Department of Labor and Industry Special Compensation Fund PO Box 64229 St. Paul, MN 55164-0229 (651) 284-5045 or 1-800-342-5354 Fax: (651) 215-9099 Notice of Intention to Claim Reimbursement From the Second Injury Fund PRINT IN INK or TYPE YOUR RESPONSES ALL DATES MUST BE ENTERED in MM/DD/YYYY R0 S5 DO NOT USE THIS SPACE WID or SSN EMPLOYEE NAME EMPLOYER NAME INSURER CLAIM NUMBER DATE OF INJURY INSURER/SELF-INSURER INSURER/ ADDRESS 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 TPA Name Address Date Phone No. (include area code & ext.) 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 52 weeks and $2,000; apportionment under M.S. § 176.131, subd.1(a) No deductibles Other: _________________________________________________________________________________________________ Claim REJECTED on __________________ by _______________________________________________________________ Deductibles No registration found Notice was filed late Documentation of automatic registration not attached Medical reports to support claim not attached Other: _________________________________________________________________________________________________ (over) American LegalNet, Inc. www.FormsWorkFlow.com MN RS05 (9/15) VOCATIONAL REHABILITATION AND WORK STATUS REPORT 1. Has the employee returned to work? Yes No Yes No Do temporary partial benefits continue to be paid? 2. Has this case been referred for vocational rehabilitation? Yes No (Complete #3) 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 Department of Labor and Industry Special Compensation Fund 443 Lafayette Road N. St. Paul, MN 55155-4301 Mailing Address Department of Labor and Industry Special Compensation Fund PO Box 64229 St. Paul, MN 55164-0229 Fax (651) 215-9099 American LegalNet, Inc. www.FormsWorkFlow.com