Minnesota Annual Claim For Reimbursement From The Second Injury FundMinnesota Annual Claim For Reimbursement From The Second Injury Fund
Download the document to the computer for easy use
There are more pages to preview,Read on

Reset
Mail completed copy to:

Annual Claim for Reimbursement
from the
Second Injury Fund

Department of Labor and Industry
Claims Services and Investigations
PO Box 64229
St. Paul, MN 55164-0229
(651) 284-5045 or
1-800-342-5354 (DIAL-DLI)
Fax: (651) 284-5733

A R 0 4

FOR CSI USE ONLY

PRINT IN INK or TYPE your responses
All dates must be entered in MM/DD/YYYY

WID or SSN

DATE OF INJURY

EMPLOYEE NAME

INSURER/SELF-INSURER (Reimbursement Payable To)

EMPLOYER NAME

INSURER/ ADDRESS

INSURER CLAIM NUMBER

CITY

STATE

ZIP CODE

Claim status
A.

First claim for this date of injury

AA.

First and last claim based upon full, final and complete settlement

B.

Continuing - Attach EVIDENCE of contact with employee during the time period which SUPPORTS
ELIGIBILITY for benefits (i.e., status check confirming employee remains disabled, medical
and/or rehabilitation reports from the time period claimed, etc.).

C.

Final Claim for this case. Reason:
1) Returned to work on: ___________________