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Workers' compensation -- Forms



Interim Status Report (ISR)

Who is responsible for completing the form?

  • The insurer, self-insured employer or third-party administrator is responsible for completing this form.

Why is this form needed?

  • The purpose of the ISR form is to notify the department of the continuing compensation payment status on longer-term claims. The department also uses the information supplied on the form to verify calculation of benefits and for statistical data.

What, specifically, is this form used for?

  • To update the department when there is continuing payments of one of the following types of compensation benefits:

    • temporary total disability (TTD)

    • permanent total disability (PTD)

    • temporary partial disability (TPD)

    • permanent partial disability (PPD)

    • retraining

    • dependency (DEP)

    • supplementary (SB)

  • To update the department with specific details about all payments of compensation, all amounts withheld and amounts paid for attorney fees

  • To update the department with specific details of Social Security benefits or other government benefits paid to the claimant that may coordinate with workers' compensation benefits

  • To comply with statutes and rules:

    • Minnesota Statutes 176.231, subd. 5

    • Minnesota Statutes 176.231, subd. 10

    • Minnesota Rules 5220.2540, subp. 3

When is this form completed?

  • This form must be filed annually, for as long as payments continue (at one year after the last payment form was filed with the department). This form must also be filed upon specific request from the Department of Labor and Industry.

Where is this form sent?

  • A copy of this form is sent to the Department of Labor and Industry, Safety and Workers' Compensation Division; keep a copy for your files.

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