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Interim Status Report Form. This is a Minnesota form and can be use in Workers Comp.
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Tags: Interim Status Report, IS03, Minnesota Workers Comp,
Minnesota Department of Labor and Industry
Workers’ Compensation Division
www.dli.mn.gov/wc/wcforms.asp
Interim Status Report
I S 0 3
PRINT IN INK or TYPE
Enter dates in MM/DD/YYYY format.
DO NOT USE THIS SPACE
WID or SSN
DATE OF INJURY
EMPLOYEE
EMPLOYER
EMPLOYEE ADDRESS
CITY
STATE
ZIP CODE
INSURER CLAIM NUMBER
THE FORM MUST BE SUBMITTED ANNUALLY ON ALL CLAIMS OF CONTINUING DISABILITY, SUPPLEMENTARY OR
DEPENDENCY BENEFITS. Please provide additional information on the Benefit Addendum (BA01).
Temporary Total*
Permanent Total*
FROM
THROUGH
WEEKS
RATE
*TOTAL
Balance Carried Forward
TOTAL:
Temporary Partial
Balance Carried Forward
TOTAL:
Permanent Partial
Permanent Partial Disability ___________%
Injuries on or after 10/01/95
Impairment Compensation (injuries 01/01/1984 - 09/30/1995)
Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995)
_______________________ [part of body] (injuries before 01/01/1984)
TOTAL:
*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of Supplementary
Benefits.
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MN IS03 (7/10)
(over)
FROM
Retraining Benefits
THROUGH
WEEKS
RATE
TOTAL
Balance Carried Forward
TOTAL:
Dependency Benefits
Balance Carried Forward
TOTAL:
Supplementary Benefits*
Balance Carried Forward
TOTAL:
Social Security Benefits or Other Government Benefits*
Retirement
Disability
Name of Program:
FROM
THROUGH
PER WEEK
*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of
Supplementary Benefits.
Attorney Fees Paid
Interest Paid
Lump Sum Payment
Under Award or Order
Attorney Fees Still Withheld
Total Compensation
Paid to Employee
Attorney Fees
Reimbursed to Employee
M.S. 176.081, subd. 7
Total Dependency Benefits Paid
(Please attached copy of worksheet)
INSURER/SELF-INSURER/TPA
CLAIM REPRESENTATIVE NAME
ADDRESS
PHONE NUMBER (include area code)
CITY
STATE
ZIP CODE
DATE SERVED
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or
1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
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.
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