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Minnesota Department of Labor and Industry

Workers' compensation -- Forms



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Workers' compensation forms (required by either statute or rule)


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

Workers' compensation forms -- Required


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Form name
Version date
Notes
Affidavit of Significant Financial Hardship (AS01) April 2012 New mailing address
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 or Payment to Estate (CP03) April 2012 New mailing address
Disability Status Report (DS01) September 2012  
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (SF0138) January 2016 Revised notice
Election to Exclude Relatives of Managers of a Limited Liability Company (SF0137) January 2016 Revised notice
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01) November 2012  
Employee's Claim Petition (EC04) April 2012 New mailing address
Employee's Objection To Discontinuance (ED02) September 2015 New fax number
Employee's Request for Administrative Conference (EQ05) -- (more information) April 2012 New mailing address
Excess Fee Exhibit (PF04) September 2015 New fax number
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 September 2015 Change to ICD-10-CM diagnostic codes
Interim Status Report (IS03) -- more information July 2010  
Medical Request (MQ03) April 2012 New mailing address
Medical Response (MR03) April 2012 New mailing address
Notice of Appearance of Attorney for Employee (NA03) April 2012 New mailing address
Notice of Benefit Payment (NB01) -- more information June 2015 Form overhaul
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 February 2010 New phone number
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 2010 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 August 2010 New phone number
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) May 2008 New mailing address
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 The changes were necessary due to a statute/law change effective Oct. 1, 2013,
to 176.102, subd. 5(b).
Rehabilitation Consultation Report (RC01)
      -- Spanish version (informational, do not file)
May 2016
May 2016
Format changes
Rehabilitation Request (RQ03) April 2012 New mailing address
Rehabilitation Response (RR03) April 2012 New mailing address
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 July 2010  
Request for Extension (QE03) -- more information July 2010  
Request for Formal Hearing (RF03) August 2012 New mailing address
Retraining Plan (EP04) January 2014  
Statement of Attorney Fees and Costs (SA04) June 2014 Corrected misinformation


Miscellaneous form




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



Workers' compensation forms -- Optional


Plus-minus graphic Click to access forms; view update dates and notes
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 (FE0005) 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 This version should be used beginning May 1, 2016.
Motion to Intervene (MO0001) August 2016 Due to statute change
effective Aug. 1, 2016
Notice of Appeal to Workers' Compensation Court of Appeals (NO0016) October 2015 New mailing address
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) September 2007 New mailing address


Rehabilitation provider forms

Workers' compensation forms -- Rehabilitation provider


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More information

 

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