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Annual Claim for Reimbursement of Supplementary Benefits form

1. Worker identification (WID) number or Social Security number

2. Date of injury

3. Employee's name

4. Insurer/self-insurer (Reimbursement payable to) – insurer’s or self-insurer’s name and complete address (city, state and ZIP code)

5. Employer's name

6. Insurer's claim number

7. Claim status (choose one):

  • First claim for this case – include all information to show eligibility for supplementary benefits

  • Continuing (benefits continue) – attach evidence of contact with the employee during the time period for which reimbursement is claimed

  • Final claim – return to work date, date of death of employee (attach a copy of the death certificate or obituary notice), closed by settlement (include a copy of the settlement document), other (include additional pertinent information)

8. Name, company name, address, phone number and email address of the person who prepared the annual claim for reimbursement

9. Type of benefit – permanent total disability (PTD) or temporary total disability (TTD); choose PTD if benefits are being offset

10. From – start date of benefit

11. Through – end date of benefit

12. Numbered columns –

  1. Number of weeks between from and through dates (each day equals .2)

  2. Weekly compensation rate:  PTD rate or TTD rate (same as comp rate)

  3. Government benefits – Weekly Social Security and weekly other (any other type of government benefit); note that other than Social Security, retirement benefits cannot be used to offset

  4. Subtotal – the sum of the PTD/TTD rate minus the government benefits

  5. Max rounded – the subtotal amount, minus the maximum supplementary benefit rate

  6. 5% offset – the 5% offset (column 5 x .05), which applies only if the employee is receiving benefits listed in column 3 and the employee is under full retirement age

  7. Net supp benefits – the total of (if 5% offset) column 5 minus column 6 or, if there is no 5% offset, the column 5 amount is copied and placed in column 7; the total equals column 1 (number of weeks) multiplied by column 7 (net supplementary benefits)

13. Employee's date of birth

14. Choose whether the government benefits listed in column 3 are retirement or disability benefits

15. Enter the total reimbursement claimed in the field marked "TOTAL"

Repeat steps as listed above for each time period a rate changes. This includes a change in the PTD/TTD rate, an offset increase or a supplementary benefit rate increase. For annual claims being completed as online submissions, "add a row" must be chosen to save the data previously entered, even if another row is not being added.


Annual Claim for Reimbursement from the Second Injury Fund form

1. Worker identification (WID) number or Social Security number

2. Date of injury

3. Employee's name

4. Insurer/self-insurer (Reimbursement payable to) – insurer’s or self-insurer’s name and complete address (city, state and ZIP code)

5. Employer's name

6. Insurer's claim number

7. Claim status (choose one):

  • First claim for this case – include all information to show eligibility

  • First and last claim as a result of full, final and complete settlement

  • Continuing (benefits continue) – attach evidence of contact with the employee during the time period for which reimbursement is claimed

  • Final claim – return to work date, date of death of employee, attach a copy of the death certificate or obituary notice, closed by settlement (include a copy of the settlement document) or other (include additional pertinent information)

8. Name, company name, address, phone number and email address of the person who prepared the annual claim for reimbursement.

Medical and rehabilitation expense detail

9. Indicate whether medical expenses claimed exceed or do not exceed fee schedule limits

10. Dates for which you are requesting reimbursement, include the from and through dates

11. Letters 1.a. through 1.e.:

  • a. Medical and rehabilitation expenses claimed this period

  • b. Subtract the statutory deductible for the date of injury (if appropriate)

  • c. Percentage of apportionment (attach proof if claiming for the first time) equals percentage

  • d. Lump sum amount to be reimbursed

  • e. Total medical and rehabilitation expenses claimed

Indemnity expense detail

12. Dates for which you are requesting reimbursement, include the from and through dates

13. Letters 2.a. through f.:

  • a. List the amount(s) for temporary partial, retraining, temporary total and permanent total benefits paid; subtotal the amounts

  • b. Subtract the statutory deductible for this date of injury (if appropriate)

  • c. Percent apportioned (attach proof if claiming for the first time)

  • d. Permanent partial (PPD), impairment compensation (IC), economic recovery compensation (ERC) claimed (choose type(s) paid)

  • e. Lump sum to be reimbursed (list the amount)

  • f. Total of indemnity reimbursement claimed (columns 2a thru 2e)

14. Total of medical amount claimed and indemnity amount claimed


Documentation requirements

Medical and rehabilitation expenses

Claims for reimbursement of medical and rehabilitation expenses should also include the following documentation.

1. A payment ledger, which includes the date of service, date of payment, payable to information and amount claimed.

  • If the bills have not been paid according to the fee schedule, attach a copy of the bills showing CPT codes.

2. For office visits, the explanation of benefit form and medical report.

3. For prescription drugs, documentation of the prescription name, dosage, amount dispensed and amount paid.

Indemnity benefits

Claims for reimbursement of indemnity benefits should also include one of the following types of documentation.

1. A completed annual claim for reimbursement of supplementary benefits that includes rate amounts and dates of compensation paid and offsets, if applied.

2. A completed Interim Status Report form that includes rates, dates, compensation rates, Social Security amounts and other offset amounts.

3. A WCRA CompCalc printout showing the above required information to support the amount of reimbursement you are claiming.