Blank Erd 991 Template

What is the ERD 991 form used for?

The ERD 991 form is a document used to report workers' compensation claims related to on-the-job injuries or occupational diseases in Montana. It serves as the first report of injury and helps employers and insurance administrators process claims efficiently.

Who needs to fill out the ERD 991 form?

The injured worker, their employer, and the claim administrator should all be involved in filling out the ERD 991 form. This ensures accurate information is collected from all relevant parties for a complete claim process.

What information is required on the ERD 991 form?

The form requires personal details about the injured worker, such as their name, address, date of birth, and social security number. It also collects information related to the accident, job title, nature of the injuries, medical treatment received, and the employer's details.

How does the employer submit the ERD 991 form?

Employers can submit the ERD 991 form by mailing it to the Montana Department of Labor and Industry. The address is provided on the form. Timely submission is crucial for the processing of the workers’ compensation claim.

What should be included in the accident description section?

In the accident description section, provide a clear and concise account of how the injury or occupational disease occurred. Include relevant details like the job title, cause of injury, and a description of the accident to support the claim.

Can the injured worker decline to sign the ERD 991 form?

While it's possible for the injured worker to decline to sign, doing so may delay or complicate the claim process. Signing the form authorizes the release of necessary records, which is vital for the evaluation of the claim.

What happens after the ERD 991 form is submitted?

Once the ERD 991 form is submitted, the claim administrator will review the information. They will then determine the validity of the claim and communicate with the employer, the injured worker, and other relevant parties about the next steps.

1. Inconsistent Personal Information: Accurate and consistent information is crucial when filling out the Erd 991 form. Individuals often make the mistake of providing different names or inconsistent birth dates in multiple sections. This can lead to significant delays in processing claims.

2. Failure to Report All Earnings: Claimants sometimes overlook additional sources of income, such as overtime or bonuses. When filling out the gross earnings for the four pay periods preceding the injury, it’s essential to include all earnings. Failure to do so may result in a lower compensation claim.

3. Neglecting Medical Treatment Details: Adequate documentation of medical treatment is vital. Many forget to include the complete name or address of the attending physician or fail to specify the type of treatment received. Missing this information can complicate the evaluation of medical necessity and eligibility for benefits.

4. Inaccurate Accident Description: A clear and concise description of the accident is necessary for the claim's validity. Common errors include vague language or omitting important details regarding the cause of the injury. Providing accurate and thorough information can facilitate a smoother claims process.

5. Ignoring Signature Requirements: The form requires the injured worker or beneficiary's signature to validate the claim. Individuals often either forget to sign the document or fail to include the date of signature. This simple oversight can lead to an outright rejection of the claim.

The ERD 991 form is a critical document in processing workers' compensation claims. When completing this form, several other documents may also be necessary to ensure that the injury claim is handled appropriately. Below is a list of forms and documents that are often utilized alongside the ERD 991.

• First Report of Injury (FROI): This is an essential document that an employer files with the workers' compensation board after a workplace injury occurs. It provides a summary of the incident, including the date, nature of the injury, and other relevant details.
• Claimant's Medical Records: These records provide evidence of the injury or condition sustained. They include details of treatments, diagnosed conditions, and any prescriptions provided, which assist in evaluating the claim.
• Employer Incident Report: This report outlines the circumstances of the incident from the employer's perspective. It can include witness statements, safety protocol adherence, and other factors influencing the incident.
• Witness Statements: Statements from individuals who witnessed the accident can provide additional context and corroborate the worker’s account of events. These statements may help in establishing fault or duty of care.
• Physician's Progress Notes: These documents detail the ongoing treatment and recovery trajectory of the injured worker. Regular updates from the treating physician can clarify the extent of the injury and prognosis.
• Return-to-Work Documentation: When an employee is ready to return to work, this documentation may be required to ensure that they can safely resume their duties, following any necessary treatment or rehabilitation.
• Release of Information Authorization: This document allows healthcare providers to share the claimant's medical history and records with the insurance company. It is crucial for assessing the merits of the claim.
• Settlement Agreement: If a claim leads to a resolution, this document will detail the terms of any settlement reached between the injured worker and the employer's insurance provider.

Employers, employees, and their representatives must ensure that these documents are correctly completed and submitted as needed. This will facilitate a smoother and more efficient claims process, aiding in the fair resolution of workplace injuries.

The ERD 991 form is notably similar to the workers' compensation claim form (WC-1), which serves a similar purpose in documenting details surrounding an employee's work-related injury or illness. Like the ERD 991, the WC-1 captures essential information such as the employee's personal details, the nature of the injury, and employer-related information. Both forms facilitate communication between the injured worker, the employer, and workers' compensation insurers. They aim to ensure that benefits are properly assessed and delivered, emphasizing the need for accuracy in reporting to expedite the claims process.

Another document akin to the ERD 991 is the OSHA Form 301, which is used to report work-related injuries and illnesses. This form collects comprehensive data on the event leading to an injury, including the location, nature of the accident, and involved employee's details. While the ERD 991 focuses more on the compensation aspect, OSHA Form 301 prioritizes safety and compliance in the workplace. Both forms aim to promote workplace safety by contributing to the overall understanding of workplace incidents and informing preventative measures.

The employee injury report is a further document that shares similarities with the ERD 991. Typically used by employers, this report captures the immediate details surrounding an accident, such as the date, time, and circumstances leading to an injury. Like the ERD 991, it serves as a formal record that both the employer and employee can refer to when pursuing a claim for benefits. The focus is on ensuring a detailed understanding of the incident to adhere to safety regulations and guidelines while also assisting in the compensation process.

Finally, the claim for disability benefits form resembles the ERD 991 in that it addresses an injured worker's need for financial compensation due to an inability to work. This form collects similar personal and employment details and assesses how the injury affects the individual’s ability to earn wages. While the ERD 991 primarily deals with workers' compensation claims, both forms underscore the importance of accurately documenting injury-related information to facilitate timely benefits and support for the affected worker.

Here are seven things to consider when filling out the ERD 991 form:

• Do: Ensure all sections are filled out clearly and accurately.
• Do: Provide detailed information about the accident, including descriptions of events and circumstances leading to the injury.
• Do: Double-check all dates, particularly the date of injury and dates of employment.
• Do: Use official names and accurate information for all parties involved, including witnesses.
• Don't: Leave any required fields empty; this could lead to delays in processing your claim.
• Don't: Intentionally provide false or misleading information; this can lead to serious legal consequences.
• Don't: Forget to sign and date the form; an unsigned form is considered incomplete.

• Misconception: The ERD 991 form is only for serious injuries. Many people believe that this form is only necessary for significant injuries. In reality, the ERD 991 is required for any on-the-job injury or occupational disease, regardless of severity.
• Misconception: Only employers can fill out the ERD 991 form. While employers are responsible for submitting the ERD 991, injured workers must provide their information as well. Both parties play crucial roles in completing the form accurately.
• Misconception: Submitting the ERD 991 guarantees compensation. Filing the form does not automatically ensure that compensation will be awarded. The claims process involves review and validation by the insurance provider and may require additional documentation or information.
• Misconception: The ERD 991 form can be submitted after a long delay. Timeliness is key. There are often strict deadlines for submitting the ERD 991 form after an injury occurs. Delays may jeopardize the rights to benefits.
• Misconception: It doesn't matter how much information I provide. Providing incomplete or inaccurate information can lead to delays or denials in processing the claim. Detailed and precise information is crucial when filling out the form.
• Misconception: The employer will not retaliate after a claim is filed. Unfortunately, retaliation can happen despite laws against it. Workers should be aware of their rights and the protections available to them under workers' compensation laws.

Filling out the Erd 991 form is crucial for initiating a workers’ compensation claim in Montana. Here are some important points to keep in mind:

• Comprehensive Information Required: Ensure all personal and employment details are accurately filled out. This includes the worker's name, social security number, employment status, and information about the injury itself.
• Accurate Reporting of Earnings: List the gross earnings for the four pay periods before the injury. Include any bonuses, overtime, or other forms of compensation to provide a complete financial picture.
• Documentation of the Incident: Clearly describe the accident, including its cause, the nature of the injury, and any witnesses. Accurate descriptions can help expedite the processing of your claim.
• Medical Treatment Information: Specify the type of medical treatment the worker received after the injury. This includes listing the attending physician and any facility where treatment was provided.
• Signature Authorization: The form requires the injured worker or beneficiary's signature. This signature serves as consent for the release of medical and employment records necessary for the claim review.

Following these guidelines will help ensure that the Erd 991 form is properly completed and submitted without unnecessary delays in the claims process.