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Workers' compensation -- Forms



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Workers' compensation forms (required by either statute or rule)


The Spanish forms, denoted by "[Spanish]" are to be used for communication purposes only; they should not be filed with the department.

Workers' compensation forms -- Required


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Form name
Last update
Notes*
Affidavit of Significant Financial Hardship (AS01) April 2012 PO
Annual Claim for Reimbursement From the Second Injury
Fund
(AR04)
November 2012 DLI
Annual Claim for Reimbursement of Supplementary Benefits (AC03)
     -- Addendum to Annual Claim for Reimbursement of
        Supplementary Benefits
February 2013 Format changes; update of work unit name
Certificate of Compliance Minnesota Workers' Compensation Law (MN LIC 04) -- more information March 2013  
Claim Petition for Dependency Benefits or Payment to Estate (CP03) April 2012 PO
Disability Status Report (DS01) January 2013  
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (CSI02) March 2014 Corrected
misinformation
Election to Exclude Relatives of Managers of a Limited Liability Company (CSI01) March 2014 Corrected
misinformation
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01) January 2013  
Employee's Claim Petition (EC04) April 2012 PO
Employee's Objection To Discontinuance (ED02) April 2012 PO
Employee's Request for Administrative Conference (EQ05) -- (more information) April 2012 PO
Excess Fee Exhibit (PF04) April 2012 PO

First Report of Injury (FR01) -- more information

Amended rules effective for first reports of injury filed on or after Jan. 1, 2014:  5220.2530, 5220.2820, 5220.2830

December 2013 NS
Health Care Provider Report (HC01) -- more information July 2010 DLI
Interim Status Report (IS03) -- more information July 2010 DLI
Medical Request (MQ03) April 2012 PO
Medical Response (MR03) April 2012 PO
Notice of Appearance of Attorney for Employee (NA03) April 2012 PO
Notice of Benefit Payment (NB01) -- more information February 2010 PH
Notice of Benefit Reinstatement (NC01) -- more information July 2010 DLI
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) -- more information February 2010 PH
Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) -- more information February 2010 PH
Notice of Insurer's Primary Liability Determination (NL01) -- more information February 2010 PH
Notice of Intention to Claim Reimbursement From the Second Injury Fund (RS05) May 2008 PO; WID
Notice of Intention to Discontinue Workers' Compensation Benefits (ND01) -- more information August 2010 PH
Objection to Penalty Assessment (CE0003) May 2008 PO; WID
On-the-Job Training Plan (JA04) September 2008 PO; TENN; WID
Permanent Total Disability Agreement (PA04) May 2008 PO; WID
Petition for Taxation of Actual and Necessary Disbursements (PT03) May 2008 PO; WID
Plan Progress Report (PR01) -- (Spanish) December 2013  
R-2 Rehabilitation Plan (RE01) -- more information January 2014 The changes were necessary due to a statute/law change effective Oct. 1, 2013,
to 176.102, subd. 5(b).
R-3 Rehabilitation Plan Amendment (RP01) -- more information January 2014 The changes were necessary due to a statute/law change effective Oct. 1, 2013,
to 176.102, subd. 5(b).
R-8 Notice of Rehabilitation Plan Closure (NR01) January 2014 The changes were necessary due to a statute/law change effective Oct. 1, 2013,
to 176.102, subd. 5(b).
Rehabilitation Consultation Report (RC01) -- (Spanish) February 2012 Technical changes
Rehabilitation Request (RQ03) April 2012 PO
Rehabilitation Response (RR03) May 2008 PO; TENN; WID
Rehabilitation Rights and Responsibilities of the Injured Worker (IW05) -- (Spanish) January 2014 Form overhaul
Report of Work Ability (RW01) -- more information July 2010 DLI
Request for Extension (QE03) -- more information July 2010 DLI
Request for Formal Hearing (RF03) August 2012 PO
Retraining Plan (EP04) January 2014  
Statement of Attorney Fees and Costs (SA04) June 2014 Corrected misinformation

*Notes:  DLI = department information updated; NS = conforms to national standards for electronically filed form; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification number**

**Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.

 



Miscellaneous forms




Optional workers' compensation forms (suggested format, not required by statute or rule)



Workers' compensation forms -- Optional


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Form name
Last update
Notes*
Attorney Request for Certification of Dispute (CA0022) June 2013 Renamed, revised
Authorization for File Review or Release of Copies of Workers' Compensation Claim File (FE0005) August 2011
Benefit Addendum (BA01) -- more information July 2010 DLI
Disclosure of Affiliations and/or Relationships May 2013  
Functional Capacity Evaluation October 2009 New form
Intervention Cover Letter (MO0001) July 2014 Revised
Intervention Motion (MO0001) November 2012 PO
Intervention Stipulation (LE0032) November 2012 PO
Notice of Appeal to Workers' Compensation Court of Appeals (NO0016) November 2012 PO
Notice of File Closing (NF01) -- more information May 2008 PO; WID
Notice of Penalty Payment (NO0015) August 2013 WID
Occupational On-site Analysis October 2009 New form
Rehabilitation Provider Complaint November 2012 New form
Request for Certification of Dispute (CA0022)
See Attorney Request for Certification of Dispute form above
N/A N/A

*Notes:  DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification number**

**Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.

 



Rehabilitation provider forms

Workers' compensation forms -- Rehabilitation provider


Plus-minus graphic Click to access forms; view update dates and notes
Form name
Last update
Notes*
R-20 Qualified Rehabilitation Consultant Intern Application January 2014 Form overhaul
R-22 Rehabilitation Vendor Application January 2014 Form overhaul
R-24 Qualified Rehabilitation Consultant Firm Application January 2014 Form overhaul
R-25 Qualified Rehabilitation Consultant Application January 2014 Form overhaul

*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification number**

**Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.

 



Spanish version of workers' compensation forms

These forms are to be used for communication purposed only; they should not be filed with the department.

Workers' compensation forms -- Spanish


Plus-minus graphic Click to access forms; view update dates and notes
Form name
Last update
Notes*
Derechos de Rehabilitacion y Responsabilidades del Trabajador Lesionado January 2014 Form overhaul
Informe de Consulta de Rehabilitacion (RC01) January 2013  
Informe de Progreso del Plan (PR01) February 2014  

*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification number**

**Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.

 



More information

 

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