Form ERD-922 "Montana Workers' Compensation Subsequent Report" - Montana

What Is Form ERD-922?

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

Form Details:

  • Released on February 9, 2010;
  • The latest edition provided by the Montana 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 ERD-922 by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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Download Form ERD-922 "Montana Workers' Compensation Subsequent Report" - Montana

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MONTANA WORKERS’ COMPENSATION SUBSEQUENT REPORT
(1)
(2)
(3)
AGENCY CLAIM NUMBER DN5
EMPLOYEE NAME (LAST, DN43 FIRST, DN44 MI, DN45)
SOCIAL SECURITY NUMBER DN42
(4) DATE OF INJURY DN31
(5) AGREEMENT TO COMPENSATE DN75
(6) DATE DISABILITY BEGAN DN56
(7) PRE-EXISTING
(8) DATE OF
(CHOOSE ONE)
DISABILITY DN69
REPRESENTATION DN76
WITHOUT LIABILITY OR PLACE UNDER 39-71-
608
YES
NO
WITH LIABILITY
(9) RTW QUALIFIER DN71
(10) DATE OF RETURN OR RELEASE TO WORK
(CHOOSE ONE)
DN72
1
ACTUAL RTW WITHOUT PHYSICAL RESTRICTIONS
5
RELEASED RTW WITHOUT PHYISICAL RESTRICTIONS
2
ACTUAL RTW WITH PHYSICAL RESTRICTIONS
6
RELEASED RTW WITH PHYSICAL RESTRICTIONS
(11) EMPLOYEE DATE OF
(12) NUMBER OF DEPENDENTS
(13) DEPENDENT PAYEE
2
WIDOW
6
MOTHER OR FATHER
DEATH DN57
DN55
RELATIONSHIP DN97
3
WIDOWER
7
DISABLED CHILD OVER 18
4
SON OR DAUGHTER
9
OTHER
(CHOOSE ALL THAT APPLY)
5
BROTHER OR SISTER
(14) DATE OF MMI DN70
99
BODY PART CODE DN83
(15) PERMANENT IMPAIRMENT
%
PERMANENT IMPAIRMENT% DN84
(16) MAINTENANCE TYPE CODE DN2 (CHOOSE
(17) CLAIM STATUS DN73 (CHOOSE ONE)
(18) CLAIM TYPE DN74 (CHOOSE ONE)
ONE)
SA
FN
UR
OPEN
(O)
REOPEN
(R)
INJURY (I)
OCCUPATIONAL DISEASE (Z)
CLOSED (C)
REOPEN/CLOSED (X)
(19) CLAIM ADMINISTRATOR FEIN DN8
(20) CLAIM ADMINISTRATOR NAME DN9
(21) CLAIM ADMINISTRATOR CLAIM NUMBER DN15
(22) PRE-INJURY WEEKLY WAGE DN62
(23) TEMPORARY TOTAL DISABILITY RATE
$
$
COMPENSATION PAYMENTS (CUMULATIVE)
(24) LATE
(25) PAYMENT
(27) NET WEEKLY
(28) PAYMENT
(29) PAYMENT
(26) AMOUNT PAID TO
(30) WEEKS PAID
(31) DAYS PAID
REASON CODE
CODE
AMOUNT
START DATE
END DATE
DATE DN86
DN90
DN91
DN77
DN85
DN87
DN88
DN89
$
$
$
$
$
$
$
$
$
$
$
$
BENEFIT ADJUSTMENTS
(Made to weekly corresponding compensation rate)
(32) PAYMENT
(33) BENEFIT
(34) BENEFIT
(35) START
CODE
ADJUSTMENT
ADJUSTMENT WEEKLY
DATE
DN85
CODE
AMOUNT
DN94
DN92
DN93
$
$
$
Weekly Rate - Benefit Adjustment Weekly Amount DN93 = Net Weekly Amount DN87
PAID TO DATE/REDUCED EARNINGS/RECOVERIES (CUMULATIVE)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
CODE
AMOUNT DN96
CODE
AMOUNT DN96
CODE
AMOUNT DN96
CODE
AMOUNT DN96
300
380
440
830
$
$
$
$
DN95
DN95
DN95
DN95
840
330
390
450
$
$
$
$
DN95
DN95
DN95
DN95
840
350
400
800
$
$
$
$
DN95
DN95
DN95
DN95
840
360
420
810
$
$
$
$
DN95
DN95
DN95
DN95
840
370
430
820
$
$
$
$
DN95
DN95
DN95
DN95
ERD-922 (Rev 02-09-10)
Mandatory – Fully complete
MONTANA WORKERS’ COMPENSATION SUBSEQUENT REPORT
(1)
(2)
(3)
AGENCY CLAIM NUMBER DN5
EMPLOYEE NAME (LAST, DN43 FIRST, DN44 MI, DN45)
SOCIAL SECURITY NUMBER DN42
(4) DATE OF INJURY DN31
(5) AGREEMENT TO COMPENSATE DN75
(6) DATE DISABILITY BEGAN DN56
(7) PRE-EXISTING
(8) DATE OF
(CHOOSE ONE)
DISABILITY DN69
REPRESENTATION DN76
WITHOUT LIABILITY OR PLACE UNDER 39-71-
608
YES
NO
WITH LIABILITY
(9) RTW QUALIFIER DN71
(10) DATE OF RETURN OR RELEASE TO WORK
(CHOOSE ONE)
DN72
1
ACTUAL RTW WITHOUT PHYSICAL RESTRICTIONS
5
RELEASED RTW WITHOUT PHYISICAL RESTRICTIONS
2
ACTUAL RTW WITH PHYSICAL RESTRICTIONS
6
RELEASED RTW WITH PHYSICAL RESTRICTIONS
(11) EMPLOYEE DATE OF
(12) NUMBER OF DEPENDENTS
(13) DEPENDENT PAYEE
2
WIDOW
6
MOTHER OR FATHER
DEATH DN57
DN55
RELATIONSHIP DN97
3
WIDOWER
7
DISABLED CHILD OVER 18
4
SON OR DAUGHTER
9
OTHER
(CHOOSE ALL THAT APPLY)
5
BROTHER OR SISTER
(14) DATE OF MMI DN70
99
BODY PART CODE DN83
(15) PERMANENT IMPAIRMENT
%
PERMANENT IMPAIRMENT% DN84
(16) MAINTENANCE TYPE CODE DN2 (CHOOSE
(17) CLAIM STATUS DN73 (CHOOSE ONE)
(18) CLAIM TYPE DN74 (CHOOSE ONE)
ONE)
SA
FN
UR
OPEN
(O)
REOPEN
(R)
INJURY (I)
OCCUPATIONAL DISEASE (Z)
CLOSED (C)
REOPEN/CLOSED (X)
(19) CLAIM ADMINISTRATOR FEIN DN8
(20) CLAIM ADMINISTRATOR NAME DN9
(21) CLAIM ADMINISTRATOR CLAIM NUMBER DN15
(22) PRE-INJURY WEEKLY WAGE DN62
(23) TEMPORARY TOTAL DISABILITY RATE
$
$
COMPENSATION PAYMENTS (CUMULATIVE)
(24) LATE
(25) PAYMENT
(27) NET WEEKLY
(28) PAYMENT
(29) PAYMENT
(26) AMOUNT PAID TO
(30) WEEKS PAID
(31) DAYS PAID
REASON CODE
CODE
AMOUNT
START DATE
END DATE
DATE DN86
DN90
DN91
DN77
DN85
DN87
DN88
DN89
$
$
$
$
$
$
$
$
$
$
$
$
BENEFIT ADJUSTMENTS
(Made to weekly corresponding compensation rate)
(32) PAYMENT
(33) BENEFIT
(34) BENEFIT
(35) START
CODE
ADJUSTMENT
ADJUSTMENT WEEKLY
DATE
DN85
CODE
AMOUNT
DN94
DN92
DN93
$
$
$
Weekly Rate - Benefit Adjustment Weekly Amount DN93 = Net Weekly Amount DN87
PAID TO DATE/REDUCED EARNINGS/RECOVERIES (CUMULATIVE)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
CODE
AMOUNT DN96
CODE
AMOUNT DN96
CODE
AMOUNT DN96
CODE
AMOUNT DN96
300
380
440
830
$
$
$
$
DN95
DN95
DN95
DN95
840
330
390
450
$
$
$
$
DN95
DN95
DN95
DN95
840
350
400
800
$
$
$
$
DN95
DN95
DN95
DN95
840
360
420
810
$
$
$
$
DN95
DN95
DN95
DN95
840
370
430
820
$
$
$
$
DN95
DN95
DN95
DN95
ERD-922 (Rev 02-09-10)
Mandatory – Fully complete