Fill and Sign the Notice of Intention to Claim Reimbursement from the Second Form

MN PA04 ( 9/15 ) Mail or fax complet ed copy to: Department of Labor and Industry Special Compensation Fund PO Box 64229 St. Paul, MN 551 64-0229 (651) 284-5045 or 1-80 0-34 2-53 54 Fax: (651) 2 84-5731 Permanent Total Disability Agreement (Effective Only for Dates of Injuries Prior to 10/01/1995) PRINT IN INK or TYPE YOUR RESPONSES ALL DATES MUST BE EN TERED in MM/DD/YYYY WID or SSN DATE OF INJURY EMPLOYEE NAME EMPLOYEE ADDRESS CITY STATE ZIP CODE INSURER/SELF -INSURER EMPLOYER NAME INSURER ADDRESS INSURER CLAIM NUMBER CITY STATE ZIP CODE 1. Attach any medical reports pertinent to the issue of perman ent total disability whether pro or con, that have not been previously filed with the Workers’ Compensation Division. (see Minn. R ule 5222.0400 , subp. 4) The parties are relying primarily upon medical reports by: Health Care Provider(s) Date of report(s) 2. The status of rehabilitation: Continuing Closed Not assigned Attach rehab ilitation reports to support this claim. (see Minn. Rule 5222.0400, subp. 5). 3. Total disability benefits have been paid to the employee without substantial interruptio n since the proposed date of permanent total disability. (see Minn. Rule 5222.0300.A ) Yes No 4. Date the employee began receiving government disability benefits or governme nt old age benefits: (see Minn. Rule 5222.0300.B) Date 5. The employee is receiving or will receive supplementary benefits after an offset for government disability benefits or government old age benefits is taken. (see Minn. Rule 5222.0300.C) Yes No 6. Has the issue of permanent total disability for the time period proposed been determine d in a judicial or administrative proceeding? (see Minn. Rule 5222.0300.D) Yes No 7. Will the offset provision of M.S. § 176.101, subd. 4 result in an overpayment of benefits to the employee? Yes No If yes, explain why there is an overpayment, the amount, and how it will be recov ered. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284 -5032 or 1 -800 -342 -5354 Voice or TDD (651) 297 -4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COM PENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, O R FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. DO NOT USE THIS SPACE PA04 WEEKLY BENEFIT CHANGE ANALYSIS Proposed Effective Dates: Permanent Total Disability $25,000 Offset Date Reached Date Supplementary Benefits Payable Before $25,000 Before PTD Date As of PTD Date TTD $ * PTD $ * SSDI $ * SSDI $ * SB $ SB $ Subtotal $ Subtotal $ OPC $ OPC $ TOT AL $ TOT AL $ After $25,000 SB NOT Payable When SB Payable PTD $ * PTD $ * SSDI $ * SSDI $ * SB $ SB $ Subtotal $ Subtotal $ OPC $ OPC $ TOT AL $ TOT AL $ *enter “F” for full benefit, “R” for reduced benefit Workers’ compensation benefits must be coordinated with most government benefi ts. When a person is receiving more than one form of benefit, either the government benefit or the workers’ compensation benefit may be reduced. If you are not currently receiving government benefits, your workers’ compensation benefits may be aff ected in the future. After a specific waiti ng period, supplementary benefits will be paid, if necessary, to assure the em ployee’s compensation benefits are not less than 65% of the state -wide average weekly wage. If you have questions call Claims Services and Investigations. KEY PTD - permanent t otal disability TTD - temporary total disability SB - supplementary benefits OPC - overpayment credit SSDI - social security disability income; include old age, PERA, etc. AGREEMENT Based on the information provided, the insurer/employer and employee agree that the employee’s total disability is permanent as of ____________________ for purposes of the employer/insurer obtaining reimbursement of supplementary benefits under Minn. Rules 5222.0100 to 5222.1000. All parties understa nd that a substantial error in the information on this form may be ba sis to vacate the agreement. Employee Signature Phone Date Employee Attorney Signature (If applicable) Phone Date Claim Representative Signature Phone Date Workers’ Compensation Divisi on Signature Approved Rejected Phone Date Reason rejected: