employee died
4. Rehabilitation discontinued by settlement, mediation, arbitration or order
5. Other
Explain:
Mail or fax completed copy to:
In Person
Mailing Address
Fax
Department of Labor and Industry
Department of Labor and Industry
(651) 215-9099
Special Compensation Fund
Special Compensation Fund
443 Lafayette Road N.
PO Box 64229
St. Paul, MN 55155-4301
St. Paul, MN 55164-0229
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