Annual Claim For Reimbursement Of Supplementary Benefits {AC03}

Annual Claim for Reimbursement of Supplementary Benefits PRINT IN INK OR TYPE YOUR RESPONSES ALL DATES MUST BE ENTERED IN MM/DD/YYYY A0 C3 FOR SCF USE ONLY WID or SSN EMPLOYEE NAME EMPLOYER NAME INSURER CLAIM NUMBER DATE OF INJURY INSURER/SELF-INSURER (Reimbursement Payable To) ADDRESS CITY STATE ZIP CODE Claim status A. AA. B. First claim for this case First and last claim as a result of full, final and complete settlement Continuing - Attach EVIDENCE of contact with employee during the time period claimed which SUPPORTS ELIGIBILITY for benefits claimed (i.e., status check confirming employee remains disabled, medical and/or rehabilitation reports from the time period claimed, etc.). Final Claim for this case. Reason: 1) Returned to work on: _______________________ 2) Death of employee on: _______________________ ATTACH DEATH CERTIFICATE 3) Closed by settlement 4) Other: Explain: C. Mail or fax completed copy to: In Person: Department of Labor & Industry Special Compensation Fund 443 Lafayette Road N. St. Paul, MN 55155-4301 Mailing Address: Department of Labor & Industry Special Compensation Fund PO Box 64229 St. Paul, MN 55164-0029 Fax: (651) 215-9099 YOU MUST COMPLETE THE BACK SIDE OF THIS FORM. Name of Preparer Company Name (if different from above) Address E-mail address Date Phone No. (include area code & ext.) Fax No. (include area code) 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 DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. (over) MN AC03 (9/15) American LegalNet, Inc. www.FormsWorkFlow.com (1) Specify TTD or PTD Number of Weeks (2) Weekly Comp Rate (3) Government Benefits* Weekly Soc Security Weekly other (4) SUBTOTAL Col 2 - 3 From Through (5) Max. (ROUNDED) supp. benefit minus Col 4 (6) 5% Offset (7) Net supp benefits Col 5 ­ 6 TOTAL Col 1 X 7 Date of Birth ______________________________ Retirement Disability TOTAL *ATTACH EVIDENCE OF GOVERNMENT DISABILITY BENEFIT CHANGES IF OTHER THAN STANDARD COST OF LIVING ADJUSTMENTS. SPECIAL COMPENSATION FUND USE ONLY Total Amount Claimed Amount Adjusted Amount Approved Approved by Paid by Date Approved Date Paid Vendor Number Batch Number American LegalNet, Inc. www.FormsWorkFlow.com Adjustment Code