Fill and Sign the Form Interim Status Report Minnesota Department of

MN IS03 (7/10) (over) Minnesota Department of Labor and Industry Workers’ Compensation Division www.dli.mn.gov/wc/wcforms.asp Interim Status Report DO NOT USE THIS SPACE PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format. 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 informat ion 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 (injur ies 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) _______________________ [part of bod y] (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. IS 0 3 FROM THROUGH WEEKS RATE TOTAL Retraining Benefits 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 Attorney Fees Still Withheld Lump Sum Payment Under Award or Order 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 DISCLO SE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.