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Minnesota Form Center -

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Form

Description

fr01.pdf First Report of Injury (FR01) Minnesota requires electronic filing of Workers' Compensation First Report of Injury (FROI) forms effective Jan. 1, 2014.
wceeinfo.pdf BROCHURE - Minnesota Workers' Compensation System Employee Information Sheet
wceeinfo.spa.pdf BROCHURE - Minnesota Workers' Compensation System Employee Information Sheet (Spanish)
eeguide2wc.pdf BROCHURE - An Employee's Guide to the Minnesota Workers' Compensation System
eeguide2wc_spanish.pdf BROCHURE - An Employee's Guide to the Minnesota Workers' Compensation System (Spanish)
ombudsman_brochure.pdf BROCHURE - Ombudsman Brochure
mediation_brochure.pdf BROCHURE - Mediation Brochure
poster.pdf POSTER - Workers' Compensation Poster
poster_sp.pdf POSTER - Workers' Compensation Poster (Spanish)
mnosha.pdf POSTER - Safety and health protection on the job
ac03.pdf Annual Claim for Reimbursement of Supplementary Benefits
ac03_addendum.pdf Addendum to Annual Claim for Reimbursement of Supplementary Benefits
ar04.pdf Annual Claim for Reimbursement from the Secondary Injury Fund
as01.pdf Affidavit of Significant Financial Hardship
ba01.pdf Benefit Addendum
disclosure_affiliations_relationships.pdf Disclosure of affiliations and/or Relationships
bd02.pdf Notice of Discontinuance of Workers' Compensation Benefits upon Death of Employee
ca0022.pdf Request for Certification of Dispute
ce0003.pdf Objection to Penalty Assessment
cp03.pdf Claim Petition for Dependency Benefits or Payment to Estate
sf0137.pdf Election to Exclude Certain Relatives of Managers of a Limited Liability Company
sf0138.pdf Election to Exclude Certain Relatives of Executive Officers of a Closely Held Corporation
db02.pdf Notice of Discontinuance of Workers' Compensation Dependency Benefits
ds01.pdf Disability Status Report
ec04.pdf Employee's Claim Petition
ed02.pdf Employee's Objection to Discontinuance
eq05.pdf Employee's Request for Administrative Conference
ep04.pdf Retraining Plan
fe05.pdf Authorization for File Review or Release of Copies of Workers' Compensation Claim File
hc01old.pdf Health Care Provider Report (Use for reports dated prior to Oct. 1, 2015)
hc01.pdf Health Care Provider Report
is03.pdf Interim Status Report
iw05.pdf Rehabilitation Rights and Responsibilities of the Injured Worker
iw05_spa.pdf Rehabilitation Rights and Responsibilities of the Injured Worker (Spanish)
ja04.pdf On the Job Training Plan (JA04) Form Name
lic04.pdf Certificate of Compliance Minnesota Workers' Compensation Law
le0032.pdf Stipulation of Intervention
mo0001.pdf Motion to Intervene
mo0001_letter.pdf Cover Letter for Motion / Application to Intervene
mq03.pdf Medical Request
mr03.pdf Medical Response
na03.pdf Notice of Appearance of Attorney for Employee
nb01.pdf Notice of Benefit Payment
nc01.pdf Notice of Benefit Reinstatement
nd01.pdf Notice of Intention to Discontinue Workers' Compensation Benefits
nf01.pdf Notice of File Closing
nl01.pdf Notice of Insurer's Primary Liability Determination
nr01.pdf Notice of Rehabilitation Plan Closure
no0015.pdf Notice of Penalty Payment
no0016.pdf Notice of Appeal to Workers' Compensation Court of Appeals
pa04.pdf Permanent Total Disability Agreement
pf04.pdf Excess Fee Exhibit
pr01.pdf Plan Progress Report
pr01_spa.pdf Plan Progress Report (Spanish)
pt03.pdf Petition for Taxation of Actual and Necessary Disbursements
qe03.pdf Request for Extension
rc01.pdf Rehabilitation Consultation Report
rc01_spa.pdf Rehabilitation Consultation Report (Spanish)
re01.pdf R-2 Rehabilitation Plan
codesheet.pdf Rehabilitation Plan Service Coding and Categories
rf03.pdf Request for Formal Hearing
rp01.pdf R-3 Rehabilitation Plan Amendment
rq03.pdf Rehabilitation Request
rr03.pdf Rehabilitation Response
rs05.pdf Notice of Intention to Claim Reimbursement From the Second Injury Fund
rt01.pdf Employee or Insurer's Objection to Requested Attorney Fees and/or Costs
rw01.pdf Report of Work Ability
r20.pdf Qualified Rehabilitation Consultant Intern Application
r22.pdf Registration or Renewal as a Registered Rehabilitation Vendor Affidavit
r24.pdf Qualified Rehabilitation Consultant Firm Application Consultant/Independent
r25.pdf Application for Renewal of Qualified Rehabilitation Consultant/Intern Registration
rehab_provider_complaint.pdf Rehabilitation Provider Complaint Form
ooa.pdf Occupational On-Site Analysis
fce.pdf Functional Capacity Evaluation
opioidcontract.pdf Model patient/provider contract for long-term treatment with opioid medication
sa04.pdf Statement of Attorney Fees
rehab_invoice.pdf Vocational Rehabilitation Invoice