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Minnesota Department of Labor and Industry

Workers' compensation -- Forms



  Forms in flux:  Some of the forms below were revised quickly to meet legislative requirements. We are working
  through those with a "Version date" of June 2018 to make them fully functioning, fillable PDF files again soon.
  We appreciate your patience as we complete the revisions.

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 filled-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.

Learn about:

Online forms submission graphicOnline submission options


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)

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 or 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 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

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 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)

July 2018 Corrections 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




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) June 2018 Legislative 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

Workers' compensation forms -- Rehabilitation provider


Plus-minus graphic Click to access forms; view update dates and notes


More information

 

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