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Workers' compensation -- Forms



Request for Extension

Who is responsible for completing the form?

  • The insurer, self-insured employer or third-party administrator

Why is this form needed?

  • The purpose of the Request for Extension form is to request additional time in which to make a decision about a new claimed period of temporary total disability that is alleged to be caused by a prior accepted claim. It cannot be used to request additional time to investigate initial time-loss on a new injury. The department also uses the form to review for compliance with the statutes and rules, and for statistical data.

What, specifically, is this form used for?

  • To report a claimed new period of temporary total disability on a prior accepted claim

  • To report why an extension of time is needed for making a decision:

    1. investigation is incomplete

    2. unable to obtain causation medical reports

    3. other

  • To comply with statutes and rules:

    • Minnesota Statutes 176.221, subd. 1

    • Minnesota Rules 5220.2540, subp. 1

    • Minnesota Rules 5220.2570, subp. 4, 6, 7 and 9

When is this form completed?

  • This form must be filed within 14 days of notice to (or knowledge by) the employer of a new period of temporary total disability that is related to a prior accepted claim.

Where is this form sent?

  • A copy of this form is sent to:

  • the Minnesota Department of Labor and Industry, Safety and Workers' Compensation Division;

  • the claimant -- although service of this form on the claimant is not required by statute or rule, it is recommended as an appropriate notification to the claimant about the insurer's rights regarding extensions of time, why additional time would be needed and instructions to help the claimant understand the process;

  • your file.

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