DOL FORM 13 (Rev. 5/05)
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 $ $
(h) (j) (a) (c) (e)
SOCIAL SECURITY NO.: NCCI CLASS CODE: CONTACT PERSON:
(b) (d) (f) (g)
Benefits Paid Plaintiff (Lien)
$ $ $
(i) (k) (l)
$
(m)
TEMPORARY PARTIAL DISABILITY
From From To To @ $ @ $ Total Weeks Total Weeks Days Days
$
(n)
PERMANENT PARTIAL DISABILITY
LUMP SUM ADVANCES From To Date @ $ Amount $
Total Weeks
$
(o)
PERMANENT TOTAL DISABILITY
From From To To @ $ @ $ Total Weeks Total Weeks
$
(p)
FATALITY (Spouse/Dependent Benefits)
From To @ $ Total Weeks
$ $
(q) (r) (s)
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.