Work comp: Forms | Minnesota Department of Labor and Industry

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Work comp: Forms

About the forms

The forms provided below are fillable PDFs that can be viewed or printed using the free Adobe Acrobat Reader software. However, that software does not allow users the option of saving data that is typed into the filled-in PDF; to have the option to save input information, visit www.adobe.com for more information about Adobe Acrobat software.

The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.

Notice of Aug. 31, 2020, effective date of required electronic filing of non-EDI workers' compensation reports or documents by web form, upload or XML attachment

Learn about

A to Z – required workers' compensation forms (required by statute, rule)

The Spanish versions of forms are to be used for communication purposes only; they should not be filed with the department.

Form name	Version date	Notes
Affidavit of Significant Financial Hardship (AS01)	June 2018	Legislative changes
Annual Claim for Reimbursement From the Second Injury Fund (AR04) – more information	September 2015	New fax number
Annual Claim for Reimbursement of Supplementary Benefits (AC03) – more information – Addendum to Annual Claim for Reimbursement of Supplementary Benefits	June 2020	Formatting change
Certificate of Compliance; Minnesota Workers' Compensation Law (MN LIC 04) – more information	November 2016	Form overhaul
Claim Petition for Dependency Benefits or Payment to Estate (CP03)	June 2018	Legislative changes
Disability Status Report (DS01)	October 2023	Removed address
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (SF0138)	May 2018	Made fillable
Election to Exclude Relatives of Managers of a Limited Liability Company (SF0137)	May 2018	Made fillable
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01)	June 2018	Legislative changes
Employee's Claim Petition (EC04)	June 2018	Legislative changes
Employee's Objection to Discontinuance (ED02)	June 2018	Legislative changes
Employee's Request for Administrative Conference (EQ05) – more information	June 2018	Legislative changes
Excess Fee Exhibit (PF04)	June 2018	Legislative changes
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	March 2016	New phone number
Health Care Provider Report (HC01) – more information	April 2017	Format changes
Interim Status Report (IS03) – more information	July 2010
Medical Request (MQ03)	September 2023	Address update
Medical Response (MR03)	September 2023	Address update
Notice of Appearance of Attorney for Employee (NA03)	October 2023	Removed address
Notice of Benefit Payment (NB01) – more information	October 2023	Removed address
Notice of Benefit Reinstatement (NC01) – more information	September 2015	Format changes
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) – more information	October 2023	Removed address
Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) – more information	October 2023	Removed address
Notice of Insurer's Primary Liability Determination (NL01) – more information	October 2023	Removed address
Notice of Intention to Claim Reimbursement From the Second Injury Fund (RS05)	September 2015	New fax number
Notice of Intention to Discontinue Workers' Compensation Benefits (ND01) – more information	October 2023	Removed address
Objection to Penalty Assessment (CE0003)	October 2023	Removed address
On-the-job Training Plan (JA04)	October 2023	Removed address
Permanent Total Disability Agreement (PA04)	September 2015	New fax number
Petition for Taxation of Actual and Necessary Disbursements (PT03)	June 2018	Legislative changes
Plan Progress Report (PR01) – Spanish version (informational, do not file)	October 2023	Removed address
R-2 Rehabilitation Plan (RE01) – more information	October 2023	Removed address
R-3 Rehabilitation Plan Amendment (RP01) – more information	October 2023	Removed address
R-8 Notice of Rehabilitation Plan Closure (NR01)	October 2023	Removed address
Rehabilitation Consultation Report (RC01) – Spanish version (informational, do not file)	October 2023 May 2016	Removed address Format changes
Rehabilitation Request (RQ03)	September 2023	Address update
Rehabilitation Response (RR03)	September 2023	Address update
Rehabilitation Rights and Responsibilities of the Injured Worker (IW05) – Spanish version (informational, do not file)	October 2023 May 2016	Removed address First time translated
Report of Work Ability (RW01) – more information	May 2017	Format changes
Request for Extension (QE03) – more information	July 2010
Request for Formal Hearing (RF03)	June 2018	Legislative changes
Retraining Plan (EP04)	October 2023	Removed address
Statement of Attorney Fees and Costs (SA04)	June 2018	Legislative changes

Miscellaneous form

Workers' Compensation Report of Benefits Paid (updated annually)

Optional forms (suggested format, not required by statute, rule)

Form name	Version date	Notes
Attorney Request for Certification of Dispute (CA0022)	October 2023	Removed address
Authorization for File Review or Release of Copies of Workers' Compensation Claim File (FE0055)	October 2023	Removed address
Benefit Addendum (BA01) – more information	July 2010
Disclosure of Affiliations and/or Relationships
Functional Capacity Evaluation	October 2009	New form
Model patient/provider contract for long-term treatment with opioid medication	May 2016
Motion to Intervene (MO0001)	August 2018	Format changes
Notice of File Closing (NF01) – more information	October 2023	Removed address
Notice of Penalty Payment (NO0015)	October 2014	Format changes
Occupational On-site Analysis	October 2009	New form
Penalty Request -- Workers' Compensation	October 2024	New form
Penalty Request for Failure to Pay or Deny Rehabilitation Invoice	September 2024	Legislative changes
Rehabilitation Provider Complaint	October 2012	New form
Stipulation of Intervention (LE0032)	June 2018	Legislative changes

Rehabilitation provider forms

Qualified rehabilitation consultant (QRC) internship completion checklist

Form name	Version date	Notes
R-20 Qualified Rehabilitation Consultant Intern Application	October 2023	Removed phone number
R-22 Rehabilitation Vendor Application	October 2023	Removed phone number
R-24 Qualified Rehabilitation Consultant Firm Application	October 2023	Removed phone number
R-25 Qualified Rehabilitation Consultant Application	October 2023	Removed phone number

More information

Rehabilitation plan service codes and categories
Vocational rehabilitation invoice form
For more information about workers' compensation forms, contact the Work Comp Help Desk at helpdesk.dli@state.mn.us, 651-284-5005 (press 3) or 800-342-5354 (press 3).