Workers' compensation -- Forms
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Learn about:
Online submission options
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New electronic forms: Medical Request, Medical Response, Rehabilitation Request, Rehabilitation Response
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User information about submission of online Medical Request and Rehabilitation Request forms
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
Click to close or re-open this windowForm 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 |
December 2009 | PO; WID; addendum separated |
| 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) | February 2011 | |
| Election to Exclude Relatives of Managers of a Limited Liability Company (CSI01) | February 2011 | |
| 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 | February 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) | February 2012 | Technical changes |
| R-2 Rehabilitation Plan (RE01) -- more information | February 2012 | Technical changes |
| R-3 Rehabilitation Plan Amendment (RP01) -- more information | February 2012 | Technical changes |
| R-8 Notice of Rehabilitation Plan Closure (NR01) | March 2012 | Technical changes |
| 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) | February 2012 | Technical changes |
| 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) | September 2008 | PO; TENN; WID |
| Statement of Attorney Fees (SA04) | April 2012 | PO |
*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)**
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Miscellaneous forms
- Workers' Compensation Report of Benefits Paid (updated annually)
Optional workers' compensation forms (suggested format, not required by statute or rule)
Workers' compensation forms -- Optional
Click to access forms; view update dates and notesForm name |
Last update |
Notes* |
|---|---|---|
| Authorization for File Review or Release of Copies of Workers' Compensation Claim File (FE0005) -- filing instructions | 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) | November 2012 | PO |
| 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) | May 2008 | WID |
| Occupational On-site Analysis | October 2009 | New form |
| Rehabilitation Provider Complaint | November 2012 | New form |
| Request for Certification of Dispute (CA0022) | April 2012 | PO |
*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)**
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Rehabilitation provider forms
Workers' compensation forms -- Rehabilitation provider
Click to access forms; view update dates and notesForm name |
Last update |
Notes* |
|---|---|---|
| R-20 Application for Approval and Registration -- Rehabilitation Consultant Intern | March 2012 | Technical changes |
| R-22 Registration or Renewal as a Registered Rehabilitation Vendor | March 2012 | Technical changes |
| R-24 Application for Registration or Renewal as Organization Approved for the Employment of Qualified Rehabilitation Consultant/Independent and Tax Notice | March 2012 | Technical changes |
| R-25 Application for Renewal of Qualified Rehabilitation Consultant/Intern Registration | March 2012 | Technical changes |
| R-21 Qualified Rehabilitation Consultant Service and Fee Notification | June 2003 | No longer required |
| R-23 Registered Rehabilitation Vendor Service and Fee Notification | June 2003 | No longer required |
*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)**
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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
Click to access forms; view update dates and notesForm name |
Last update |
Notes* |
|---|---|---|
| Derechos de Rehabilitacion y Responsabilidades del Trabajador Lesionado (IW05) | January 2013 | |
| Informe de Consulta de Rehabilitacion (RC01) | January 2013 | |
| Informe de Progreso del Plan (PR01) | January 2013 | |
*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)**
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More information
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Rehabilitation plan service codes and categories
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For more information about workers' compensation forms, contact Kathy Hanson in the Compliance, Records and Training unit, at (651) 284-5299 or dli.wcrequest@state.mn.us.
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