Workers' compensation forms

The forms on this page are PDFs that can be viewed or printed. The forms have been converted to fill-in PDFs that allow users to type directly into the form and then print it. The free Adobe Acrobat Reader software does not allow users the option of saving data that is typed into the fill-in PDF; for the option to save, visit www.adobe.com for more information about Adobe Acrobat software.

Experience faster data entry for dates, phone numbers and Social Security number by entering numbers only. 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.

Miscellaneous forms

Form name Last update Notes

Certificate of Compliance Minnesota Workers' Compensation Law (MN LIC 04) -- [more info] March 2009

Customer Request for Cancellation Notice November 2005

Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (BMR02) May 2008

Election to Exclude Relatives of Managers of a Limited Liability Company (BMR01) May 2008 PO

Workers' Compensation Report of Benefits Paid February 2007

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

Rehabilitation plan service codes and categories
Vocational rehabilitation invoice form
For more information about workers' compensation forms, contact Jana Williams, Data Management and Training director, at (651) 284-5304 or dli.wcrequest@state.mn.us.

Form name	Last update	Notes
Certificate of Compliance Minnesota Workers' Compensation Law (MN LIC 04) -- [more info]	March 2009
Customer Request for Cancellation Notice	November 2005
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (BMR02)	May 2008
Election to Exclude Relatives of Managers of a Limited Liability Company (BMR01)	May 2008	PO
Workers' Compensation Report of Benefits Paid	February 2007
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.