Workers' compensation forms

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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.

Form name Last update Notes*

Affidavit of Significant Financial Hardship (AS01) May 2008 PO; TENN; WID

Annual Claim for Reimbursement From the Second Injury Fund (AR04) May 2008 PO; WID

Annual Claim for Reimbursement of Supplementary Benefits (AC03)
-- Addendum to Annual Claim for Reimbursement of
Supplementary Benefits December 2009 PO; WID; addendum separated

Claim Petition for Dependency Benefits or Payment to Estate (CP03) -- [filing instructions] May 2008 PO; TENN; WID

Disability Status Report (DS01) May 2008 PO; WID

Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01) May 2008 PO; TENN; WID

Employee's Claim Petition (EC04) -- [filing instructions] May 2008 PO; TENN; WID

Employee's Objection To Discontinuance (ED02) May 2008 PO; TENN; WID

Employee's Request for Administrative Conference (EQ05) -- [more info] May 2008 PO; TENN; WID

Excess Fee Exhibit (PF04) May 2008 PO; WID

First Report of Injury (FR01) -- [more info] May 2008 PO

Health Care Provider Report (HC01) -- [more info] July 2010 DLI

Interim Status Report (IS03) -- [more info] July 2010 DLI

Medical Request (MQ03) -- [filing instructions] May 2008 PO; TENN; WID

Medical Response (MR03) May 2008 PO; TENN; WID

Notice of Appearance of Attorney for Employee (NA03) May 2008 PO; WID

Notice of Benefit Payment (NB01) -- [more info] February 2010 PH

Notice of Benefit Reinstatement (NC01) -- [more info] July 2010 DLI

Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) -- [more info] February 2010 PH

Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) -- [more info] February 2010 PH

Notice of Insurer's Primary Liability Determination (NL01) -- [more info] 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 info] February 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] May 2008 PO; WID

R-2 Rehabilitation Plan (RE01) -- [more info] [Spanish] September 2008 PO; TENN; WID

R-3 Rehabilitation Plan Amendment (RP01) -- [more info] [Spanish] September 2008 PO; TENN; WID

R-8 Notice of Rehabilitation Plan Closure (NR01) -- [Spanish] May 2008 PO; WID

Rehabilitation Consultation Report (RC01) May 2008

Rehabilitation Request (RQ03) -- [filing instructions] [Spanish] May 2008 PO; TENN; WID

Rehabilitation Response (RR03) -- [Spanish] May 2008 PO; TENN; WID

Rehabilitation Rights and Responsibilities of the Injured Worker (IW05) -- [Spanish] May 2008

Report of Work Ability (RW01) -- [more info] July 2010 DLI

Request for Extension (QE03) -- [more info] July 2010 DLI

Request for Formal Hearing (RF03) May 2008 PO; TENN; WID

Retraining Plan (EP04) September 2008 PO; TENN; WID

Statement of Attorney Fees (SA04) May 2008 PO; WID

*Notes: DLI = department information updated; PH = phone number change; 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 forms

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*
Affidavit of Significant Financial Hardship (AS01)	May 2008	PO; TENN; WID
Annual Claim for Reimbursement From the Second Injury Fund (AR04)	May 2008	PO; WID
Annual Claim for Reimbursement of Supplementary Benefits (AC03) -- Addendum to Annual Claim for Reimbursement of Supplementary Benefits	December 2009	PO; WID; addendum separated
Claim Petition for Dependency Benefits or Payment to Estate (CP03) -- [filing instructions]	May 2008	PO; TENN; WID
Disability Status Report (DS01)	May 2008	PO; WID
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01)	May 2008	PO; TENN; WID
Employee's Claim Petition (EC04) -- [filing instructions]	May 2008	PO; TENN; WID
Employee's Objection To Discontinuance (ED02)	May 2008	PO; TENN; WID
Employee's Request for Administrative Conference (EQ05) -- [more info]	May 2008	PO; TENN; WID
Excess Fee Exhibit (PF04)	May 2008	PO; WID
First Report of Injury (FR01) -- [more info]	May 2008	PO
Health Care Provider Report (HC01) -- [more info]	July 2010	DLI
Interim Status Report (IS03) -- [more info]	July 2010	DLI
Medical Request (MQ03) -- [filing instructions]	May 2008	PO; TENN; WID
Medical Response (MR03)	May 2008	PO; TENN; WID
Notice of Appearance of Attorney for Employee (NA03)	May 2008	PO; WID
Notice of Benefit Payment (NB01) -- [more info]	February 2010	PH
Notice of Benefit Reinstatement (NC01) -- [more info]	July 2010	DLI
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) -- [more info]	February 2010	PH
Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) -- [more info]	February 2010	PH
Notice of Insurer's Primary Liability Determination (NL01) -- [more info]	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 info]	February 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]	May 2008	PO; WID
R-2 Rehabilitation Plan (RE01) -- [more info] [Spanish]	September 2008	PO; TENN; WID
R-3 Rehabilitation Plan Amendment (RP01) -- [more info] [Spanish]	September 2008	PO; TENN; WID
R-8 Notice of Rehabilitation Plan Closure (NR01) -- [Spanish]	May 2008	PO; WID
Rehabilitation Consultation Report (RC01)	May 2008
Rehabilitation Request (RQ03) -- [filing instructions] [Spanish]	May 2008	PO; TENN; WID
Rehabilitation Response (RR03) -- [Spanish]	May 2008	PO; TENN; WID
Rehabilitation Rights and Responsibilities of the Injured Worker (IW05) -- [Spanish]	May 2008
Report of Work Ability (RW01) -- [more info]	July 2010	DLI
Request for Extension (QE03) -- [more info]	July 2010	DLI
Request for Formal Hearing (RF03)	May 2008	PO; TENN; WID
Retraining Plan (EP04)	September 2008	PO; TENN; WID
Statement of Attorney Fees (SA04)	May 2008	PO; WID
Notes: DLI = department information updated; PH = phone number change; 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.