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Workers' compensation -- Submission of online Annual Claim for Reimbursement From the Second Injury Fund forms and Annual Claim for Reimbursement of Supplementary Benefits forms



User information

All data submitted to the Minnesota Department of Labor and Industry via this site shall become part of the file that is maintained by the Workers' Compensation Division for the specified claim. You agree to maintain the confidentiality of the data you submit as required by applicable state and federal laws.

All applicable statutes and rules regarding the filing of annual claim reimbursement forms apply to the forms available electronically from this website. You agree to comply with all of these statutes and rules, including providing copies to all parties, and retaining copies with original signatures, if required by statute or rule.

Data submitted electronically will be accepted as received only during regular DLI business hours, 8 a.m. to
4:30 p.m. (Central Time), Monday through Friday, excluding holidays. Data received after 4:30 p.m. or on a Saturday, Sunday or state holiday will be electronically date-stamped for the next business day that DLI is open for business.

Online Annual Claim for Reimbursement From the Second Injury Fund form and Annual Claim for Reimbursement of Supplementary Benefits form

  • Access the online forms

  • User requirements:

    • Internet Explorer 9 or above (if using Internet Explorer 11, enable compatibility mode);

    • 5 MB or better Internet connection;

    • standard keyboard and mouse input devices;

    • standard monitor and printer;

    • Adobe Acrobat Reader version 9 or above for printing;

    • enabled JavaScript (a browser setting); and

    • use of the worker identification (WID) number instead of the Social Security number to submit an annual claim reimbursement request (learn more about WID numbers).

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