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1. Date of injury

2. Date of birth

3. Average annual wage (AWW)

4. Last claim submitted, including any adjustment letter:  permanent total disability (PTD) rate, Social Security weekly offset amount and dates claimed

Information, resources

From DLI

From other sources

Second-injury fund claims only

1. Indemnity claimed – If the second-injury claim is not accompanied by a supplementary benefit claim, a completed Interim Status Report form is needed, showing from and through dates, rates, Social Security offset amounts and any other type of government benefit received by the employee.

2. Medical claimed – A payment ledger is needed listing each amount claimed and including the date of service, name of payee and amount paid.

  • For office visits, a medical report is needed and an explanation of benefit (EOB) form is helpful.

  • For prescription drugs, the drug name is needed, as well as the dosage, amount dispensed and amount paid.