Work comp: Forms | Minnesota Department of Labor and Industry

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About the forms

The forms provided below are fillable PDFs that can be viewed or printed using the free Adobe Acrobat Reader software. However, that software does not allow users the option of saving data that is typed into the filled-in PDF; to have the option to save input information, visit www.adobe.com for more information about Adobe Acrobat software.

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.

Learn about

Online submission options

Annual claim reimbursement
– User information about submission of online annual claim reimbursement form
Attorney Request for Certification of Dispute, Medical Request, Medical Response, Rehabilitation Request, Rehabilitation Response
A feature of this online filing tool allows users to save filed dispute documents. It also requires users to login to the system in a new way – learn more. Because of the feature, users can now save incomplete files they are still working on, save completed files and review dispute documents that have already been filed.
– User information about submission of online Medical Request and Rehabilitation Request forms.
Mediation request available online from DLI's Alternative Dispute Resolution unit
Rehabilitation forms submission

A to Z – required workers' compensation forms (required by statute, rule)

The Spanish versions of forms are to be used for communication purposes only; they should not be filed with the department.

Form name	Version date	Notes
Affidavit of Significant Financial Hardship (AS01)	June 2018	Legislative changes
Annual Claim for Reimbursement From the Second Injury Fund (AR04)	September 2015	New fax number
Annual Claim for Reimbursement of Supplementary Benefits (AC03) – Addendum to Annual Claim for Reimbursement of Supplementary Benefits	September 2015	New fax number
Certificate of Compliance; Minnesota Workers' Compensation Law (MN LIC 04) – more information	November 2016	Form overhaul
Claim Petition for Dependency Benefits of Payment to Estate (CP03)	June 2018	Legislative changes
Disability Status Report (DS01)	September 2012
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (SF0138)	May 2018	Made fillable
Election to Exclude Relatives of Managers of a Limited Liability Company (SF0137)	May 2018	Made fillable
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01)	June 2018	Legislative changes
Employee's Claim Petition (EC04)	June 2018	Legislative changes
Employee's Objection to Discontinuance (ED02)	June 2018	Legislative changes
Employee's Request for Administrative Conference (EQ05) – more information	June 2018	Legislative changes
Excess Fee Exhibit (PF04)	June 2018	Legislative changes
First Report of Injury (FR01) – more information Amended rules effective for first reports of injury filed on or after Jan. 1, 2014: 5220.2530, 5220.2820, 5220.2830	March 2016	Instruction changes
Health Care Provider Report (HC01) – more information	April 2017	Format changes
Interim Status Report (IS03) – more information	July 2010
Medical Request (MQ03)	June 2018	Legislative changes
Medical Response (MR03)	June 2018	Legislative changes
Notice of Appearance of Attorney for Employee (NA03)	April 2012	New mailing address
Notice of Benefit Payment (NB01) – more information	April 2017	Format changes
Notice of Benefit Reinstatement (NC01) – more information	September 2015	Format changes
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) – more information	May 2018	Format changes
Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) – more information	February 2010	New phone number
Notice of Insurer's Primary Liability Determination (NL01) – more information	February 2017	New phone number
Notice of Intention to Claim Reimbursement From the Second Injury Fund (RS05)	September 2015	New fax number
Notice of Intention to Discontinue Workers' Compensation Benefits (ND01) – more information	January 2017	Format, instruction changes
Objection to Penalty Assessment (CE0003)	May 2008	New mailing address
On-the-job Training Plan (JA04)	September 2008	New mailing address
Permanent Total Disability Agreement (PA04)	September 2015	New fax number
Petition for Taxation of Actual and Necessary Disbursements (PT03)	June 2018	Legislative changes
Plan Progress Report (PR01) – Spanish version (informational, do not file)	January 2014 November 2014
R-2 Rehabilitation Plan (RE01) – more information	August 2015	Format changes
R-3 Rehabilitation Plan Amendment (RP01) – more information	August 2015	Format changes
R-8 Notice of Rehabilitation Plan Closure (NR01)	November 2013	Statute/law change
Rehabilitation Consultation Report (RC01) – Spanish version (informational, do not file)	May 2016 May 2016	Format changes
Rehabilitation Request (RQ03)	July 2018	Corrections to legislative changes update
Rehabilitation Response (RR03)	June 2018	Legislative changes
Rehabilitation Rights and Responsibilities of the Injured Worker (IW05) – Spanish version (informational, do not file)	October 2013 May 2016	Form overhaul First time translated
Report of Work Ability (RW01) – more information	May 2017	Format changes
Request for Extension (QE03) – more information	July 2010
Request for Formal Hearing (RF03)	June 2018	Legislative changes
Retraining Plan (EP04)	January 2014
Statement of Attorney Fees and Costs (SA04)	June 2018	Legislative changes

Miscellaneous form

Workers' Compensation Report of Benefits Paid (updated annually)

Optional forms (suggested format, not required by statute, rule)

Form name	Version date	Notes
Attorney Request for Certification of Dispute (CA0022)	June 2013	Renamed, revised
Authorization for File Review or Release of Copies of Workers' Compensation Claim File (FE0055)	June 2011
Benefit Addendum (BA01) – more information	July 2010
Disclosure of Affiliations and/or Relationships
Functional Capacity Evaluation	October 2009	New form
Model patient/provider contract for long-term treatment with opioid medication	May 2016
Motion to Intervene (MO0001)	August 2018	Format changes
Notice of Appeal to Workers' Compensation Court of Appeals (NO0016)	June 2018	Legislative changes
Notice of File Closing (NF01) – more information	May 2008	New mailing address
Notice of Penalty Payment (NO0015)	October 2014	Format changes
Occupational On-site Analysis	October 2009	New form
Rehabilitation Provider Complaint	October 2012	New form
Stipulation of Intervention (LE0032)	June 2018	Legislative changes

Rehabilitation provider forms

Form name	Version date	Notes
R-20 Qualified Rehabilitation Consultant Intern Application	July 2015	Law change
R-22 Rehabilitation Vendor Application	July 2015	Law change
R-24 Qualified Rehabilitation Consultant Firm Application	July 2015	Law change
R-25 Qualified Rehabilitation Consultant Application	July 2015	Law change

More information

Rehabilitation plan service codes and categories
Vocational rehabilitation invoice form
For more information about workers' compensation forms, contact Karen Ryba in the Compliance, Records and Training unit, at 651-284-5425 or dli.wcrequest@state.mn.us.