Report Of Benefits And Related Expenses Paid {13}

DOL FORM 13 (Rev. 9/09) State File No. Ins. Co. File Date of Injury Fed. ID No. DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION REPORT OF BENEFITS AND RELATED EXPENSES PAID EMPLOYEE: EMPLOYER: INS. CARRIER: ADJUSTING CO. (if different from carrier): REPORT TOTAL EXPENSES PAID TO DATE FOR THIS CLAIM. Date Completed. VOCATIONAL REHABILITATION Contractual (VR Vendor) LEGAL - Defense (Contractual) MEDICAL TEMPORARY TOTAL DISABILITY From From To To @$ @$ Total Weeks Total Weeks Days Days $ $ NCCI CLASS CODE: CONTACT PERSON: Benefits Paid Plaintiff (Lien) $ $ $ $ TEMPORARY PARTIAL DISABILITY From From To To @$ @$ Total Weeks Total Weeks Days Days $ PERMANENT PARTIAL DISABILITY LUMP SUM ADVANCES From To Date @$ Amount $ Total Weeks $ PERMANENT TOTAL DISABILITY From From To To @$ @$ Total Weeks Total Weeks $ FATALITY (Spouse/Dependent Benefits) From To @$ Total Weeks $ $ FUNERAL (Including payment to the 2nd Injury Fund, if appropriate) SETTLEMENT AGREEMENTS (Check One) 14 15 16 $ EACH BLANK MUST BE COMPLETED. USE N/A WHERE APPROPRIATE. American LegalNet, Inc. www.FormsWorkFlow.com