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Fill and Sign the Montana Workers Form

Fill and Sign the Montana Workers Form

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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 DN69 YES 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 FATHER 7 DISABLED CHILD OVER 18 9 OTHER (14) DATE OF MMI DN70       (15) PERMANENT IMPAIRMENT BODY PART CODE DN83 99 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 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        $       $                                $       $                                $       $                                $       $                                $       $                                $       $                         (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 DN96 300 DN95 $       380 DN95 $       440 DN95 $       830 DN95 $      330 DN95 $       390 DN95 $       450 DN95 $       840 DN95 $       350 DN95 $       400 DN95 $       800 DN95 $      360 DN95 $       420 DN95 $       810 DN95 $       370 DN95 $       430 DN95 $       820 DN95 $       ERD-922 (Rev 02-09-10) BENEFIT ADJUSTMENTS Mandatory – Fully complete BENEFIT ADJUSTMENTS (Made to weekly corresponding compensation rate) Weekly Rate - Benefit Adjustment Weekly Amount DN93 = Net Weekly Amount DN87

Useful tips on setting up your ‘Montana Workers’ online

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Adhere to this comprehensive guide:

  1. Log in to your account or register for a complimentary trial with our service.
  2. Click +Create to upload a file from your device, cloud storage, or our template collection.
  3. Access your ‘Montana Workers’ in the editor.
  4. Click Me (Fill Out Now) to arrange the document on your end.
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Here is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

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Montana Works Login
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Montana job Service job listings
Montana Department of Labor phone number
Request payment Unemployment Montana
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Montana workers' compensation
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Follow the step-by-step guide to eSign your montana workers form in Gmail:

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  • 3.Open an email with an attachment that needs approval and use the S key on the right sidebar to launch the add-on.
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How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device

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Follow the step-by-step guide to eSign your montana workers form in a browser:

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  • 5.Add the My Signature area to the form, then enter your name, draw, or add your signature.

In a few easy clicks, your montana workers form is completed from wherever you are. As soon as you're done with editing, you can save the file on your device, build a reusable template for it, email it to other individuals, or ask them to eSign it. Make your documents on the go speedy and productive with airSlate SignNow!

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Follow the step-by-step guidelines to eSign your montana workers form on iOS devices:

  • 1.Go to the App Store, find the airSlate SignNow app by airSlate, and set it up on your device.
  • 2.Launch the application, tap Create to import a form, and select Myself.
  • 3.Opt for Signature at the bottom toolbar and simply draw your signature with a finger or stylus to eSign the form.
  • 4.Tap Done -> Save after signing the sample.
  • 5.Tap Save or utilize the Make Template option to re-use this paperwork later on.

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Follow the step-by-step guide to eSign your montana workers form on Android:

  • 1.Open Google Play, find the airSlate SignNow application from airSlate, and install it on your device.
  • 2.Sign in to your account or create it with a free trial, then import a file with a ➕ key on the bottom of you screen.
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  • 4.Tap on Tools tab -> Signature, then draw or type your name to electronically sign the form. Complete empty fields with other tools on the bottom if required.
  • 5.Utilize the ✔ button, then tap on the Save option to finish editing.

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