Section Lab 506.04 - Reimbursement from the Special Fund for Second Injuries(a) Self-insured employers and insurance carriers shall give notice to the department of possible claim against the second injury fund in writing not later than 100 weeks after the date of injury. The employer or carrier may complete and file "Application for the Use of the Second Injury Fund", form WCSIF-1 (9/2015), contained in Appendix II.(b) Self-insured employers and insurance carriers who desire to invoke the reimbursement provisions of RSA 281-A:54 shall file proof of eligibility for the use of the second injury fund established by RSA 281-A:55.(c) Proof of eligibility under (b) shall be submitted not later than September 1 for reimbursement of the prior year's benefits.(d) Proof of eligibility shall include: (1) Either notarized true copies of the written record of knowledge by the employer that the employee had a permanent impairment, prior to the work related injury which the employer is using as a basis for reimbursement by the fund along with a completed "Second Injury Fund Sworn Statement of Employer", form WCSIF-1a (3/2010), contained in Appendix II or an affidavit stating that the employer had knowledge of the employee's permanent physical or mental impairment which must be executed by the employer at the time of hire or retention but before the second injury may be used as written record;(2) Medical evidence of the preexisting permanent impairment;(3) Medical evidence of a subsequent disability as a result of the second injury or disability; and(4) A medical evaluation which indicates that the disability is greater due to the combined effects of the preexisting impairment and the work related injury than would have been caused by subsequent injury alone. The employer or carrier may use "Second Injury Fund Certification by Physician", form WCSIF-1b (12/1996), contained in Appendix II to submit this information.(e) Self-insured employers and insurance carriers shall request reimbursement not later than September 1 for all reimbursable benefits paid in the preceding calendar year. Supporting documentation shall include verification of the first $10,000 paid and all other payments made on the case for the preceding calendar year shall be submitted with "Request for Reimbursement from the Second Injury Fund", form WCSIF 2 (5/2013), and "Schedule of Reimbursable Payments", form WCSIF-2a (5/2013), contained in Appendix II. A self-insured employer or insurance carrier who fails to make timely annual application for such reimbursement shall forfeit the right to reimbursement for payment made during the preceding calendar year.(f) Self-insured employers and insurance carriers who desire to invoke the reimbursement provisions of RSA 281-A:15, III, shall request reimbursement from the special fund for the additional weekly compensation or permanent impairment award resulting from the increase in average weekly wages due to the employee's concurrent employment. The reimbursement request shall be completed and filed on "Application for Reimbursement of Paid Combined Earnings Differential" form 9WCA 3 (9/2015), contained in Appendix II, by September 1 for benefits paid in the preceding calendar year. A self-insured employer or insurance carrier who fails to make timely annual application for such reimbursement shall forfeit the right to reimbursement for payment made during the preceding calendar year.N.H. Admin. Code § Lab 506.04
#2264, eff 1-6-83; amd by #2935, eff 12-27-84; amd by #4854, eff 6-29-90; amd by #5041, eff 1-9-91; ss by #5235, eff 9-27-91, EXPIRED: 9-27-97
New. #6631, INTERIM, eff 11-16-97, EXPIRED: 3-16-98
New. #6806, eff 7-18-98); ss by #8682, INTERIM, eff 7-15-06, EXPIRED: 1-11-07
New. #9019, eff 11-1-07
Amended by, Volume XXXVI Number 14, Filed April 7, 2016, Proposed by #11067, Effective 4/1/2016, Expires 4/1/2026.