MONTANA WORKERS' COMPENSATION SUBSEQUENT REPORT (1) AGENCY CLAIM NUMBER DN5 (4) DATE OF INJURY DN31 (2) EMPLOYEE NAME (LAST, DN43 FIRST, DN44 MI, DN45) (6) DATE DISABILITY BEGAN DN56 (3) SOCIAL SECURITY NUMBER DN42 (7) PRE-EXISTING DISABILITY DN69 YES NO (8) DATE OF REPRESENTATION DN76 (5) AGREEMENT TO COMPENSATE DN75 (CHOOSE ONE) WITHOUT LIABILITY OR PLACE UNDER 39-71608 WITH LIABILITY (9) RTW QUALIFIER DN71 (CHOOSE ONE) 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 DEATH DN57 DN55 RELATIONSHIP DN97 (CHOOSE ALL THAT APPLY) (10) DATE OF RETURN OR RELEASE TO WORK DN72 3 4 5 WIDOWER SON OR DAUGHTER BROTHER OR SISTER BODY PART CODE DN83 PERMANENT IMPAIRMENT% DN84 6 7 9 MOTHER OR FATHER DISABLED CHILD OVER 18 OTHER (14) DATE OF MMI DN70 (15) PERMANENT IMPAIRMENT (16) MAINTENANCE TYPE CODE DN2 (CHOOSE ONE) 99 % (17) CLAIM STATUS DN73 (CHOOSE ONE) OPEN (O) CLOSED (C) REOPEN (R) REOPEN/CLOSED (X) (18) CLAIM TYPE DN74 (CHOOSE ONE) INJURY (I) OCCUPATIONAL DISEASE (Z) SA FN UR (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 REASON CODE DN77 (25) PAYMENT CODE DN85 (26) AMOUNT PAID TO DATE DN86 (27) NET WEEKLY AMOUNT DN87 (28) PAYMENT START DATE DN88 (29) PAYMENT END DATE DN89 (30) WEEKS PAID DN90 (31) DAYS PAID DN91 $ $ $ $ $ $ $ $ $ $ $ $ BENEFIT ADJUSTMENTS (Made to weekly corresponding compensation rate) (32) PAYMENT CODE DN85 (33) BENEFIT ADJUSTMENT CODE DN92 (34) BENEFIT ADJUSTMENT WEEKLY AMOUNT DN93 (35) START DATE DN94 $ $ $ Weekly Rate - Benefit Adjustment Weekly Amount DN93 = Net Weekly Amount DN87 PAID TO DATE/REDUCED EARNINGS/RECOVERIES (CUMULATIVE) (36) CODE 300 DN95 330 DN95 350 DN95 360 DN95 370 DN95 (37) AMOUNT DN96 (38) CODE 380 DN95 390 DN95 400 DN95 420 DN95 430 DN95 (39) AMOUNT DN96 (40) CODE 440 DN95 450 DN95 800 DN95 810 DN95 820 DN95 (41) AMOUNT DN96 (42) CODE 830 DN95 840 DN95 (43) AMOUNT DN96 $ $ $ $ $ Mandatory � Fully complete $ $ $ $ $ $ $ $ $ $ $ $ ERD-922 (Rev 02-09-10) American LegalNet, Inc. www.FormsWorkFlow.com Mandatory - (Based on the event)