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The Request for Extension form is used by an insurer, self-insured employer or third-party administrator to request additional time to make a decision about a new claimed period of temporary total disability from an accepted claim. It is not used to request additional time to investigate an initial injury.

Examples of when this form is used:

  • 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 --

    • investigation is complete,

    • unable to obtain causation medical reports or

    • other; and

  • to comply with statutes and rules --

    • Minnesota Statutes 176.221, subd. 1,

    • Minnesota Rules 5220.2540, subp. 1 and

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

The Request for Extension 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.

The form must be filed with the Department of Labor and Industry and it is suggested the employee also receive a copy (service is not required by statute or rule, but it is recommended as an appropriate notification to the employee about the insurer's rights regarding extensions of time).