How can airSlate SignNow help with the First Report Of Injury Or Occupational Disease Montana State?

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First Report of Injury or Occupational Disease Montana State Form

Q: What is the First Report Of Injury Or Occupational Disease Montana State?

The First Report Of Injury Or Occupational Disease Montana State is a crucial document that employers must file when an employee suffers a work-related injury or illness. This report helps initiate the workers' compensation process and ensures that employees receive the necessary benefits. Understanding this document is essential for compliance and protecting both employee rights and employer responsibilities.

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MONTANA WORKERS’ COMPENSATION SUBSEQUENT REPORT (1) AGENCY CLAIM NUMBER DN5 (2) EMPLOYEE NAME (LAST, DN43 FIRST, DN44 MI, DN45) (3) SOCIAL SECURITY NUMBER DN42 (4) DATE OF INJURY DN31 (5) AGREEMENT TO COMPENSATE DN75 (CHOOSE ONE) WITHOUT LIABILITY OR PLACE UNDER 39-71- 608 WITH LIABILITY (6) DATE DISABILITY BEGAN DN56 (7) PRE-EXISTING DISABILITY DN69YES NO (8) DATE OF REPRESENTATION DN76 (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 (10) DATE OF RETURN OR RELEASE TO WORK DN72 (11) EMPLOYEE DATE OF DEATH DN57 (12) NUMBER OF DEPENDENTS DN55((( (13) DEPENDENT PAYEE RELATIONSHIP DN97(CHOOSE ALL THAT APPLY) 2 WIDOW 3 WIDOWER 4 SON OR DAUGHTER 5 BROTHER OR SISTER 6 MOTHER OR FATHER7 DISABLED CHILD OVER 18 9 OTHER BODY PART CODE DN8399(14) DATE OF MMI DN70 (15) PERMANENT IMPAIRMENT PERMANENT IMPAIRMENT% DN84 %(16) MAINTENANCE TYPE CODE DN2 (CHOOSE ONE) SA FN UR (17) CLAIM STATUS DN73 (CHOOSE ONE) OPEN (O) REOPEN (R) CLOSED (C) REOPEN/CLOSED (X) (18) CLAIM TYPE DN74 (CHOOSE ONE) INJURY (I) OCCUPATIONAL DISEASE (Z) (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 CODEDN77 (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((((( $ $ (( ((((((( $ $ (( ((((((( $ $ (( ((((((( $ $ (( ((((((( $ $ (( ((((((( $ $ (( (( (32) PAYMENT CODE DN85 (33) BENEFIT ADJUSTMENT CODE DN92(34) BENEFIT ADJUSTMENT WEEKLY AMOUNT DN93 (35) START DATE DN94 $ $ $ PAID TO DATE/REDUCED EARNINGS/RECOVERIES (CUMULATIVE) (36)CODE (37) AMOUNT DN96 (38)CODE (39) AMOUNT DN96 (40)CODE (41) AMOUNT DN96 (42)CODE (43) AMOUNT DN96300DN95$ 380 DN95$ 440 DN95$ 830DN95 $ 330 DN95$ 390 DN95$ 450 DN95$ 840DN95 $ 350DN95$ 400 DN95$ 800 DN95$ 360 DN95$ 420DN95$ 810 DN95$ 370 DN95$ 430DN95$ 820 DN95$ ERD-922 (Rev 02-09-10) BENEFIT ADJUSTMENTS Mandatory - (Based on the event)Mandatory – Fully complete BENEFIT ADJUSTMENTS (Made to weekly corresponding compensation rate) Weekly Rate - Benefit Adjustment Weekly Amount DN93 = Net Weekly Amount DN87

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Fill and Sign the First Report of Injury or Occupational Disease Montana State Form