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.

Optional workers' compensation forms (suggested format, not required by statute or rule)

Form name Last update Notes

Authorization for file review or release of copies of workers' comp claim file (FE0005) -- [filing instructions] August 2008 PO; WID; Language concerning WID

Benefit addendum (BA01) -- [more info] May 2008 WID

Functional capacity evaluation October 2009 New form

Intervention Cover Letter (MO0001) May 2008 PO; WID

Intervention Motion (MO0001) May 2008 PO; WID

Intervention Stipulation (LE0002) May 2008 PO; WID

Intervention Service Affidavit January 2005

Notice of Appeal to Workers' Compensation Court of Appeals (NO0016) May 2008 PO; WID

Notice of File Closing (NF01) -- [more info] May 2008 PO; WID

Notice of Penalty Payment (NO0015) May 2008 WID

Occupational on-site analysis October 2009 New form

Request for Certification of Dispute (CA0022) May 2008 PO; TENN; WID

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
Authorization for file review or release of copies of workers' comp claim file (FE0005) -- [filing instructions]	August 2008	PO; WID; Language concerning WID
Benefit addendum (BA01) -- [more info]	May 2008	WID
Functional capacity evaluation	October 2009	New form
Intervention Cover Letter (MO0001)	May 2008	PO; WID
Intervention Motion (MO0001)	May 2008	PO; WID
Intervention Stipulation (LE0002)	May 2008	PO; WID
Intervention Service Affidavit	January 2005
Notice of Appeal to Workers' Compensation Court of Appeals (NO0016)	May 2008	PO; WID
Notice of File Closing (NF01) -- [more info]	May 2008	PO; WID
Notice of Penalty Payment (NO0015)	May 2008	WID
Occupational on-site analysis	October 2009	New form
Request for Certification of Dispute (CA0022)	May 2008	PO; TENN; WID
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.