Department of Labor: WC Batg 7

Section 7
Forms
Overview of Forms
Most of the forms that the department has created are required by statute and rule
and are necessary to all of the users of the workers’ compensation system. They
are kept as up-to-date and user-friendly as possible.
All parties must use the required forms to report information, including payments
made on claims. The department uses the information to verify the accuracy and
timeliness of payments, and for statistical purposes.
Besides the obvious data (compensation rate, periods of lost time, etc.), the forms
include instructions to the employee that are extremely important. For instance,
the forms tell employees about their time limits for requesting a discontinuance
conference or the statute of limitations on contesting a primary denial of liability.
The timely filing of these forms is important for several reasons:
• Filing of the FROI starts the statute of limitations.
• Employees are informed of their rights and benefits quickly.
• Parties will avoid getting requests from the department for additional claim
information.
• Parties can avoid penalties for late filing.
Note: If a claim does not involve any claimed disability beyond the waiting period
and doesn’t include possible PPD, the statute does NOT require that it be reported
to the department. Requirements for filing subsequent documents apply to this
type of claim ONLY if the FROI has already been (perhaps mistakenly) sent to the
department.
First Report of Injury (FROI)

The FROI is the reporting document for all work-related injury claims. It provides
basic information necessary to start the claim. Deaths and serious injuries must be
reported to the department within 48 hours. This can be done via telephone,
facsimile, or electronic transmission, to be followed by the FROI. For all other
injuries, where claimed disability exceeds three calendar days, the employer must
get the FROI to their insurance company within 10 days of the first day of disability
or the date they were aware of disability, whichever is later. Likewise, the
insurance company must file the FROI with the department within 14 days of the
first day of disability or the date the employer was aware of disability, whichever is
later. For self-insured employers, the FROI must be filed with the department
within 14 days of the first day of disability or the date the employer was aware of
Basic Adjusters’ Training Guide July 2007
MN Department of Labor and Industry 7-1
Forms
disability, whichever is later. The employee must be given a copy of the FROI
along with the employee information sheet.
Employees are not responsible for completing the FROI. The form should be
completed accurately, completely, legibly, and timely by the employer. Again, it is
very important that the FROI be submitted timely to avoid unnecessary penalties.
More information regarding penalties for late filing of the FROI can be found in the
Section 5.
July 2007 Basic Adjusters’ Training Guide

7-2 MN Department of Labor and Industry
Minnesota Department of Labor and Industry
Workers’ Compensation Division First Report of Injury
443 Lafayette Road North See Instructions on Reverse Side
St. Paul, MN 55155-4305 PRINT or TYPE your responses.
(651) 284-5030 F R 0 1
Enter dates in MM/DD/YYYY format.
1. EMPLOYEE SOCIAL SECURITY # 2. OSHA Case # DO NOT USE THIS SPACE
3. DATE OF CLAIMED INJURY 4. Time of am 5. Time employee am

injury began work on date
pm of injury pm
6. EMPLOYEE Name (last, first, middle) 7. Gender 8. Marital Married
M F
Status Unmarried
9. Home Address 10. Home phone # 11. Date of birth
City State Zip Code 12. Occupation 13. Regular department 14. Date hired
15. Average weekly wage 16. Rate per hour 17. Hours per day 18. Days per week 19. Employment Full time Part time
Status
Seasonal Volunteer
nd
20. Weekly value of: Meals Lodging 2 Income 21. Apprentice Yes No
22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: “Worker was driving lift truck with a pallet of boxes when
the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”
23. What was the injury or illness (include the part(s) of body)? Examples: chemical 24. What tools, equipment, machines, objects, or substances were involved?
burn left hand, broken left leg, carpal tunnel syndrome in left wrist. Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
25. Did injury occur on employer’s premises? 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOI)
Yes No Yes No No lost time on DOI
If no, indicate name and address of place of occurrence
28. Date employer notified of injury 29. Date employer notified of lost time
30. Return to work date 31. Date of death
32. TREATING PHYSICIAN (name, address, and phone) 33. HOSPITAL/CLINIC (name and address) (if any) 34. Emergency Room Visit
Yes No
35. Overnight in-patient
Yes No
36. EMPLOYER Legal name 37. EMPLOYER DBA name (if different)
38. Mailing address 39. Employer FEIN 40. Unemployment ID#
City State Zip Code 41. Employer’s contact name and phone #
42. Physical address (if different) 43. Witness (name and phone)
City State Zip Code 44. NAICS code 45. Date form completed
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one) Insurer
TPA
47. Insured legal name 52. CA address
48. Policy # or self-insured certificate # City State Zip Code
49. Insurer FEIN 50. Date insurer received notice 53. CA FEIN 54. Claim #
MN FR01 (02/06) Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)
GENERAL INSTRUCTIONS TO THE EMPLOYER
Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work-
related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially
incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within
ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured
employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly
to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary.
If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer
within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-
5731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence.
Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits.
Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give
a copy to the employee and the employee’s local union office. You are required to provide the employee with a copy of the Employee
Information Sheet, which is available on the Department’s web site at www.doli.state.mn.us. Employees are not responsible for
completing this form.
SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT
SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM
• Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form
301.
• Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week
wage statement so your insurer can calculate the appropriate average weekly wage.
• Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.),
and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved.
• Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the
employee for the lost time.
• Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time.
• Item 28: Fill in the date you first became aware of the injury or illness.
• Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury.
• Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to
work, fill in the date and notify your insurer if the employee misses time due to this injury after that date.
• Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on
Employer ID Number under Business.
• Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are
both assigned by the Minnesota Unemployment Insurance Program (651-296-6141).
• Items 46-54: Your insurer or claims administrator will complete this information.
INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER
The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s
name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the
First Report will be rejected and returned to you (per Minn. Stat. § 176.275). Providing the name of the third party administrator does
not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting
period or potential PPD, the form does NOT need to be filed with the Department.
• Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self-
insured company or group.
• Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy
number. If the employer is licensed to self-insure, fill in the certificate number.
• Item 49: Fill in the insurer’s Federal Employment ID number (FEIN) number.
• Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be
sure to mark either the “Insurer” or “TPA” box.
• Item 53-54: Fill in the claims administrator’s FEIN and claim number.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030
or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL
FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
Minnesota workers’ compensation system
employee information sheet
What does workers’ compensation pay for?
• Medical care for the work injury, as long as it is reasonable and necessary
• Wage-loss benefits for part of your lost income (there is a three-calendar-day waiting period before these benefits start)
• Benefits for permanent damage or loss of function of a body part
• Benefits to your spouse and/or dependents if you die of a work injury
• Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer
How are workers’ compensation benefits paid?

Your workers’ compensation benefits are paid by an insurance company or your employer, if your employer is self-
insured. State law sets the benefit levels. Please note: pursuant to statute, the insurer can obtain medical information
specific to your work injury without your authorization.
If the insurer accepts your claim for wage loss benefits and you have been disabled for more
than three calendar days:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating your
claim is accepted.
• The insurer must start paying wage-loss benefits within 14 days of the date your employer knows about your work
injury and lost wages. The insurer must pay benefits on time. Wage-loss benefits are paid at the same intervals as
your work paychecks.
If the insurer denies your claim for wage loss benefits:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating it is
denying primary liability for your claim. The form must clearly explain the facts and reasons why the insurer believes
your injury or illness did not result from your work.
• If you disagree with the denial, you should talk with the insurance claims adjuster who is handling your claim. Your
employer’s insurance company can answer most questions about your claim.
Insurer name: Phone :
• If you are not satisfied with the response you receive from the insurer and still disagree with the denial, you should
contact the Department of Labor and Industry at one of the numbers listed below to see what to do next.
If you have other questions or need more help, call the Minnesota Department of Labor and
Industry Workers’ Compensation Hotline:
Twin Cities and Southern Minnesota: (651) 284-5005 or 1-800-342-5354; TTY (651) 297-4198
Duluth and Northern Minnesota: (218) 733-7810 or 1-800-365-4584
Your call will be answered by experienced workers’ compensation specialists, who will provide instant, accurate
information and assistance.
Additional workers’ compensation information is available on the department’s Web site at:
www.doli.state.mn.us
Your employer is required by law to give you this information. This material can be made available in different formats,
such as large print, Braille or on audiotape, by calling the numbers printed above.
Updated April 2003 (format-change only). This form may be copied or reproduced electronically. Do not file this form with the department.
Forms
Notice of Insurer’s Primary Liability Determination (NOPLD)

Time Requirements
For injuries with claimed disability extending more than three calendar days, the
insurer must make a determination regarding liability within 14 days of the first day
of disability or the date the employer was aware of disability, whichever is later.
This means insurer must pay or deny a claim within 14 days. Failure to pay or
deny within 14 days can result in penalties. More information regarding penalties
for late payments and late denials are discussed in the Section 5.
The NOPLD form is used to notify the employee (or heirs/dependents of an

employee), the employer, and the department of the insurer’s position regarding
primary liability on the claim, including specific details of the accepted or denied
claim. It is important to remember that this form could be completed several
different times on the same claim to reflect changes in the insurer’s position or
changes in the specific details of the claim. These subsequent filings of the form
would be considered amended NOPLD forms. In addition, this form outlines the
employee’s rights and responsibilities.
The department uses the information supplied on the form to review for timely and
accurate compliance with the statutes and rules, for statistical data, and to publish
a legislatively mandated annual report about the promptness of insurers’ first
actions on claims.
Reasons to File
The NOPLD must be filed at least once whenever a FROI has been filed - NO
EXCEPTIONS. It is used to report:
• the first payment of wage loss benefits;
• acceptance of liability, but denial of initial wage loss benefits;
• a denial of primary liability.
The NOPLD can be required more than once for some claims. For instance:
• When the insurer initially denies primary liability, but later accepts liability.
• When the insurer initially accepts a claim and pays wage loss benefits, but
later denies primary liability within 60 days pursuant to Minnesota Statutes
§176.221, Subd. 1.
• When the insurer accepts a claim on which there are no wage loss benefits
initially paid, but later pays wage loss benefits voluntarily.
Note: This form is not to be used to report a resumption of wage-loss payments

after they have been previously discontinued. The Notice of Benefit Reinstatement
form is used for this purpose.
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When to File
• When making payment, the form should be filed at the time the initial payment
is made.
• When denying primary liability or denying partial liability (for the initial claimed
disability), the form must be filed within 14 days of the first day of disability or
the date the employer was aware of disability, whichever is later.
How to Complete the Form

The boxes (in the upper left-hand corner on the front of the form) containing claim
identifying information must be fully completed each time the form is filed. The
boxes containing the dates of lost time, notice, and initial return to work, and the
average weekly wage must be completed, if applicable, each time the form is filed,
regardless of the liability determination.
Note: If the employee initially returns to work before the insurer sends this form to
the department, (e.g. initial claimed disability was within the waiting period) and
there is a subsequent period of disability, they must fill in the first date of the period
of subsequent disability and the date the employer was notified of this new period.
• Check Box 1, 2, or 3. Only one box should be checked.
• Check Box 1 to report acceptance of liability for the claim and payment wage
loss benefits. Complete all fields in this section.
• Check any additional box in this section as needed (i.e. full wage
continuation, fatality, etc.).
Note: If the insurer indicates that the employer paid “full wages,” they must still
file a Notice of Intention to Discontinue (NOID) form at the appropriate time
showing the date of return to work or other reason for discontinuance, and the
payment data on the back of the form as required by Minnesota Statutes
§176.221, Subd. 9
• Check Box 2 to report acceptance of liability for the claim, but without payment
of wage loss benefits (a partial denial). Also check one of the boxes, “A”, “B”,
or “C”.
• Choose “A” if the employee did not have any days of claimed disability or
if the claimed disability did not exceed the waiting period. To help clarify
possible waiting period questions, explain employee’s work schedule if not
Monday through Friday.
• Choose “B” if this is a TPD-only claim and are accepting liability but are
unable to make payment because there is not sufficient wage loss
verification to determine the any amount due. The NOPLD must be filed
again at the time TPD payment is made.

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• Choose “C” to deny payment for the claimed disability for any other
reason. The specific facts forming and the legal basis for the reason for
the denial must be stated clearly in the space provided.
• Check Box 3 to report a denial of primary liability for the claim. Specify
whether it is the injury or the death (or both) that is being denied. The specific
facts and legal basis for the reason for the denial must be stated clearly in the
space provided.
• Fill in the claim representative’s name and phone number, and the date the
form is being served on the parties. No signature is required, but it is important
to note that the name and phone number, including extension, must be for the
person who actually made the primary liability determination, not for the person
who is filling out the form (if different).

Forms

Notice of Insurer’s Primary Liability Determination
See instructions on reverse side.
Enter dates in MM/DD/YYYY format. N L 0 1
Amended DO NOT USE THIS SPACE
SOCIAL SECURITY NUMBER DATE OF INJURY DATE OF DEATH (if applicable)
EMPLOYEE
EMPLOYER
INSURER/SELF-INSURER/TPA
INSURER CLAIM NUMBER
First date of lost time Date employer notified of this lost time Initial date of return to work Average weekly wage at date of injury
If the initial return to work was followed by a new period of lost time, complete the following information:
First date of new Date employer
period of lost time: ____________________________________________ notified of this lost time: ________________________________
1. Your claim is ACCEPTED and wage loss benefits will be paid.
Benefit type: Temporary Total (TTD) Temporary Partial (TPD) Permanent Total (PTD) Dependency (DEP)
Date of payment Amount of payment Time period covered with this payment Compensation rate
Date from Date through
__
Any ongoing payments will be made on ____________________ (day of week) at________________________(weekly, biweekly, etc.) intervals.
Full wage continuation by the employer under M.S. § 176.221, subd. 9.

that apply
Check all
TPD payment made according to the wage loss verification received by the insurer on __________________________(date).
Fatality with dependents. Payment is being made according to dependent information, which must be ATTACHED.
Fatality with no dependents. Payment is being made to the estate or the Special Compensation Fund.
2. Your claim is ACCEPTED. However, wage loss benefits will not be paid at this time for the following reason:
A. Injury did not cause lost time from work beyond the three calendar day waiting period. If employee’s work schedule is not
Monday through Friday, explain: _______________________________________________________________________
B. Verification of reduced wages for TPD has not been received from the employee or employer.
Check only one
C. Other reason (include legal and factual basis):
3. Primary liability is DENIED for the claimed work related injury and/or death. (Check one or both)
Reason for denial (include legal and factual basis):
NAME OF THE PERSON MAKING THIS DETERMINATION (print) PHONE NUMBER EXTENSION DATE SERVED (must be completed)
MN NL01 (12/05) Distribution: Workers’ Compensation Division, Employer, Insurer, Employee/Heirs and Dependents
INSTRUCTIONS TO EMPLOYEE/HEIRS AND DEPENDENTS
PLEASE KEEP A COPY OF THIS NOTICE FOR YOUR RECORDS
General Information
This liability determination is the opinion of the insurer. If the claim has been denied, this opinion may not be final. If you have
questions about any of the information on this form, you should first contact the person making this determination (see name and
phone number on the front side of this form). If you still have questions, contact the Department of Labor and Industry (DLI),
Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you (listed below). For the
hearing impaired, please call our Telecommunication Device for the Deaf (TDD) at (651) 297-4198. If there are problems with
your claim, there are several options available to resolve them informally.
Minnesota Department of Labor and Industry Minnesota Department of Labor and Industry
5 North Third Avenue West, Suite 400 443 Lafayette Road North
Duluth, MN 55802-1614 St. Paul, MN 55155-4301
Telephone: (218) 733-7810 Telephone: (651) 284-5030
1-800-365-4584 1-800-342-5354
Time Limitations
If the injury claim has been denied, you may lose your right to benefits if you do not commence legal proceedings within three
years after your employer/insurer filed a written report of your claimed injury with DLI, not to exceed six years after the date of
the claimed injury. If you have an occupational disease, you have three years to begin legal proceedings from the date you
learned that the cause of the disease might be work related and the disease first caused disability.
If the death claim has been denied, you may lose your right to benefits if you do not commence legal proceedings within three
years after the employer/insurer filed the written notice of death with DLI, except that:
1) For claims where the employer/insurer did not pay benefits for the injury, commencement of legal proceedings
cannot exceed six years from the date of injury resulting in the death.
2) For claims where the employer/insurer did pay benefits for the injury, commencement of legal proceedings cannot
exceed six years from the date of death.
In very rare circumstances, there may be exceptions to the time limits noted above.
Vocational Rehabilitation
If the insurer is denying primary liability for your claim and you disagree, cannot return to your former employment, and would
like vocational rehabilitation assistance, contact DLI, Vocational Rehabilitation Unit at (651) 284-5038.
Instructions to Insurer/Claims Administrator

1. If the claim is a fatality with dependents and payment is being made, attach dependent information.
2. The reason for a denial must be clear and specific, and state a legal and factual basis in language which is easily
understood. If the reason for a denial is based on medical information, attach medical reports or summary of any health care
provider contacts that support your reason for denial.
3. This form may be filed more than once if your liability determination changes. (Examples: when you initially deny primary
liability, but later accept liability; when you initially accept a claim and pay wage loss benefits, but later deny primary liability
within 60 days pursuant to M.S. § 176.221, subd 1; when you accept liability, but are unable to pay TPD benefits until
verification of wage loss is received, but later issue the first TPD check.)
4. If you file this form more than once, check the Amended box in the upper left-hand corner for each subsequent filing.
5. Do not use this form to reinstate benefits. Use the Notice of Benefit Reinstatement (NOBR) form.
6. If you indicate that the employer paid “full wage,” you must also file a Notice of Intention to Discontinue (NOID) at the
appropriate time showing the date of return to work or other reason for discontinuance and the payment data on the back of
the form as required by M.S. § 176.221, subd. 9.
7. The date served must be completed each time you file this form.
8. The boxes (in the upper left-hand corner on the front of the form) containing claim identifying information must be fully
completed each time you file the form. The boxes containing the dates of lost time, notice, and initial return to work, and the
average weekly wage must also be completed, if applicable, each time you file the form, regardless of your liability
determination.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651)
284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS
NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF
THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
Forms
Notice of Intention to Discontinue Workers’ Compensation

Benefits (NOID)
The purpose of the NOID form is to notify the employee of a reduction or
discontinuance of wage-loss benefits, the amount of benefits paid on the claim, and
their right to an administrative conference. It must be served on parties as noted
on the form.
The department uses the form to review for compliance with the statute and rules,
to verify calculation of benefits, and for statistical data.
Always attach an “Employee’s Request for Administrative Conference” form to the

employee’s copy.
Reasons to File
To discontinue or reduce TTD, TPD, or PTD:
1) when the employee returns to work at full wage;
2) when the employee returns to work at reduced wage; or
3) for reasons other than a return to work.
When to File
• Within 14 days of the date the insurer receives notice that the employee has
returned to work (# 1 or 2 above).
• At the time of discontinuance for reasons other than return to work (#3 above).
This includes situations where the insurer is discontinuing benefits when they
are denying primary liability and it is more than 60 days from the first day of
disability or the date the employer was aware of disability, whichever is later.
Note: In most situations, payment must be made through the date of service of the
NOID when reason #3 is being used.
Statutory Language
176.238 Notice of Discontinuance of Compensation. (1995)

Subd. 2. Continuance of employer’s liability; suspension.
(a) Discontinuance because of return to work. If the reason for the
discontinuance is that the employee has returned to work, temporary total
compensation may be discontinued effective the day the employee
returned to work. Written notice shall be served on the employee and filed
with the division within 14 days of the date the insurer or self-insured
employer has notice that the employee has returned to work.

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(b) Discontinuance for reasons other than return to work. If the reason for the
discontinuance is for other than that the employee has returned to work,
the liability of the employer to make payments of compensation continues
until the copy of the notice and reports have been filed with the division.
When the division has received a copy of the notice of discontinuance, the
statement of facts and available medical reports, the duty of the employer
to pay compensation is suspended, except as provided in the following
subdivisions and in section 176.239.
176.239 Administrative Decision Concerning Discontinuance of

Compensation. (1995)
Subd. 3. Payment through date of discontinuance conference.
If a notice of discontinuance has been served and filed due to the employee’s
return to work, and the employee requests a conference, the employer is not
obligated to reinstate or otherwise pay temporary total, temporary partial, or
permanent total compensation unless so ordered by the commissioner.
When an administrative conference is conducted under circumstances in which

the employee has not returned to work, compensation shall be paid through
the date of the administrative conference unless:
(a) the employee has returned to work since the notice was filed;
(b) the employee fails to appear at the scheduled administrative conference;
or
(c) due to unusual circumstances or pursuant to the rules of the division, the
commissioner orders otherwise.
Front Page
• Check one box for type of benefit being discontinued (TTD, TPD, or PTD).
• Check one box for reason for discontinuance.
• #1 for return to work at full wage
• #2 for return to work at reduced wage
• #3 other - supply specific reason and supporting documentation
Back Page
• TTD/PTD, TPD, and Retraining benefits:
• Use the format provided on the form — from, through, weeks, rate, total.
• Each period of TTD/PTD should be listed separately on the form (or an

attached worksheet if there is not enough room on the form). A break in
continuous dates of TTD/PTD or a change in the weekly payment rate
constitutes a start of a separate period of disability.
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• Each period of TPD should be listed separately on the form (or an

continuous dates of TPD constitutes a start of a separate period of
disability.
• Permanent Partial Disability:
• Enter the percent of PPD.
• Check the appropriate box for the date of injury and type of benefit being
paid - PPD, IC, or ERC.
• Enter the weeks, rate if applicable, and total.
• Attorney Fee Expenses:
• Enter the amounts on the appropriate lines.
Note: When withheld fees are paid, remove them from the “withheld” line.
• Totals:
Note: The starred items on the form should not be shown with attorneys fees
deducted from the totals. Benefit totals shown on the form for these items should
always include amounts withheld or paid for attorney fees.
form is being served on the parties. No signature is required.

Forms

Notice of Intention to Discontinue
Workers’ Compensation Benefits N D 0 1
Enter dates in MM/DD/YYYY format. DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER DATE OF INJURY
EMPLOYEE EMPLOYER
EMPLOYEE ADDRESS
CITY STATE ZIP CODE
Your benefits for (check one) TEMPORARY TOTAL TEMPORARY PARTIAL PERMANENT TOTAL
disability are being discontinued for one of the following reasons:
1. You have returned to work on (date) at full wage.
2. You have returned to work on (date) at reduced hours or wages.
Temporary partial will will not be paid. Temporary partial is usually based on the difference
between your wage of $ at the time of the injury and your current weekly wage.
3. Reasons other than return to work. Payment will be made through (date)
Give reasons and facts below. (Appropriate medical reports must be attached).
Reasonable medical expenses and any permanent partial disability due will still be paid, unless your claim has been denied.
INSTRUCTIONS TO EMPLOYEE – THIS REQUIRES YOUR IMMEDIATE ATTENTION
You are responsible for reviewing this form to make sure that you have been properly paid the benefits due you.
YOU DO NOT NEED TO TAKE ANY ACTION IF YOU BELIEVE THAT YOU HAVE RECEIVED ALL BENEFITS DUE OR THAT THE
REDUCTION OF BENEFITS IS PROPER.
If Box 1 or 2 is checked above and you believe that your benefits should be reinstated due to an occurrence during the initial 14
calendar days after your return to work, you may request a conference. Your request must be received by the Workers’
Compensation Division within 30 calendar days after the date that you returned to work.
If Box 3 is checked above and you think the reason for stopping your benefits is incorrect, or you disagree with the proposed
discontinuance, you may request a conference. Your request must be received within 12 calendar days after this notice is received
by the Workers’ Compensation Division.
TO REQUEST A CONFERENCE, YOU MUST MAIL OR DELIVER THE ATTACHED FORM TO THE WORKERS’ COMPENSATION
DIVISION SO THAT IT IS RECEIVED WITHIN THE ABOVE TIME LIMITS. TELEPHONE REQUESTS WILL ALSO BE ACCEPTED AT (612)
349-2513 OR 1-800-342-5354.
The conference will be scheduled within 10 calendar days of the date your request is received by the Division. You, your employer, and the
insurer will be invited to attend. You are not required to bring an attorney, but may bring one if you wish. You should bring to the conference
any current reports and return-to-work restrictions, if available.
You may instead file an Objection to Discontinuance with the Division. This is a formal procedure before a compensation judge which takes
longer than the administrative conference process and usually requires an attorney. If you do this, your benefits will stop on the date stated in
this notice and will not be paid during the time you wait for the hearing.
MN ND01 (11/05) (over)

If the insurer is denying primary liability for your claim and you disagree with the denial, cannot return to your former employment and would
like vocational rehabilitation assistance, contact the Department of Labor and Industry, Vocational Rehabilitation Unit at (651) 284-5038.
If you have questions about your benefits, you should first contact the claim representative whose telephone number is at the bottom of the
page. Be sure to provide that person with any additional information you have to support your claim. If you still have questions, contact the
Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you.
1-800-365-4584 1-800-342-5354
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or
1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY
KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE
SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
THE FOLLOWING BENEFITS HAVE BEEN PAID FROM THROUGH WEEKS RATE *TOTAL
Temporary Total Disability or

Permanent Total Disability
Benefit Addendum Attached
Temporary Partial Disability
Retraining Benefits
Permanent Partial Disability ___________%

Injuries on or after 10/01/95
Impairment Compensation (injuries 01/01/1984 - 09/30/1995)
Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995)
_______________________ [part of body] (injuries before 01/01/1984)
Attorney Fees/Expenses Benefit Totals
M.S. 176.081, subd. 1 & 3 Paid *Lump sum Payment Under

Award or Order
M.S. 176.081, subd. 1 & 3 Attorney Fees Reimbursed to
Still Withheld Employee (M.S. 176.081, subd. 7)
Heaton Fees Paid Interest Paid
Roraff Fees Paid *TOTAL COMPENSATION PAID
M.S. 176.191 Paid *Total Supplementary Benefits
Other Fees Paid Total Medical Expenses Paid to Date
Costs & Disbursements Paid
INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME
ADDRESS PHONE NUMBER (include area code)
CITY STATE ZIP CODE DATE SERVED ON EMPLOYEE DATE SERVED ON ATTORNEY
*Include attorney fees in these totals. Distribution: Workers’ Compensation Division, Employer, Employee, Insurer
Employee’s Request for Administrative Conference
Minn. Stat. § 176.239, subd. 2 E Q 0 5
DO NOT USE THIS SPACE

PRINT or TYPE your responses.
EMPLOYEE EMPLOYER
EMPLOYEE ADDRESS THIS REQUIRES YOUR

IMMEDIATE ATTENTION
Private or confidential data which you supply
CITY STATE ZIP CODE on this form will be used to process your
workers’ compensation claim. You may refuse
to supply the data, but your request may be
delayed, or under Minn. Stat. Sec. 176.275, the
INSURER CLAIM NUMBER INSURER/SELF-INSURER/TPA Department may refuse to accept any formal
document that lacks identifying information.
This data may be supplied to employers and
insurers for the claimed date of injury, the
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION
Department of Revenue, the Department of
BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING,
Health and the Workers’ Compensation
MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL
Reinsurance Association. It may also be used in
BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
workers’ compensation hearings and for state
This material can be made available in different forms, such as large print, Braille or investigations and statistics.
on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD
(651) 297-4198.
INSTRUCTIONS TO EMPLOYEE
DO NOT COMPLETE THIS FORM IF YOU AGREE THAT YOUR WEEKLY WORKERS’ COMPENSATION BENEFITS MAY BE STOPPED
OR CHANGED.
HOWEVER, IF YOU DISAGREE THAT YOUR BENEFITS MAY BE STOPPED OR CHANGED, YOU MAY BE ENTITLED TO AN
ADMINISTRATIVE CONFERENCE. At the conference, a decision can be made about your right to further weekly benefits.
TO REQUEST A CONFERENCE, MAIL OR DELIVER THIS COMPLETED FORM TO:

DEPARTMENT OF LABOR AND INDUSTRY
WORKERS’ COMPENSATION DIVISION
443 LAFAYETTE ROAD NORTH
ST PAUL, MN 55155-4301
Requests will also be accepted by telephone. Call (612) 349-2513 or 1-800-342-5354
TIME LIMIT TO REQUEST A CONFERENCE
IF BOX 1 OR 2 is checked on the Notice of Intention to Discontinue Workers’ Compensation Benefits, your request for a conference must be
received by the Workers’ Compensation Division WITHIN 30 DAYS AFTER YOU RETURNED TO WORK.
IF BOX 3 is checked on the Notice of Intention to Discontinue Workers’ Compensation Benefits, your request for a conference must be
received WITHIN 12 DAYS AFTER A COPY OF THE NOTICE OF INTENTION TO DISCONTINUE WORKERS’ COMPENSATION
BENEFITS IS RECEIVED BY THE WORKERS’ COMPENSATION DIVISION.
EMPLOYEE’S REQUEST FOR ADMINISTRATIVE CONFERENCE

1. BOX (check one) 1 2 3 is checked on the Notice of Intention to Discontinue Workers’ Compensation Benefits.
2. My weekly benefits should not be changed/stopped because:
(attach separate sheet if more room is needed)
EMPLOYEE SIGNATURE EMPLOYEE PHONE # (include area code) DATE
ATTORNEY (if you have one) ATTORNEY # ATTORNEY PHONE # (include area code) QRC (if you have one)
MN EQ05 (12/05) QUESTIONS: Call (651) 284-5032 Toll free within Minnesota 1-800-342-5354 ASK FOR BENEFIT MANAGEMENT AND RESOLUTION
Forms
Notice of Benefit Reinstatement (NOBR)

The purpose of the NOBR form is to report payments to the department when there
is a resumption in payments of wage-loss benefits after they have been previously
discontinued. It is also used to report other specific benefit payment changes on
the claim.
The department uses this form to review for compliance with the statute and rules,
and for statistical data.
Reasons to File
• To report a resumption of benefits, either voluntarily or pursuant to an order,

after an NOID has been filed.
• To report a change of wage loss benefits being paid from TPD to TTD.
• To report a change from full wage continuation by the employer to insurer-paid

benefits.
Note: This form is not to be used to report the initial payment of wage loss
benefits. The NOPLD form is used for this purpose.
When to File
• The form should be filed at the time of the payment.
• Fill in all information in the top section.
• Fill in all fields of the next section (date of new payment, amount, etc.)
• Check Box 1-4, only one box should be checked and fill in all the requested
information in that box.
• The pre-injury wage information section needs to be completed only if the

information differs from prior submissions. Otherwise, it can be left blank.
• Fill in the claim representative’s name and phone number, and the date this
form is being sent. No signature is required.
Note: The insurer is not required to send a copy of this form to the employee or
employer, but you may wish to use it to notify them as well as the department.

Forms

Notice of Benefit
Reinstatement N C 0 1
Please PRINT or TYPE your responses.
SOCIAL SECURITY NUMBER DATE OF INJURY DATE OF DEATH (if applicable)
EMPLOYEE
EMPLOYER
INSURER/SELF-INSURER-TPA
THIS IS NOTIFICATION THAT WORKERS’ COMPENSATION BENEFITS HAVE BEEN REINSTATED.
Date of new payment Amount of payment Type of benefit Time period covered with this payment Compensation rate
Date from - Date through
TTD TPD
PTD DEP
Insurer: Check appropriate box and enter data information:
1. Payment resumed voluntarily. First date of new period of time lost:
Date of notice to employer of new period of time lost:
2. Payment resumed pursuant to order served and filed on
M.S. § 176.239 decision OR Other decision (OAH, WCCA, or Supreme Court)
3. TPD changed to TTD effective
4. Full wage continuation changed to TTD effective
Please provide the following pre-injury wage information ONLY if it differs from prior submissions:
Average Weekly Wage Weekly value of: Meals Lodging 2nd income
Straight time:
Rate per Hours Days per 26 week Total days worked Total weeks worked
hour per day week earnings in last 26 weeks in last 26 weeks
IF OVERTIME IS PAID OR IF EMPLOYEE IS IRREGULARLY SCHEDULED, ATTACH A 26 WEEK WAGE STATEMENT.
CLAIM REPRESENTATIVE NAME PHONE # (include area code) DATE
MN NC01 (8/04) Distribution: Workers’ Compensation Division, Insurer

Forms
Notice of Benefit Payment (NOBP)

The purpose of the NOBP form is two-fold. It is used:
1) to notify the employee about payment(s) of PPD benefits and how those PPD
benefits are paid; and
2) to notify the employee of a final benefit payment according to an award,

decision, or order.
In addition, this form supplies the employee with a summary total of all benefits that
have been paid or withheld on the claim.
The department uses the form to review for compliance with the statute and rules,
to verify calculation of benefits, and for statistical data.
Reasons to File
• When paying PPD in a lump sum.
• When making the first payment of periodic PPD benefits.
• When paying under an award, order or administrative decision.
• When making the final payment of periodic PPD.
When to File
• The form should be filed at the time the payment is made.
Front Page
Check the box for PPD or final payment.
PPD
• Enter the rule number(s) from the PPD schedule, the name of doctor, and the
date of medical report. Attach the medical report giving the PPD rating.
• Check the box if this is a preliminary payment.
• For injuries on or after October 1, 1995
• Enter the amount per week, beginning date, number of weeks, and total
amount to be paid.
Forms
• For injuries between January 1, 1984 and September 30, 1995
• Lump sum IC - Indicate the dollar amount, date paid, and weeks of
eligibility for Monitoring Period Compensation.
• Periodic IC or ERC - Check box for type of benefit and enter the amount
per week, beginning date, and number of weeks.
Final Payment
• Check the appropriate box A through D.
• Indicate the date of the decision, award, or prior NOBP.
Back Page
• TTD/PTD, TPD, and Retraining benefits:
• Use the format provided on the form — from, through, weeks, rate, total.
• Each period of TTD/PTD should be listed separately on the form (or an

continuous dates of TTD/PTD or a change in the weekly payment rate
constitutes a start of a separate period of disability.
• Each period of TPD should be listed separately on the form (or an

continuous dates of TPD constitutes a start of a separate period of
disability.
• Permanent Partial Disability:
• Attorney Fee Expenses:
Note: When withheld fees are paid, remove them from the “withheld” line.
• Totals:

Forms
Note: The starred items on the form should not be shown with attorneys fees
deducted from the totals. Benefit totals shown on the form for these items should
always include amounts withheld or paid for attorney fees.
form is being served on the parties. No signature is required.

Forms

Notice of Benefit Payment
N B 0 1

EMPLOYEE EMPLOYER
EMPLOYEE ADDRESS
CITY STATE ZIP CODE
THE FOLLOWING PERMANENT PARTIAL DISABILITY BENEFIT WILL BE PAID TO YOU:
% of whole body according to Minnesota Workers’ Compensation Permanent Partial Disability Schedule
number(s)
The rating is based on the attached medical report of Dr. dated
This payment is based on the preliminary rating. If your final disability rating is higher, further payments will be made.
For injuries on or after 10/01/1995 payment will be made at $ per week beginning on
(date) for a total of weeks and a total amount of $
For injuries on or after 10/01/2000 a total lump sum payment of $ , rather than weekly payments
will be made as requested by the employee.
For injuries between 01/01/1984 and 09/30/1995 payment will be made as follows:
$ Impairment compensation will be paid in a lump sum on (date).
(if you are laid off from your job for economic reasons within weeks of the day your returned to work,
you may be entitled to monitoring period compensation, in addition to Impairment Compensation.)

Periodic impairment compensation or Periodic economic recovery compensation
of $ per week beginning on (date) will be paid for up to weeks. If you
return to work before this number of weeks, you will receive the balance due in a lump sum after working 30 days.
26 weeks economic recovery compensation (M.S. § 176.101, subd. 3t) of $
per week will be paid beginning on (date).
YOUR FINAL PAYMENT OF $ FOR

BENEFITS WAS WILL BE ISSUED ON (DATE) ACCORDING TO:
A. An award on agreement of the parties dated
B. A prior Notice of Benefit Payment for periodic payment of permanent partial disability dated
. C. An administrative decision under M.S. § 176.239 dated
D. A judge’s decision and order dated
MN NB01 (12/05) (over)

INSTRUCTIONS TO EMPLOYEE
You are responsible for reviewing this form to make sure that you have been properly paid the benefits due you. YOU DO NOT
NEED TO TAKE ANY ACTION IF YOU BELIEVE THAT YOU HAVE RECEIVED ALL BENEFITS DUE YOU OR THAT THE REDUCTION OF
BENEFITS IS PROPER.
If you have questions about your benefits, you should first contact the claim representative whose telephone number is at the bottom of the
page. Be sure to provide that person with any additional information you have to support your claim. If you still have questions, contact the
Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you.
1-800-365-4584 1-800-342-5354
THE FOLLOWING BENEFITS HAVE BEEN PAID FROM THROUGH WEEKS RATE *TOTAL
Temporary Total Disability or

Permanent Total Disability
Benefit Addendum Attached
Temporary Partial Disability
Retraining Benefits

Attorney Fees/Expenses Benefit Totals
M.S. 176.081, subd. 1 & 3 Paid *Lump sum Payment Under

Award or Order
M.S. 176.081, subd. 1 & 3 Attorney Fees Reimbursed to
Still Withheld Employee (M.S. 176.081, subd. 7)
Heaton Fees Paid Interest Paid
Roraff Fees Paid *TOTAL COMPENSATION PAID
M.S. 176.191 Paid *Total Supplementary Benefits
Other Fees Paid Total Medical Expenses Paid to Date
Costs & Disbursements Paid
CITY STATE ZIP CODE DATE SERVED ON EMPLOYEE DATE SERVED ON ATTORNEY
*Include attorney fees in these totals. Distribution: Workers’ Compensation Division, Employer, Employee, Insurer
Forms
Interim Status Report (ISR)

The purpose of the ISR form is to notify the department of continuing compensation
payments on longer-term claims. Consider filing the forms on the anniversary date
of the injury to avoid calculation errors.
The department uses the information supplied on the form to verify calculation of
benefits and for statistical data.
Reasons and When to File
• Annually on all claims with ongoing payments and/or supplementary benefits.
Front Page
• Temporary Total and Permanent Total disability:
• Check the appropriate box.
• Enter the balance carried forward from the last ISR or NOID filed.
• Enter each separate new period of TTD/PTD paid (attach a worksheet if

there is not enough room on the form). A break in continuous dates of
TTD/PTD or a change in the weekly payment rate constitutes a start of a
separate period of disability.
• Temporary Partial disability:
• Enter the balance carried forward from the last ISR or NOID filed.
• Enter each separate new period of TPD paid (attach a worksheet if there
is not enough room on the form). A break in continuous dates of TPD
constitutes a start of a separate period of disability. (Do not itemize each
week of TPD.)
• Permanent Partial disability:
Back Page
• Retraining and Dependency benefits:

Forms
• Enter the dates, weeks, rate, and total.
• Social Security/Government benefits:
• Check retirement or disability.
• Enter the name of the program.
• Enter the dates and the amount per week.
• Supplementary benefits:
• Enter the dates, weeks, rate, and total.
• Attorney fees:
Note: When withheld fees are paid, please remove them from the “withheld” line.
• Total:

Interim Status Report
I S 0 3
EMPLOYEE EMPLOYER
EMPLOYEE ADDRESS
CITY STATE ZIP CODE
THE FORM MUST BE SUBMITTED ANNUALLY ON ALL CLAIMS OF CONTINUING DISABILITY, SUPPLEMENTARY OR
DEPENDENCY BENEFITS. Please provide additional information on the Benefit Addendum (BA01).
Temporary Total* Permanent Total* FROM THROUGH WEEKS RATE *TOTAL
Balance Carried Forward
TOTAL:
Temporary Partial
TOTAL:
Permanent Partial
TOTAL:
*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of Supplementary
Benefits.
MN IS03 (8/04) (over)

FROM THROUGH WEEKS RATE TOTAL
Retraining Benefits
TOTAL:
Dependency Benefits
TOTAL:
Supplementary Benefits*
TOTAL:
Social Security Benefits or Other Government Benefits* Retirement Disability
Name of Program:
FROM THROUGH PER WEEK
*These areas need not be completed if this form is being attached to and filed with the Annual Claim for Reimbursement of
Supplementary Benefits.
Attorney Fees Paid Interest Paid
Attorney Fees Still Withheld Lump Sum Payment

Under Award or Order
Total Compensation
Attorney Fees
Paid to Employee
Reimbursed to Employee
M.S. 176.081, subd. 7 Total Dependency Benefits Paid
(Please attached copy of worksheet)
CITY STATE ZIP CODE DATE SERVED
Forms
Notice of File Closing

The purpose of this form is to notify the department that the insurer’s file is about to
be closed. Although filing of this form is not required by statute or rule, the
voluntary use of it often avoids requests from the department to the insurer after
their file has been closed and shipped to off-site storage.
The department uses the receipt of the form as a trigger to perform a final audit of
the file for compliance with the statute and rules.
Reasons to File
• To notify department staff that the insurer is closing a file.
When to File
• At the time the insurer determines their file can be closed. Be sure that all
required documents have been sent to the department before filing this form.

Forms

N F 0 1
Notice of File Closing

EMPLOYEE
EMPLOYER
THIS IS TO NOTIFY YOUR OFFICE THAT ALL PAYMENTS AND OTHER ACTIVITIES HAVE BEEN COMPLETED ON THIS
FILE. AS A RESULT, WE ARE NOW CLOSING IT ON OUR SYSTEM.
CLAIM REPRESENTATIVE NAME DATE
ADDRESS INSURER/SELF-INSURER/TPA
CITY STATE ZIP CODE PHONE NUMBER (include area code)
Send completed form to: Minnesota Department of Labor and Industry

Workers’ Compensation Division
443 Lafayette Road North
St. Paul, MN 55155-4317
or 1 800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
MN NF01 (8/04)
Forms
Health Care Provider Report (HCPR)

The purpose of the HCPR form is to request required medical information that is
critical to proper administration of the claim. When requesting this information from
a health care provider, a party must complete the general information section (at
the top of the form) identifying the employee, the employer, and the insurer. Also,
they must specify all items to be answered by the health care provider.
The health care provider must respond on this report form or in a narrative report
that contains the same information within 10 calendar days of the request.
The health care provider is not reimbursed for providing the information on this
form.
If the report indicates that the employee has reached MMI, the insurer must serve
the report on the employee (see MMI in Section 1 for more information). If the
report indicates a preliminary or final permanent partial disability rating, it must be
filed with the department.
Report of Work Ability (RWA)

A health care provider treating an employee who alleges a work related injury must
complete a RWA within 10 days of a request for a RWA from the insurer. In
addition, the primary health care provider must provide a RWA to the employee at
the following intervals (Minnesota Rules Part 5221.0410, Subp. 6):
• every visit if visits are less frequent than one every two weeks; or
• every two weeks if visits are more frequent than once every two weeks, unless
work restrictions change sooner; or
• at expiration of the end date or review date specified in previous RWA.
The RWA must either be on the prescribed form or in a report that contains the
same information.
The health care provider must provide the RWA to the employee and place a copy
in the medical record.
It is not necessary to file the RWA with the department unless the report is the
basis for a discontinuance or needed to resolve a dispute.

Forms

Health Care Provider Report
See Instructions on Reverse Side
(WHEN COMPLETED RETURN TO REQUESTER) H C 0 1
EMPLOYEE EMPLOYER
INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER
INSURER ADDRESS
CITY STATE ZIP CODE
REQUESTER must specify all items to be completed by health care provider. Items: MMI (#9) PPD (#10)
HEALTH CARE PROVIDER TO COMPLETE ITEMS REQUESTED ABOVE
1. Date of first examination for this injury by this office

2. Diagnosis (include all ICD-9-CM codes):
3. History of injury or disease given by employee:
4. In your opinion (as substantiated by the history and physical examination) was the injury or disease caused, aggravated or accelerated
by the employee’s alleged employment activity or environment? No Yes
5. Is there evidence of pre-existing or other conditions that affect this disability? No Yes If yes, describe:
6. Is further treatment of this injury or referral to another doctor planned? No Yes If yes, describe:
7. Has surgery been performed? No Yes If yes, date and describe:
8. Attach the most recent Report of Work Ability. Date of Report:

9. Has the employee reached maximum medical improvement? No Yes Date reached:
(If yes, complete item #10) (See definition on back)
10. Has the employee sustained any permanent partial disability from the injury? No Yes Too early to determine
The permanent partial disability is % of the whole body. This rating is based on Minn. Rules:
5223. % 5223. %
5223. % 5223. %
NAME SIGNATURE DEGREE
ADDRESS STATE LICENSE #/REGISTRATION #
CITY STATE ZIP CODE PHONE # (include area code) DATE SIGNED
MN HC01 (8/04)
NOTICE TO EMPLOYEE: SERVICE OF THIS REPORT OF MAXIMUM MEDICAL IMPROVEMENT (SEE DEFINITION IN INSTRUCTIONS
FOR ITEM 9) MAY HAVE AN IMPACT ON YOUR TEMPORARY TOTAL DISABILITY WAGE LOSS BENEFITS. IF THE INSURER
PROPOSES TO STOP YOUR BENEFITS, A NOTICE OF INTENTION TO DISCONTINUE BENEFITS SHOULD BE SENT TO YOU. IF YOU
HAVE ANY QUESTIONS CONCERNING YOUR BENEFITS OR MAXIMUM MEDICAL IMPROVEMENT, YOU MAY CALL THE CLAIM
REPRESENTATIVE OR THE DEPARTMENT OF LABOR AND INDUSTRY, WORKERS’ COMPENSATION DIVISION AT (651) 284-5030
OR 1-800-342-5354.
INSTRUCTIONS TO THE INSURER AND HEALTH CARE PROVIDER
Within ten (10) calendar days of receipt of a request for information on the Health Care Provider Report from an employer, insurer, or the
commissioner, a health care provider must respond on the report form or in a narrative report that contains the same information. (Minn. Rules
5221.0410, subp. 2)
A. The employer, insurer, or Commissioner may request required medical information on the Health Care Provider Report form.
• The requester must complete the general information identifying the employee, employer, and insurer.
• The requester must specify all items to be answered by the health care provider.
• For those injuries that are required to be reported to the Division, the self-insured employer or insurer must file reports with the
Division. (M.S. § 176.231, subd. 1 and Minn. Rules 5221.0410, subp. 5 and subp. 8)
• The self-insured employer or insurer must serve the report of maximum medical improvement (MMI) on the employee. (M.S. §
176.101, subd. 1(j) and Minn. Rules 5221.0410, subp. 3)
B. Instructions to the Health Care Provider for completing the Health Care Provider Report:
• Items 1 - 5: Fill in all information as required.
• Item 6: Indicate if further treatment or referral is planned. Describe the treatment plan (e.g., continue medication, refer to physical
therapy, refer to a specialist, perform surgery).
• Item 7: State if surgery has been performed. If yes, fill in the date performed and describe the procedure.
• Item 8: Attach the most recent Report of Work Ability. (Minn. Rules 5221.0410, subp. 6)
• Item 9: Indicate if the employee has reached MMI. If yes, fill in the date MMI was reached. At MMI, permanent partial disability
(PPD) must be reported (item 10). (M.S. § 176.011, subd. 25 and Minn. Rules 5221.0410, subp. 3)
MAXIMUM MEDICAL IMPROVEMENT means “The date after which no further significant recovery from or significant lasting
improvement to a personal injury can reasonably be anticipated, based upon reasonable medical probability, irrespective and
regardless of subjective complaints of pain.”
• Item 10: The health care provider must render an opinion of PPD when ascertainable, but no later than the date of MMI. (M.S. §
176.011, subd. 25 and Minn. Rules 5221.0410, subp. 4)
Indicate if the employee sustained PPD from this injury. Check one of the three boxes (too early to determine, no, yes). If yes,
specify any applicable category of the PPD schedule in effect for the employee’s date of injury. Report any zero ratings.
• Identify the health care provider completing the report by name, professional degree, license or registration number, address, and
phone number.
• The health care provider must sign and date the report.
Report of Work Ability
See Instructions of Reverse Side
R W 0 1
This form must be provided to the employee.
(Minn. Rules 5221.0410,l subd. 6)
NOTICE TO EMPLOYEE: YOU MUST PROMPTLY PROVIDE A COPY OF THIS REPORT
TO YOUR EMPLOYER OR WORKERS’ COMPENSATION INSURER, AND QUALIFIED
REHABILITATION CONSULTANT IF YOU HAVE ONE.
EMPLOYEE
EMPLOYER
INSURER/SELF-INSURER-TPA
Date of most recent examination by this office
Select the appropriate option(s) below and fill in the applicable dates.
1. Employee is able to work without restrictions as of (date)
2. Employee is able to work with restrictions, from (date) to (date)
The restrictions are:
3. Employee is unable to work from (date) to (date)
The next scheduled visit is: as needed OR
NAME (Type or Print) SIGNATURE DEGREE
ADDRESS STATE LICENSE #/REGISTRATION #
CITY STATE ZIP CODE PHONE # (include area code) DATE SIGNED
MN RW01(9/04)
INSTRUCTIONS FOR COMPLETING REPORT OF WORK ABILITY
Each health care provider directing the course of treatment for an employee who alleges to have incurred an injury on the job must complete a
Report of Work Ability within 10 days of a request for a Report of Work Ability from the insurer, or at the applicable interval (Minn. Rules
5221.0410, subp. 6):
1. every visit if visits are less frequent that one every two weeks;
2. every 2 weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner; and
3. upon expiration of the ending or review date of the restrictions specified in a previous Report of Work Ability.
The Report of Work Ability must either be on this form or in a report that contains the same information. The Report of Work Ability must:
• Identify the employee by name, social security number, and date of injury.
• Identify the employer at the time of the employee’s claimed work injury.
• If known, identify the workers’ compensation insurer at the time of the claimed injury, or the workers’ compensation third-
party administrator. Also indicate this workers’ compensation payer’s claim number.
• Indicate the date of the most recent examination by this office. The Report of Work Ability should be completed based on
this evaluation.
• Identify the appropriate option which best describes the employee’s current ability to work by checking box 1, 2, or 3.
1. If the employee is able to work without restrictions, fill in the beginning date.
2. If the employee is able to work with restrictions, fill in the date any restriction of work activity is to begin and the
anticipated ending or review date. Describe any restrictions in functional terms (e.g., employee can lift up to 20 pounds,
15 times per hour; should have 10 minute break every hour).
3. If the employee is unable to work at all, fill in the date the restriction of work activity is to begin and the anticipated ending
or review date.
• Indicate the date of the next scheduled visit or indicate that additional visits will be scheduled as needed.
• Identify the health care provider completing the report by name, professional degree, license or registration number, address
and phone number.
• Include the signature of the health care provider and date of the report.
The health care provider must provide the Report of Work Ability to the employee and place a copy in the medical record.
If you have questions, please call the claim representative or the Department of Labor and Industry, Workers’ Compensation Division at (651)
284-5030 or 1-800-342-5354.
Forms
Disability Status Report (DSR)

To ensure that a rehabilitation consultation is provided when necessary, Minnesota
Rules Part 5220.0110, Subp. 7 requires that the insurer send the employee a DSR
and file a copy with the department, when any of the following occur:
• within 14 calendar days of knowledge that the employee’s TTD is likely to

exceed 13 cumulative weeks; or
• within 90 calendar days of the date of injury when the employee has not
returned to work following a work injury; or
• within 14 calendar days after receiving a request for a rehabilitation

consultation, whichever is earlier.
In addition, a DSR must be filed within 14 calendar days of expiration of an

approved waiver of rehabilitation services.
An insurer who files a DSR must refer the employee for a rehabilitation consultation
or request a waiver of rehabilitation services. A rehabilitation waiver is granted
when the employer documents that the otherwise qualified employee will return to
suitable gainful employment with the date-of-injury employer within 90 calendar
days after the request for the waiver is filed. The waiver shall not be effective more
than 90 calendar days after the waiver is granted. If the insurer is requesting a
waiver, please note the Instructions to Insurer on the back of the prescribed DSR
form. Documentation that the employee will return to suitable gainful employment
is satisfied by submitting a written offer of suitable gainful employment, signed by
the employer, that is within the treating doctor’s restrictions and to which the
employee will return within 90 calendar days after the waiver is filed.
The department reviews all requests for waivers and notifies the insurer whether a
waiver is granted or denied. If the department grants a waiver, it is only effective
until 90 calendar days after the waiver is granted. A waiver of consultation and
rehabilitation services may not be renewed.
If a waiver is not granted, the insurer must provide a rehabilitation consultation.

When referring an employee to a QRC for a consultation, the insurer must send a
copy of the DSR, the FROI, and the treating physician’s RWA to the QRC prior to
the consultation. If the insurer does not refer the employee for such a consultation,
the department will order a consultation by the department’s Vocational
Rehabilitation unit or by the employee’s choice of QRC.

Forms

Department of Labor and Industry
443 Lafayette Road North Disability Status Report
St. Paul, MN 55155 Filed as required by Minn. Rules 5220.0110, subp. 7
(651) 284-5030 or D S 0 1
1-800-342-5354 (DIAL-DLI) Enter dates in MM/DD/YYYY format.

1. SOCIAL SECURITY NUMBER 2. DATE OF INJURY
3. EMPLOYEE NAME
4. EMPLOYEE ADDRESS
CITY STATE ZIP CODE 5. EMPLOYEE PHONE #
6. EMPLOYER 7. EMPLOYER CONTACT PERSON 8. PHONE #
9. INSURER/SELF-INSURER/TPA 12. TITLE OF JOB AT DATE OF INJURY
10. INSURER ADDRESS 13. AVERAGE WEEKLY WAGE 14. JOB AT DATE OF INJURY
AT DATE OF INJURY FULL TIME
PART TIME
CITY STATE ZIP CODE 15. NUMBER OF DAYS OF 16. IS THE EMPLOYEE
DISABILITY CURRENTLY WORKING?
YES NO
11. INSURER CLAIM NUMBER 17. WILL THE DISABILITY LIKELY EXTEND BEYOND 13 WEEKS?
(see instructions on back)
YES NO
18. REASON FOR FILING THE DISABILITY STATUS REPORT: (Check A or B)
Was a consultation requested? NO YES If yes, consultation requested by:
Insurer Employer Employee on (date of request)
A. The employee is being referred for a rehabilitation consultation. (Insurer must send a copy of this Disability Status
Report, the First Report of Injury, and the treating physician’s Report of Work Ability to the QRC before the
rehabilitation consultation.)
Name of QRC
B. A waiver of the rehabilitation consultation is being requested. (An offer of suitable gainful employment signed by the
date-of-injury employer and the Report of Work Ability must be attached.)
Projected return to work date
Name of insurer representative completing form Phone number Extension Date served on employee
MN DS01 (12/05) Distribution: Workers’ Compensation Division, Employee

Instructions to Insurer
The Disability Status Report (DSR) is used to notify parties that you are either referring the injured worker for a rehabilitation
consultation or requesting a waiver of the consultation. The DSR, with a Report of Work Ability (RWA), must be mailed to the
injured worker and filed with the Department of Labor and Industry:
• Within 14 calendar days of knowledge that the employee’s temporary total disability is likely to exceed 13 cumulative
weeks; or
• Within 90 calendar days of the date of injury when the employee has not returned to work following a work injury; or
• Within 14 calendar days after receiving a request for a rehabilitation consultation, whichever is earlier; or
• Within 14 calendar days of expiration of an approved waiver of rehabilitation services.
To Refer for a Rehabilitation Consultation:
If you are referring the injured worker for a rehabilitation consultation, check Box 18A. Send a copy of the DSR form, the First
Report of Injury and the treating physician’s Report of Work Ability to the QRC prior to the consultation. Fill in the name of the
QRC on the form and indicate which party requested the consultation. If the employee requested the consultation, fill in the date
of the request.
To Request a Waiver of a Rehabilitation Consultation:
M.S. § 176.102, subd. 4 and Minn. Rules 5220.0110 and 5220.0120 provide that the commissioner may grant a waiver of a
rehabilitation consultation to an otherwise qualified employee if there is documentation that the employee will return to suitable
gainful employment with the date-of-injury employer within 90 calendar days after the request for waiver is filed. A waiver will
not be granted unless documentation is submitted that a suitable job offer within the treating doctor’s restrictions has been
made.
If you are requesting a waiver, check Box 18B and attach the following documentation:
• Report of Work Ability or other medical report with the same information from the treating doctor which indicates that the
employee will be released to return to work within 90 calendar days after the request for waiver is filed and specifying the
employee’s work restrictions in functional terms.
• Written offer of suitable gainful employment signed by the employer that is within the treating doctor’s restrictions to which
the employee will return within the timeframe indicated above. Include one of the following:
• If the employer is offering the employee his/her date-of-injury job, any modifications of the job to accommodate the
employee’s restrictions must be noted.
• If the written offer of suitable gainful employment (which does not include temporary, light-duty) is for a different job
with the date-of-injury employer, the offer must include the job title, job environment, work tasks, weekly wage,
physical, mental and educational demands of the job, and/or employer modifications of the job to accommodate the
employee’s restrictions.
Instructions to Employee
If you do not agree with the insurer’s recommendation for a rehabilitation consultation or a waiver of rehabilitation consultation,
you may file a Rehabilitation Request with the Department of Labor and Industry. If you have questions call the Benefit
Management and Resolution Unit at 1-800-342-5354 or 651-284-5032.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call
(651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.
Forms
Rehabilitation Consultation Report (RCR)

The rehabilitation consultation is a meeting between the employee and a QRC to
determine whether the employee is eligible for rehabilitation services. According to
Minnesota Rules Part 5220.0100, Subp. 22, an employee is eligible if, because of
the effects of an injury or disease, whether or not combined with the effects of a
prior injury or disability, the employee:
• is permanently precluded or is likely to be permanently precluded from

engaging in the employee’s usual and customary occupation or from engaging
in the job the employee held at the time of injury;
• can not reasonably be expected to return to suitable gainful employment with

the date-of-injury employer; and
• can reasonably be expected to return to suitable gainful employment through

the provision of rehabilitation services, considering the treating physician’s
opinion of the employee’s work ability.
During the consultation, the QRC must disclose any affiliations with the employer or
insurer and must discuss the information on the “Rehabilitation Rights and
Responsibilities of the Injured Worker” form.
To determine the employee’s eligibility for rehabilitation services, the QRC talks not
only with the employee, but also the employer and the treating doctor, when
necessary. The QRC completes RCR which spells out the likelihood that the
employee will return to the pre-injury employer or pre-injury occupation, and gives
an assessment of whether or not the employee is a qualified employee for
rehabilitation services. This form must be filed with the department within 14 days
of the first in-person meeting with the employee. The QRC is required to provide
copies of the RCR, a signed Rehabilitation Rights and Responsibilities of the
Injured Worker form, and a narrative report explaining the basis for the
determination to the employer, the employee, any attorney for the employee, and
the insurer (see Minnesota Rules Parts 5220.0130, Subp. 3C(4) and 5220.0100,
Subp. 31).

Forms

Mail completed copy to:
Rehabilitation Consultation
443 Lafayette Road North Report R C 0 1
St. Paul, MN 55155
(651) 284-5030 or Enter dates in MM/DD/YYYY format.
1-800-342-5354 (DIAL-DLI)
3. EMPLOYEE NAME
4. EMPLOYEE ADDRESS
CITY STATE ZIP CODE 5. EMPLOYEE PHONE NUMBER 6. DATE OF BIRTH
7. EMPLOYER NAME 8. EMPLOYER CONTACT PERSON 9. PHONE #
10. INSURER CLAIM NUMBER 15. QRC NAME
11. INSURER/SELF-INSURER/TPA 16. QRC FIRM
12. INSURER ADDRESS 17. ADDRESS
CITY STATE ZIP CODE CITY STATE ZIP CODE
13. CLAIM REPRESENTATIVE 14. PHONE # 18. QRC # 19. QRC FIRM # 20. PHONE NUMBER
21. Date of rehabilitation consultation File this form with the Department of Labor and Industry within 14 days of date of
rehabilitation consultation. See Minn. Rule 5220.0130, subp. 3 D.
22. Is the employee receiving assistance from employer in returning to work there? Yes No Unknown
If “NO”, do you recommend such assistance in returning to the date-of-injury
employer? Yes No
23. In your opinion is the employee expected to return to the date-of-injury employer? Yes No Unknown
24. In your opinion is the employee expected to return to the date-of-injury occupation? Yes No Unknown
25. Can the employee be expected to return to suitable gainful employment through
rehabilitation services considering the treating physician’s Report of Work Ability? Yes No
26. Is the employee eligible for rehabilitation services at this time? Yes No
ATTACH A NARRATIVE REPORT EXPLAINING THE BASIS FOR YOUR DETERMINATION

27. QRC Signature Date
QRC: If the employee is eligible for rehabilitation services, a Rehabilitation Plan (R-2) must be developed and implemented within 30 days of
the initial meeting and filed with the Department within 45 days of the initial meeting.
Employee: If you disagree with or have questions about the information provided on this form, you are encouraged to contact the QRC and
insurer to discuss any concerns. If your concerns are not resolved, you may call the Department’s Benefit Management and Resolution Unit at
(651) 284-5032 or 1-800-342-5354 or request a determination by filing a Rehabilitation Request with the Department.
1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.
MN RC01 (12/05) cc: Employee, Employer, Insurer, and Attorney(s)

Rehabilitation Rights and
Responsibilities of the Injured Worker I W 0 5
EMPLOYEE NAME
The purpose of vocational rehabilitation is to assist you (the injured worker) so that you may return to your
former job, to a job related to your former employment, or to a job in another work field. The job should be physically
appropriate and produce an economic status as close as possible to that which you would have enjoyed without
disability.
The first step in this return to work process is a Rehabilitation Consultation with a Qualified Rehabilitation
Consultant (QRC) to determine if you qualify for rehabilitation services. If the QRC determines that you are qualified,
the next step is the development of a rehabilitation plan. Your QRC will help you develop and implement this plan.
Consideration will be given to your former employment, the current labor market and your qualifications, including
transferable skills, previous work history, age, education and interests.
YOUR RIGHTS
Under the provisions of the Minnesota Workers’ Compensation Law, you (the injured worker) have certain
rehabilitation rights. These rights include:
• Selection of your own Qualified Rehabilitation Consultant (QRC). The employer/insurer will generally
refer you to a QRC. You may choose your own QRC up to 60 days after a written rehabilitation plan
is filed with the State. Any further change of QRC must be mutually agreed upon or determined to be
in the best interest of the parties by the Commissioner or a compensation judge.
• When a QRC first meets or writes to contact you, he or she is required to disclose to you in writing,
any affiliation or ownership interest between the QRC (or the QRC firm) and your employer/insurer or
adjusting company. The QRC is also required to disclose to you and all parties to a case, any
affiliation or business referral arrangement between the QRC (or the QRC firm) and any other parties
to the case, including attorneys and doctors.
• If the QRC determines that you are eligible for vocational rehabilitation, a rehabilitation plan, which
may include training if needed, will be developed. The rehabilitation services required to carry out the
plan will be provided at no cost to you.
• The right to request a change in your rehabilitation plan.
• The right to receive a copy of your rehabilitation plan. The right to obtain a copy of any required
progress records upon request.
• The right to request assistance from the Workers’ Compensation Division of the Minnesota
Department of Labor and Industry. If you have questions about your rehabilitation plan, call 651-284-
5032 or 800-342-5354. If there is a dispute about your eligibility for statutory rehabilitation services or
the rehabilitation plan, you may file a Rehabilitation Request and the Department may schedule an
administrative conference in order to resolve the dispute.
MN IW05 (12/06) (over)

SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE NAME
I W 0 5
YOUR RESPONSIBILITIES
In addition to the above rights, you (the injured worker) have certain rehabilitation responsibilities under the
workers' compensation law. These responsibilities include the following:
• You must cooperate with reasonable medical and rehabilitation examinations and evaluations as
ordered by the Commissioner.
• You must make a good faith effort to participate in your rehabilitation plan. Failure to do so may result
in suspension or termination of your rehabilitation or monetary benefits.
• You must advise your QRC and insurance company of your wage, hours, employer and job title when
you return to work and when your hours or wages change. This is necessary to accurately calculate
your wage loss benefits and to ensure rehabilitation services are appropriate. Failure to accurately
report wages earned while receiving workers’ compensation benefits may result in civil or criminal
consequences.
The statements below are requested to verify whether you received the documents listed and that the information on
this form has been explained to you. You are not required to provide the information requested below or sign this
form. Your workers’ compensation benefits will not be affected if you choose not to provide the information or sign
the form. This form will be filed with the Minnesota Department of Labor and Industry, and may also be provided to
the Office of Administrative Hearings and law enforcement agencies.
Employee, check any that apply:
The above information has been explained to me and I have been provided with a copy of this form.
I have received written notification from the QRC disclosing any affiliation or business referral
arrangement the QRC or QRC firm may have with any parties to my case and a written explanation of
any affiliation or ownership interest the QRC or QRC firm may have with my employer/insurer, and
any other insurer or adjusting company.
The QRC has informed me that he/she and the QRC firm have no affiliation or ownership interest or
business referral arrangement with any parties to my case or any other insurer or adjusting company.
EMPLOYEE SIGNATURE DATE
QRC SIGNATURE QRC NUMBER DATE
PROVIDING THE INFORMATION ON THIS FORM TO THE INJURED WORKER IS REQUIRED BY MINNESOTA STATUTES SECTION
176.102, SUBD. 4C AND MINNESOTA RULES, PART 5220.1803, SUBP. 1 AND 1A.
THIS MATERIAL CAN BE MADE AVAILABLE IN DIFFERENT FORMS, SUCH AS LARGE PRINT, BRAILLE OR ON TAPE. TO
REQUEST, CALL (651) 284-5030 OR 1-800-342-5354 (DIAL-DLI)/VOICE OR TDD (651) 297-4198.
The QRC must sign and date this form at the first in-person contact with the employee, and must provide a copy to the
employee and the insurer. The QRC must also provide a copy of this form to the Department of Labor and Industry.

St. Paul, MN 55155
(651) 284-5032
1-800-342-5354 (DIAL-DLI)
Forms
R-2 Rehabilitation Plan

The purpose of the plan is to communicate to all parties the vocational goal, the
rehabilitation services to be provided, and the projected amounts of time and
money needed to achieve the vocational goal. The QRC must complete a
proposed plan and send it to the parties within 30 days of the consultation. Upon
receipt of the proposed plan, each party must, within 15 days, either sign and return
the plan to the QRC or promptly notify the QRC of any objection to the plan and
work with the QRC to overcome this objection. If the objection is not resolved, the
objecting party must file a Rehabilitation Request form with the department within
the 15 days of receipt of the proposed plan.
A plan signed by all parties is considered approved upon filing with the department.
If a party fails to sign the plan or file a Rehabilitation Request within 15 days, it shall
be assumed that the parties are in substantial agreement with the plan’s vocational
objective and the rehabilitation services proposed.
R-3 Rehabilitation Plan Amendment

The QRC submits a Rehabilitation Plan Amendment whenever circumstances
indicate that the plan’s objectives are not likely to be achieved. The procedure for
filing, approval, and requirements follow the same pattern for the plan amendments
as for plans.
Plan Progress Report (PPR)

The PPR is used to inform parties of the current status of the plan and provide a
current estimate of the plan cost and duration. The PPR must be filed with the
department (with copies to parties) within 15 days after six months have passed
from the date the plan was filed. If the QRC has filed a plan amendment 15 days
before or after the six month time period, it is not necessary to also file the PPR.

Forms

R-2
443 Lafayette Road North Rehabilitation Plan R E 0 1
St. Paul, MN 55155
1-800-342-5354 (DIAL-DLI)
Private or confidential data which you supply on this form will be used to process
your workers’ compensation claim. You may refuse to supply the data, but your
request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may
refuse to accept any formal document that lacks identifying information. This data
may be supplied to employers and insurers for the claimed date of injury, the
Department of Revenue, the Department of Health and the Workers’ Compensation
Reinsurance Association. It may also be used in workers’ compensation hearings
and for state investigations and statistics.
3. EMPLOYEE NAME
4. EMPLOYEE ADDRESS
CITY STATE ZIP CODE 5. EMPLOYEE PHONE NUMBER 6. DATE OF BIRTH
7. EMPLOYER NAME 8. EMPLOYER CONTACT PERSON 9. PHONE #
13. CLAIM REPRESENTATIVE 14. PHONE NUMBER 18. QRC # 19. QRC FIRM # 20. QRC PHONE NUMBER
21. Occupation at time of injury 22. Pre-injury AWW 25. Highest grade completed (select one)
a. No high school diploma or GED
23. Job at date of injury: Part time Full time b. High school diploma or GED
24. Employee’s work status c. Some post secondary course work
a. Off work from DOI to start of rehabilitation d. Post secondary vocational/technical program
e. Bachelor’s degree
b. Some work between DOI and start of rehabilitation, not
working at start of rehabilitation
f. Master’s, PhD or professional degree
c. Working at start of rehabilitation

26. Employee may require an interpreter: Yes No
27. Date of rehabilitation consultation (start date)
28. Vocation goal

a. RTW same employer b. RTW different employer
Comments:
MN RE01 (6/05) (over) cc: Employee, Insurer, Attorney(s) or other parties

VOCATIONAL REHABILITATION PLAN
SERVICE CATEGORY DESCRIPTION SERVICE SERVICE ESTIMATED ESTIMATED
and CODE (from VRI) START DATE END DATE DAYS COST
TOTALS
Employee Comments:
STATEMENT OF EMPLOYER/INSURER RESPONSIBILITY: The employer/insurer understands its responsibility to pay for services
reasonably required and to monitor the costs and timelines of the services. M.S. § 176.102, subd. 9 and Minn. Rules 5220.1900,
subp. 1g.
STATEMENT OF QRC RESPONSIBILITY: I understand that I am responsible for the timely delivery of the above specified services
pursuant to M.S. § 176.102 and Minn. Rules 5220.0100-.1900 and agree to conscientiously carry out my professional duties as a
Qualified Rehabilitation Consultant in the interest of the employee’s rehabilitation. Should the estimated cost of this plan be exceeded
or if additional time is required for completion of the plan, I will notify the Department and the parties by submitting a Rehabilitation Plan
Amendment (R-3) in accordance with M.S. § 176.102, subd. 8 and Minn. Rules 5220.0510.
STATEMENT OF EMPLOYEE RESPONSIBILITY: I understand that it is my responsibility to cooperate with all parties involved in my
rehabilitation and I agree to make a good faith effort to participate in this plan. This includes attendance at scheduled activities and
appointments, and adherence to reasonable medical advice.
TO THE PARTIES: If you disagree with the plan, you have 15 days from the receipt of the proposed plan to resolve the disagreement
or object to the proposed plan. The objection must be filed with the Department on a Rehabilitation Request form.
Send a copy of this plan to the employee's treating health care provider if permitted by Minn. Rules 5220.1802, subp. 5 (Minn.
Rules 5220.0410, subp. 7).
Attach a copy of your initial evaluation report (Minn. Rules 5220.1803, subp. 5).
Employee has read and signed the form “Rights and Responsibilities of the Injured Worker”
Employee has read and declined to sign the form “Rights and Responsibilities of the Injured Worker”
Employee Signature Date
Claim Representative Signature Date
QRC Signature Date
or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL
FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
R-3
443 Lafayette Road North Rehabilitation Plan Amendment R P 0 1
St. Paul, MN 55155
1-800-342-5354 (DIAL-DLI)
Private or confidential data which you supply on this form will be used to process your workers’
compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn.
Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying
information. This data may be supplied to employers and insurers for the claimed date of injury, the
Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association.
It may also be used in workers’ compensation hearings and for state investigations and statistics.
3. EMPLOYEE NAME 7. QRC NAME
4. INSURER/SELF-INSURER/TPA 8. ADDRESS
5. INSURER CLAIM NUMBER CITY STATE ZIP CODE
6. EMPLOYER NAME 9. QRC # 10. QRC FIRM # 11. PHONE NUMBER
12. CHANGE OF QRC Yes No PREVIOUS QRC # NEW QRC #

13. WITHDRAWAL OF QRC? Yes No
14. PROPOSED AMENDMENT/RATIONALE (attach separate sheet as necessary)
15. EMPLOYEE COMMENTS
Plan costs to date Other costs necessary to complete plan Estimated total cost
16. Costs + =
17. Plan duration from plan Duration to date Expected additional duration to plan completion Estimated total duration
filing date (in weeks) + =
18. Specify any additional rehabilitation services or changes to the current plan that will be required:
SERVICE CATEGORY and PROJECTED
DESCRIPTION
CODE (from VRI) COMPLETION DATE COST
19. Is this form being filed in lieu of a Plan Progress Report? Yes No If yes, complete #20-22.
See Minn. Rule 5220.0450, subp. 3.A.
with without Medical report date
20. Is the employee released to return to work? Yes, restrictions Yes, restrictions No
If working, is this a temporary job?
21. Current work status: Not working Part time Full time Seasonal layoff
Yes No
22. Do barriers to successful completion of the rehabilitation plan exist? Yes No

If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form.
Employee Signature Date
Claim Representative Signature Date
QRC Signature Date
MN RP01 (8/05) cc: Employee, Insurer, Attorney(s) or other parties

Instructions to QRC
Proposed plan amendment without a change of QRC:
The QRC or other parties may propose amendments to current rehabilitation plans. It is the QRC’s responsibility to facilitate
discussion of proposed amendments and file the Rehabilitation Plan Amendment (R-3) form when appropriate. Once an
amendment has been proposed, the QRC shall provide copies of the R-3 to the employee, insurer, and any attorneys
representing the employee or insurer. The QRC shall also send a copy of the R-3 to the date of injury employer if the goal is to
return the employee to work with that employer.
Proposed plan amendment including a change of QRC:
1. If the employee has the right to change QRC’s without approval per Minn. Rule 5220.0710, subpart 1, the new QRC must
file an R-3 with the Department of Labor and Industry within 15 calendar days of receipt of the information transferred by the
former QRC. However, it is not necessary to circulate for signatures. Copies must be sent to the parties listed on the form.
2. If approval of a change of QRC is required per Minn. Rule 5220.0710 and the insurer has approved the change, the new
QRC must circulate the R-3 for signatures and file with the Department of Labor and Industry within 15 days of obtaining the
signatures.
3. If approval of a change of QRC is required and the insurer objects to the change, the insurer should file a Rehabilitation
Request form with the Department of Labor and Industry within 15 days of the receipt of the R-3.
Proposed plan amendment for withdrawal of QRC when insurer has denied further liability for the injury for which
rehabilitation services are being provided:
If a claim petition, objection to discontinuance, request for administrative conference, or any other document initiating litigation
has been filed on the liability issue, a QRC who elects to withdraw must file the R-3 with the Department of Labor and Industry
and send copies to the parties, including a separate copy to the Department’s Vocational Rehabilitation Unit. If no litigation is
pending on the liability issue, the QRC may withdraw by filing an R-8 Plan Closure form if permitted by Minn. Rule 5220.0510,
subp. 7.
Instructions to Other Parties
Within 15 days of receiving a proposed amendment:
1. If you agree with the amendment, sign the R-3 and return to the QRC; or
2. If you disagree with the amendment, notify the QRC of your objections and try to work with the QRC to resolve them. If the
issues are not resolved, the objecting party must file a Rehabilitation Request with the Department of Labor and Industry
within 15 days of the receipt of the R-3.
NOTE: If a party fails to sign or object to a proposed amendment within 15 days of receiving the R-3, the amendment is deemed
approved.
This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or
Plan Progress Report
443 Lafayette Road North Enter dates in MM/DD/YYYY format.
P R 0 1
St. Paul, MN 55155
(651) 284-5030 or
1-800-342-5354 (DIAL-DLI)
1. DATE OF THIS REPORT
4. EMPLOYEE NAME
5. EMPLOYEE ADDRESS
CITY STATE ZIP CODE
6. EMPLOYER NAME 7. EMPLOYER CONTACT PERSON 8. PHONE NUMBER
12. CLAIM REPRESENTATIVE 13. PHONE NUMBER 17. QRC # 18. QRC FIRM # 19. PHONE NUMBER
with without Medical report date

20. Is the employee released to return to work? Yes, restrictions Yes, restrictions No
If working, is this a temporary job?

21. Current work status: Not working Part time Full time Seasonal layoff
Yes No
22. Is the plan still current? Yes No
Plan costs to date Other costs necessary to complete plan Estimated total cost
23. Costs + =
24. Plan duration from plan Duration to date Expected additional duration to plan completion Estimated total duration
filing date (in weeks) + =
25. Do barriers to successful completion of the rehabilitation plan exist? Yes No

If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form.
This form is required to be filed 6 months after filing the R-2 (unless an R-3 is filed 15 days before or after 6 months
have passed since the R-2 filing date). See Minn. Rules 5220.0450, subp. 3 A. Send copies to the employee, insurer,
and attorney(s). Send to the date-of-injury employer if the goal of the rehabilitation plan is to return to work with that
employer.
This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or
MN PR01 (6/05)
Forms
On-the-Job Training
On-the-job training means training while employed at a workplace where the
employee receives instruction from an experienced worker and which is likely to
result in employment with the on-the-job training employer upon its completion.
When an on-the-job training plan is submitted to the department, the department

reviews the proposed plan within 30 days of its submission and notifies the parties
of plan approval or rejection. The plan approval process is subject to the
procedures under Minnesota Rules Part 5220.0410, Subp. 6. The commissioner
may make a determination or pursue resolution of disputes regarding the plan
consistent with Minnesota Rules Part 5220.0950, Subp. 3.
Retraining
Retraining is training for a new occupation and obtaining the necessary skills to
obtain work which produces an economic status as close as possible to what the
employee would have enjoyed without disability. Retraining is to be given equal
consideration with other rehabilitation services and may be proposed for approval if
other considered services are not likely to lead to suitable gainful employment.
When the QRC determines retraining to be appropriate, the QRC completes a
Retraining Plan describing the recommended course of study and circulates it to
the employee, employer, and insurer for their signatures.
When the QRC submits a Retraining Plan to the department with all three
signatures, the department reviews the plan within a day or two of its submission,
notifies the parties of its approval or denial and mails the Proof of Service to all
parties with a signed copy of the Retraining Plan.
For injuries from October 1, 1995 through September 30, 2000, a request for
retraining of an employee must be filed with the department before the insurer has
paid 104 weeks of temporary total and/or temporary partial disability benefits.
For injuries on or after October 1, 2000, any request for retraining must be filed with
the department before 156 weeks of temporary total and/or temporary partial
disability benefits have been paid.
The insurer must notify the employee in writing of this requirement, and this
notice must be given before 80 weeks of temporary total and/or temporary
partial benefits have been paid.

Forms

On the Job Training Plan
443 Lafayette Road North Enter dates in MM/DD/YYYY format. J A 0 4
St. Paul, MN 55155
(651) 284-5030 or
1-800-342-5354 (DIAL-DLI)
EMPLOYEE NAME
INSURER CLAIM NUMBER OJT JOB TITLE
OJT EMPLOYER NAME OJT BEGINNING DATE
OJT EMPLOYER ADDRESS OJT ENDING DATE
CITY STATE ZIP CODE OJT PLAN PROGRESS EVALUATION DATE(S)
Does this OJT employer intend to hire the employee upon completion of the OJT? Yes No
JOB DESCRIPTION (attach a job analysis, or describe the nature of the work, giving examples of duties)
Job must be within the employee’s physical restrictions. ATTACH MEDICAL REPORT.
List the skills the employee will acquire through this training:
List supplies and tools needed during training (itemize costs):
TOTAL COSTS
WEEKLY WAGES AND WORKERS’ COMPENSATION BENEFITS Start of OJT End of OJT
Weekly wages paid by OJT Employer
Weekly workers’ compensation benefits paid by Insurer
MN JA04 (12/05) (over) cc: Employee, Insurer, OJT Employer

RATIONALE FOR OJT: see Minn. Rule 5220.0850, subp. 2(N)
[NOTE: Justification is required for plans EXCEEDING 6 months: see Minn. Rule 5220.0850, subp. 3]
ACCEPTED PLAN: If all parties are in agreement with (and have signed) this OJT Plan, submit it to the Department with the
required attachments for approval or denial (see Minn. Rule 5220.0850, subp. 4).
Employee Signature Print or type name Phone number Date
Insurer Representative Signature Print or type name Phone number Date
OJT Employer Signature Print or type name Phone number Date
OJT Trainer Signature Print or type name Phone number Date
QRC Signature Print or type name Phone number Date
QRC Number
INSTRUCTIONS TO QRC
DISPUTED PLAN: To resolve a disputed OJT Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032, and/or
file a Rehabilitation Request (see Minn. Rule 5220.0850, subp. 5). DO NOT SUBMIT A DISPUTED PLAN to the Department without
attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party.
For Department Use Only
Approved Denied
DLI Representative Signature Print or type name Phone number Date
Reason for denial:

Retraining Plan
443 Lafayette Road North Enter dates in MM/DD/YYYY format. E P 0 4
St. Paul, MN 55155
(651) 284-5030 or
1-800-342-5354 (DIAL-DLI)
EMPLOYEE NAME
EMPLOYER NAME
INSURER CLAIM NUMBER CLAIM REPRESENTATIVE PHONE NUMBER
Pre-injury job title Pre-injury wage Current compensation rate
Occupational goal(s) Anticipated wage (from Labor Market Survey)

to
Certificate/Degree program title Program length (weeks) Program start date Program completion date
School name City, State
ITEMIZED COSTS:
* Explain (for example, tutoring, board and lodging)
Tuition/Lab/Activity fees
Books/Tools
Special/Unique costs*
Custodial Day Care
Travel/Parking
Total retraining costs

(excluding wage benefits)
REQUIRED ATTACHMENTS: Pursuant to Minn. Rule 5220.0750, subp. 2(H), the following items MUST BE ATTACHED.
a. Course syllabus/class titles.
b. Physical requirements of the job for which the employee is being trained. (On-site job analysis is preferred.)
c. Medical information that the training and the occupational goals are within the employee’s restrictions.
d. Test results which support course choice.
e. Recent labor market survey.
MN EP04 (12/05) (over) cc: Employee, Insurer

RETRAINING RATIONALE: see Minn. Rule 5220.0750, subp. 2(F)
ACCEPTED PLAN: If all parties are in agreement with (and have signed) this Retraining Plan, submit it to the Department with
the required attachments for approval or denial (see Minn. Rule 5220.0750, subp. 5).
Employee Signature Print or type name Phone number Date
Insurer Representative Signature Print or type name Phone number Date
QRC Signature Print or type name Phone number Date
QRC Number
INSTRUCTIONS TO QRC
NOTE: Retraining is limited to 156 weeks.
DISPUTED PLAN: To resolve a disputed Retraining Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032
and/or file a Rehabilitation Request (see Minn. Rule 5220.0950). DO NOT SUBMIT A DISPUTED PLAN to the Department without
attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party.
For Department Use Only
Approved Denied
DLI Representative Signature Print or type name Phone number Date
Reason for denial:

Forms
R-8 Notice of Rehabilitation Plan Closure

When an employee’s rehabilitation plan is completed and closure of rehabilitation
services is not disputed, the QRC must file a Notice of Rehabilitation Plan Closure
along with a Closure Report summarizing services provided. When the reason for
the closure is a return to work, the QRC may not complete and file the closure
report until the employee has continued working for at least 30 calendar days
following the return to work. This form must be filed with the department, with
copies sent to the employee and the insurer.
At any time, the insurer or employee may request the closure or suspension of
rehabilitation services by filing a “Rehabilitation Request” form. The commissioner
or a compensation judge may close rehabilitation services for good cause,
including, but not limited to the following reasons:
• denial of primary liability
• lack of medical causation
• employee is not cooperating with the plan
• employee is not likely to benefit from further rehabilitation services
Note: An insurer intending to discontinue rehabilitation benefits as well as TTD or

TPD benefits must file a “Rehabilitation Request” form in addition to the NOID form.

Forms

R-8
443 Lafayette Road North Notice of N R 0 1
St. Paul, MN 55155
(651) 284-5030 or Rehabilitation Plan Closure
1-800-342-5354 (DIAL-DLI) DO NOT USE THIS SPACE
1. DATE OF REHABILITATION CONSULTATION: (#27 on R-2)
2. SOCIAL SECURITY NUMBER 3. DATE OF INJURY 8. QRC NAME
4. EMPLOYEE NAME 9. ADDRESS
5. DATE-OF-INJURY EMPLOYER CITY STATE ZIP CODE
6. INSURER/SELF-INSURER/TPA 10. QRC NUMBER 11. QRC FIRM # 12. QRC PHONE #
7. INSURER CLAIM NUMBER 13. NAME OF LAST REGISTERED REHAB VENDOR 14. VENDOR #
15. EMPLOYMENT STATUS AT PLAN CLOSURE (check one) 21. REASON FOR REHABILITATION PLAN CLOSURE (check one)
a. Employee RTW with DOI employer (see instructions on back)
b. Employee RTW with different employer a. Plan completed (employee returned to suitable gainful employment)
c. Employee not employed (Skip to item 21)
b. Award on Stipulation/Mediation
COMPLETE #16-20 IF EMPLOYEE RETURNED TO WORK
c. Commissioner or Compensation Judge Order
16. EMPLOYER AT PLAN CLOSURE
d. Employee and insurer have agreed to close the plan
17. JOB TITLE AT PLAN CLOSURE e. Unable to locate employee
f. Death of employee
g. QRC withdrawal
18. Gross weekly wage at RTW 19. RTW DATE 22. Did employee have an attorney? 23. PLAN CLOSURE DATE
Yes No
20. RETURN TO WORK JOB: 24. Check if services provided:
Same job Modified job Different job On-the-job training Retraining
25. Cost of prior QRC Firm services other than placement $
26. Cost of current QRC Firm services other than placement $
27. Cost of any job placement and job development provided by prior QRC Firm $
28. Cost of any job placement and job development provided by current QRC Firm $
29. Cost of job placement and job development by Registered Rehabilitation Vendor(s) (including CARF accredited) $
30. Cost of other rehabilitation services (retraining, on-the-job training, relocation, testing, etc.) $
31. Total cost of rehabilitation services (add 25-30) $
By signing this form, I certify that copies of this form and attachments are being sent to the insurer, any attorney(s), the
Department of Labor and Industry , and if required to the VRU, and to the employee at the following address:
32. QRC signature 33. Date form completed
EMPLOYEE: IF YOU HAVE QUESTIONS ABOUT THE CLOSURE OF THIS REHABILITATION PLAN, CALL THE DEPARTMENT OF
LABOR AND INDUSTRY AT 651-284-5032 OR 1-800-342-5354
MN NR01 (6/05)
Instructions to QRC
The Notice of Rehabilitation Plan Closure (R-8) form must be filed with the Department of Labor and
Industry within 30 calendar days of knowledge that: (see Minn. Rules 5220.0510, subps. 7 and 7a)
a. the employee has been steadily working at suitable gainful employment for 30 days or more, or the
time period provided for in the plan
b. the employee’s rehabilitation benefits have been closed out by an award on stipulation or award on
mediation
c. the commissioner or a compensation judge has ordered that the rehabilitation plan be closed and
there has been no timely appeal of that order
d. the employee and insurer have agreed to close the rehabilitation plan
e. the QRC has been unable to locate the employee following a good faith effort to do so
f. the employee has died
g. the QRC decides to withdraw after the insurer has provided written notice to the employee, the
employee’s attorney, the commissioner, and the QRC that the insurer is denying further liability for
the injury for which rehabilitation services are being provided. In this situation, the QRC must file
the R-8 and attach a copy of the insurer’s notice of denial, copying appropriate parties,
including a separate copy to the Department’s Vocational Rehabilitation Unit.
NOTE: This does not apply if a claim petition, objection to discontinuance, request for an
administrative conference, or other document initiating litigation has been filed on the liability
issue. If one of these documents has been filed and the QRC decides to withdraw, the QRC
shall document the withdrawal by filing a Rehabilitation Plan Amendment (R-3).
ATTACH A CLOSURE REPORT SUMMARIZING SERVICES PROVIDED. (see Minn. Rule 5220.0510,
subp. 7(4))
Send copies of the R-8 to the employee, insurer, and attorney(s). If the insurer is denying further liability,
send a separate copy addressed to the Department’s Vocational Rehabilitation Unit.
This material can be made available in different forms, such as large print, Braille or on a tape. To request,
call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.
Forms
Medical Request
A Medical Request form is used to request the department’s help in resolving a
workers’ compensation dispute that involves medical issues. This form should not
be used if the dispute involves rehabilitation, wage loss, or permanency benefits.
Parties involved in a medical dispute should try to resolve the dispute themselves
prior to filing the request form. They can also call the department’s Workers’
Compensation Hotline for help in resolving the dispute informally.
Medical Requests are usually filed by employees or healthcare providers to get

approval for payment of a medical service which was denied by the insurer. An
insurer may also file such a request to resolve a dispute over treatment. This form
is also filed to a request for a change of treating doctor. Be sure to fill out the name
of the current treating doctor and the name of the doctor to whom treatment should
be switched. If the employee is requesting a change of doctor and the insurer
agrees, this form does not need to be filed. Medical Responses are filed within 20
days after the Medical Request is filed.
If the dispute involves surgery or medical services exceeding $7,500.00, the

request is automatically referred to OAH for a formal hearing. Otherwise, the
matter will be set for an administrative conference with a mediator at the
department.
Medical Response
If the employee or health care provider has filed a Medical Request form, the
insurer must file a Medical Response form with the department and serve copies on
the other parties no later than 20 days after service of the Medical Request.
Once the department processes both the Medical Request and the Medical
Response, a legally binding written decision may be made based on the
information submitted on the forms. It is important that the insurer make their
response as complete as possible.
Rehabilitation Request
A Rehabilitation Request form is used to request the department’s help in resolving
a workers’ compensation dispute that involves rehabilitation issues. This form
should not be used if the dispute involves medical, wage loss, or permanency
benefits.
Parties involved in a rehabilitation dispute should try to resolve the dispute

themselves prior to filing the request form. They can also call the department’s
Workers’ Compensation Hotline for help in resolving the dispute informally.
Typical disputes filed by insurers include requesting that a plan be changed or

terminated. For example, the insurer could file a Rehabilitation Request form if the
QRC believes the employee should be retrained and they believe it is not

Forms
necessary. If the insurer submits a request to terminate the rehabilitation plan, they
must send the employee a Rehabilitation Response form with the employee’s copy
of the request.
Rehabilitation Response
If another party has filed a Rehabilitation Request form, the responding party
should file a Rehabilitation Response form in a timely manner. The department
expedites the processing of all Rehabilitation Requests and will begin to intervene
immediately.
Request for Formal Hearing

When a party wishes to appeal a medical or rehabilitation decision and order per
Minnesota Statutes §176.106, this form must be filed within 30 days after the
decision and order was served on the parties.
Objection to Penalty Assessment

When a party wishes to object to a penalty assessment, this form must be served on the
parties and with the department within 30 days after the notice of penalty assessment
was served on the parties.

CHECK BOX IF THIS
REQUEST ADDS
Medical Request
MEDICAL ISSUES TO NOTE: Before filing this form, call the workers’ compensation insurer. M Q 0 3
A PENDING If that does not resolve the issue, call Workers’ Compensation Benefit
MEDICAL REQUEST Management and Resolution at (651) 284-5032 (or 1-800-342-5354). DO NOT USE THIS SPACE
EMPLOYEE NAME PHONE # (include area code)
EMPLOYEE ADDRESS INSURER/SELF-INSURER/TPA
CITY STATE ZIP CODE INSURER ADDRESS
EMPLOYER NAME CITY STATE ZIP CODE
EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME
CITY STATE ZIP CODE INSURER CLAIM # INSURER PHONE # EXT
INSTRUCTIONS:
• This form must be filled out completely; otherwise, it may be returned to you.
• The injured worker’s name, social security number, and date of injury must be written on all attached documents.
• This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits.
I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION.

For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. YES NO
1. THIS REQUEST IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s Health Care
Employee Employer
Attorney Self-insured Attorney Provider
2. Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information
showing that the dispute resolution process of the certified managed care plan has already been exhausted.
3. MEDICAL ISSUES (check only those that apply)
I request:
a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets
if needed. Itemized bills and supporting medical reports must be attached.)
NAME ADDRESS UNPAID BALANCE
b. a change of treating doctor:

NAME ADDRESS SPECIALTY
FROM:
NAME ADDRESS SPECIALTY

TO:
c. that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting
medical reports.)
d. that the employee’s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports.
e. a second opinion or consultation with NAME SPECIALTY
f. other (explain):
MN MQ03 (12/05) (over)

IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST.
4. HAS ANYONE OTHER THAN THE WORKERS’ COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO
THIS DISPUTE? YES NO
If yes, bills were paid by: employee Veterans Administration Dept. of Human Services (Welfare)
Medicare Social Security Administration private health insurance other
In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.
NAME ADDRESS POLICY NUMBER
5. Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment
parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers’ Compensation
Division file, and the response to this form.
6. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys,
and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if
necessary.
NAME ADDRESS CITY, STATE, ZIP CODE
I sent a copy of this form and all attachments to the parties listed in #6 on (date)
PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE
ADDRESS ATTORNEY REGISTRATION #
CITY STATE ZIP CODE PHONE # (include area code) EXT DATE SIGNED
WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit
FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division
St. Paul, Minnesota 55155-4312
Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may
refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept
any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of
injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also
be used in workers’ compensation hearings and for state investigations and statistics.
Medical Response
M R 0 3
THIS FORM RESPONDS TO ISSUES
RAISED ON THE MEDICAL REQUEST
FORM THAT WAS SIGNED ON (date)
INSTRUCTIONS:
• All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these
attempts fail.
• This form must be filled out completely.
• You must complete this response form and send it to the address on the back of this form within 20 days of the date you received the
Medical Request.

1. THIS RESPONSE IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s Health Care
Employee Employer
Attorney Self-insured Attorney Provider
2. The employee has not exhausted the dispute resolution process of the certified managed care plan. The employee may contact
at (phone) to initiate this process.

Name of the Certified Managed Care Plan
3. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply)
a. I respond to the request for payment of medical or chiropractic bills as follows: (List the health care providers and your
response to the specific bill amounts listed on the Request form. Attach extra sheets if needed).
HEALTH CARE PROVIDER ALREADY PAID AGREE TO PAY REFUSE TO PAY
b. I agree disagree with the request to change treating doctors.

c. I agree refuse to pay for the requested treatment, surgery or equipment.
d. I agree refuse to reimburse the employee for medical expenses.
e. I agree disagree with the request for a second opinion or consultation.
f. Response to “Other”:
MN MR03 (12/05) (over)

YOU MUST COMPLETE # 4 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST.
4. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical
reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely
upon review of this form, its attachments, the Workers’ Compensation Division file, and the Medical Request form.
Specify any applicable treatment parameter(s): Minn. Rule 5221.
5. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, and
attorneys. Provide the names and addresses below. Attach extra sheets if necessary.
PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE
CHECK BOX IF THIS
REQUEST ADDS
Rehabilitation Request
REHABILITATION NOTE: Before filing this form, call the workers’ compensation insurer. If R Q 0 3
ISSUES TO A PENDING that does not resolve the issue, call Workers’ Compensation Benefit
REHABILITATION Management and Resolution Unit at (651) 284-5032 (or 1-800-342-5354). DO NOT USE THIS SPACE
REQUEST
INSTRUCTIONS:
• This form must be filled out completely; otherwise, it may be returned to you.
• This form may not be used to request wage loss, medical, or permanent partial disability benefits.

1. THIS REQUEST IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s QRC/
Employee Employer
Attorney Self-insured Attorney Vendor
2. REHABILITATION ISSUES (check only those that apply)
I request:
a. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions.
b. a change of QRC (qualified rehabilitation consultant):
NAME NAME
F FIRM NAME FIRM NAME

R T
O ADDRESS O ADDRESS
M
PHONE # (include area code) PHONE # (include area code)
c. that the rehabilitation plan be changed.

d. retraining or exploration of retraining.
e. that the rehabilitation plan be terminated.
f. that the rehabilitation plan be suspended.
g. that the employee’s rehabilitation expenses be reimbursed. Attach itemized bills and supporting documentation.
h. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills.
i. other (explain)
MN RQ03 (11/05) (over)

3. Explain the details of your request. Attach all documents, such as medical reports and rehabilitation reports/bills, which support your
request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.
4. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor and attorneys.
Provide the names and addresses below. Attach extra sheets if necessary.
PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE
Rehabilitation Response
THIS FORM RESPONDS TO ISSUES R R 0 3
RAISED ON THE REHABILITATION
REQUEST FORM WHICH WAS SIGNED ON (date)
INSTRUCTIONS:
• All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these
attempts fail.
• This form must be filled out completely.
• Insurers must file this form with the Department of Labor and Industry, and serve this form on the other parties, within 10 days after service
of the Rehabilitation Request. All others should file this form with the Department of Labor and Industry, and serve it on all parties, within
20 days after service of the Rehabilitation Request.

1. THIS RESPONSE IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s QRC/
Employee Employer
Attorney Self-insured Attorney Vendor
2. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply)
a. I agree disagree with the request for rehabilitation consultation/services.
IF A QRC IS BEING ASSIGNED, GIVEN NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC.
NAME FIRM NAME ADDRESS SELECTED BY
b. I agree disagree with the request to change QRCs.

c. I agree disagree that the rehabilitation plan should be changed.
d. I agree disagree with the request for retraining/exploration of retraining.
e. I agree disagree that the rehabilitation plan should be terminated.
f. I agree disagree that the rehabilitation plan should be suspended.
g. I agree refuse to reimburse the employee for rehabilitation expenses.
to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for
h. I agree refuse
dispute.
i. Response to “Other”:
MN RR03 (11/05) (over)

YOU MUST COMPLETE # 3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST.
3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical
reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely
upon review of this form, its attachments, the Workers’ Compensation Division file, and the Rehabilitation Request form.
4. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor, and attorneys.
Provide the names and addresses below. Attach extra sheets if necessary.
PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE
SOCIAL SECURITY NUMBER Minnesota Department of Labor and Industry
St. Paul, MN 55155 R F 0 3
DATE(S) OF CLAIMED INJURY
(651) 284-5030
1-800-342-5354 (DIAL-DLI) DO NOT USE THIS SPACE
EMPLOYEE
VS.
EMPLOYER
AND
INSURER
Request for Formal Hearing
(under M.S. 176.106 or 176.305)
AND
ADDITIONAL PARTIES (INCLUDING INTERVENORS)
Please PRINT or TYPE.
Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the
data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks
identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the
Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for
state investigations and statistics.
TO THE ABOVE NAMED PARTIES AND THEIR ATTORNEYS:
The above-named party, , requests
a formal hearing. An administrative decision on the issues was previously issued by:
(Name) .
The decision was served and filed on: (date). The specific issues in dispute and the
specific reason(s) for disputing the decision are as follows:
MN RF03 (10/04) (over)

Copies of this request have been served on all parties and their attorneys who are listed with addresses and attorney registration numbers as
follows: (attach additional sheet if necessary)
Employee: Employee Attorney:
Employer: Employer/Insurer Attorney:
Insurer: Other Party (Specify):
REQUESTOR SIGNATURE ATTORNEY FOR PARTY SIGNATURE
REQUESTOR PRINTED NAME ADDRESS
DATE CITY STATE ZIP CODE
ATTORNEY REGISTRATION # PHONE # (include area code)
INSTRUCTIONS
This form must be served on each party and each party’s attorney, and received by the Department within 30 days after the date the decision
was served and filed. Issues and reasons for the request must be specifically listed. For example, a general statement that the prior decision
is not in conformity with the Workers’ Compensation Act is not a specific statement of the disputed issues.
All requests will be referred to the Office of Administrative Hearings for a formal hearing before a workers’ compensation judge.
St. Paul, Minnesota 55155 C E 0 0 0 3
(651) 284-5030
SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE NAME
PENALTY NUMBER INSURER’S CLAIM NUMBER
DEPARTMENT OF LABOR AND INDUSTRY

WORKERS’ COMPENSATION DIVISION
VS.
EMPLOYER
OBJECTION TO PENALTY
ASSESSMENT
AND
INSURER
Minnesota Rules Part 5220.2870 PENALTY OBJECTION AND HEARING states: “A party to whom notice of assessment has
been issued may object to the penalty assessment by filing a written objection with the division on the form prescribed by the
commissioner. The objection must also be served on the employee if the penalty is payable to the employee. The objection
must be filed and served within 30 days after the date the notice of assessment was served on that party by the division.
(emphasis added) The written objection must contain a detailed statement explaining the legal or factual basis for the objection
and including any documentation supporting the objection. Upon receipt of a timely objection, unresolved issues shall be
referred for a hearing to determine the amount and conditions of any penalty. Objections which are not served and filed within
the 30-day objection period must be dismissed by a compensation judge.”
The above-named Employer/Insurer objects to the following portion of the Notice of Assessment of Penalty filed in this matter
and requests that this matter be set for hearing.
1) Additional award to the Employee (M.S. § 176.225)
2) Payment to the Assigned Risk Safety Account (M.S. § 176.221, subd. 3 or 3a)
3) Penalty for failure to file required report (M.S. § 231, subd. 10)
4) Other, please explain:
Detailed statement/documentation to support your objection (M.R. 5220.2870): (Attached additional sheets as necessary.)
Objection to Penalty Assessment filed by: Filing party is

NAME
Employer
COMPANY NAME
Insurer
ADDRESS
Attorney
CITY STATE ZIP

Other_____________________________
TELEPHONE
MN CE0003 (9/03)
PROOF OF SERVICE
STATE OF MINNESOTA
ss.
COUNTY OF ____________
I, ________________________________________________________, being first duly sworn, depose and state that on
__________________, 20___, I served a true and correct copy of the enclosed document upon all interested parties to this
objection, with postage prepaid, in the United States mail at ____________________, _______________, addressed as follows:
(City) (State)
SEND ORIGINAL TO:

Compliance Services
St. Paul, Minnesota 55155
SEND COPIES TO:

(Provide Names and Addresses)
Employer (if objection filed by Insurer, or other party): Other parties (if applicable):
Insurer (if objection filed by Employer, or other party):
Employee (if applicable)
Subscribed and sworn to before me
this ____ day of ________________, 20___.
___________________________________ ______________________________________________
Notary Public Signature
Forms
Forms Filing Table

(when to file common forms with the department)
FORM # FORM NAME AKA WHEN TO FILE

Indemnity Benefits
FR01 First Report of FROI This form must be filed by the insurer if the claim results in
Injury the employee’s inability to work for a period of more than
three calendar days or results in PPD:
• within 14 days of the first day of disability, or the date the
employer was aware of the disability, whichever is later;
• within 10 days of a request from the department, to
complete a substitute filing of this form if the employer is
unable or refuses to file this form.
This form must also be filed within 21 days upon
specific request from the department.
NL01 Notice of NOPLD This form must be filed by the insurer when, after reviewing
Insurer’s the FROI, there appears to be claimed lost time beyond the
Primary Liability waiting period.
Determination When accepting liability and making payment of wage-loss
benefits, this form must be filed whenever the following
occurs:
• liability is accepted and the initial payment is made for
TTD, TPD, or PTD benefits;
• liability is accepted for wage-loss benefits and the
employer has a full-wage plan;
• liability is accepted payment is made on a fatality.
The first payment must be made within 14 days of the first
day of disability, or the date the employer was aware of the
disability, whichever is later.
When partially accepting liability but not making payment
of wage-loss benefits, this form must be served on the
employee and filed the department within 14 days of the
first day of the disability or the date the employer was aware
of the disability, whichever is later, whenever the following
occurs:
• liability is accepted but denial of the initial claimed
disability is determined; or
• liability is accepted for temporary partial benefits and
payment will be made in the future, upon receipt of
wage-loss information.
When denying primary liability, this form must be served
on the employee and filed the department within 14 days
of the first day of the disability or the date the employer was
aware of the disability, whichever is later.
NOTE: NOPLDs may be filed multiple times on a claim.
ND01 Notice of NOID This form must be filed by the insurer to reduce or
Intention to discontinue TTD, TPD, or PTD benefits:
Discontinue WC • within 14 days of the date the insurer receives notice
Benefits that the employee has returned to work at full or reduced
wages;
• at the same time that benefits are reduced or
discontinued for reasons other than return to work;

Forms

• when discontinuing benefits and denying primary liability
on a previously accepted claim when it is more than 60
days from the first day of disability or the date the
employer was aware of disability, whichever is later.
NC01 Notice of Benefit NOBR This form must be filed by the insurer at the time TTD, TPD,
Reinstatement or PTD benefits are reinstated, TPD benefits are changed to
TTD benefits, or payment of wage continuation by the
employer for TTD or TPD is changed to TTD or TPD paid by
the insurer.
NB01 Notice of Benefit NOBP This form must be filed by the insurer at the time the initial
Payment and final PPD payments are made or when a final payment
is made per award or order.
IS03 Interim Status ISR This form must be filed by the insurer annually, for as long
Report as indemnity benefits continue, at one year after the last
payment form was filed with the department.
BD02 Notice of This form must be filed by the insurer to discontinue TTD,
Discontinuance TPD, or PTD benefits as soon as the insurer learns of the
of WC Benefits death of the employee.
Upon Death of This form must also be filed within 21 days upon
Employee specific request from the department.
DB02 Notice of This form must be filed at the time the insurer reduces or
Discontinuance stops payment of dependency benefits.
of Dependency This form must also be filed within 21 days upon
Benefits specific request from the department.
BA01 Benefit This form should only be filed when the insurer needs
Addendum additional space when filing one of the following forms:
NOID, NOBP, ISR, or NOD Death.
QE03 Request for This form may be filed by the insurer within 14 days of notice
Extension to or knowledge by the employer of a new period of TTD that
is related to a prior paid claim.
Medical
HC01 Health Care HCPR This form is completed by the primary health care provider
Provider Report and must be filed by the insurer when there is a preliminary
or final permanent partial disability rating.
The completed form may be filed by the insurer when the
employee has reached maximum medical improvement.
RW01 Report of RWA This form must be completed by the primary health care
Workability provider every two weeks or at every visit if visits are less
frequent and given to the employee (but not filed with the
department). The employee provides the RWA to the
employer or insurer.

Forms

MQ03 Medical This form may be filed by any party when there is a dispute
Request involving medical issues.
MR03 Medical This form is filed within 20 days after service of the medical
Response request or within the time period provided by Minnesota
Rules Part 5221.6050, Subp. 7.
Rehabilitation
DS01 Disability Status DSR This form must be filed by the insurer within 14 days of
Report knowledge that the TTD will likely exceed 13 weeks or
within 90 calendar days of the date of injury when the
employee has not returned to work after the injury or within
14 calendar days after receiving a request for a rehabilitation
consultation, whichever comes first.
RC01 Rehabilitation RCR This form must be filed by the QRC within 14 days of the
Consultation first in-person meeting with employee A signed copy of the
Report “Rights and Responsibilities of the Injured Worker” as well
as an assessment of whether or not the employee is a
qualified employee for rehabilitation services should be filed
with the RCR.
IW05 Rights and Needs to be filed with the RCR.
Responsibilities
of the Injured
Worker
RE01 R-2 R-2 This form must be filed by the QRC within 45 days of the
Rehabilitation first in-person contact with employee or within 15 days of
Plan circulation of the parties, whichever is earlier. A copy of the
QRC’s initial evaluation narrative report must also be filed
with the R-2.
RP01 R-3 R-3 This form must be filed by the QRC within 15 days of
Rehabilitation circulation to the parties.
Plan
Amendment
PR01 Plan Progress PPR This form must be filed by the QRC within 15 days after 6
Report months have passed from date of filing of the rehabilitation
plan. An R-3 may be used in lieu of the PPR if filed within
the same time period.
JA04 On the Job OJT This form must be filed by the QRC to submit on-the-job
Training Plan training plan for approval. The department shall review the
proposed plan within 30 days of its submission and notify
the parties of the plan’s approval or rejection.
EP04 Retraining Plan This form must be filed by the QRC to submit a retraining
plan for approval. The department shall review the
proposed retraining plan within 30 days of its submission
and notify the parties of the plan’s approval or denial.
NR01 R-8 Notice of R-8 This form must be filed by the QRC within 30 calendar days
Rehabilitation of knowledge that:
Plan Closure 1) the employee has been steadily working at suitable
gainful employment for 30 days or more, or the time
period provided in the plan.
2) the employee’s rehabilitation benefits have been closed

Forms

out by an award on stipulation or an award on mediation.
3) the employee and insurer have agreed to close the
rehabilitation plan.
4) the QRC has been unable to locate the employee
following a good faith effort to do so.
5) the employee has died.
6) the commissioner or a compensation judge has ordered
that the rehabilitation plan be closed and there has been
no timely appeal of that order.
7) the QRC decides to withdraw after the insurer has
provided written notice to the employee, the employee’s
attorney, the department, and the QRC that the insurer
is denying further liability for the injury for which
rehabilitation services are being provided.
RQ03 Rehabilitation This form may be filed by any party when there is a dispute
Request involving rehabilitation issues.
RR03 Rehabilitation It is recommended that a response be filed within twenty
Response days after receipt of the rehabilitation request.
Miscellaneous
CE0003 Objection to When a party wishes to object to a penalty assessment, this
Penalty form must be served on the parties and filed with the
Assessment department within 30 days after the notice of penalty
assessment was served on the parties.
CA0022 Request for This form must be filed by the employee’s attorney, prior to
Certification of filing a medical or rehabilitation request form, to allow the
Dispute department to certify that a medical or rehabilitation dispute
exists. Exception: It is not needed when there is other
pending litigation.
RF03 Request for When a party wishes to appeal a medical or rehabilitation
Formal Hearing decision and order per Minnesota Statutes §176.106, this
form must be filed within 30 days after the decision and
order was served on the parties.
NF01 Notice of File This form may be filed at the time the insurer determines
Closing their file can be closed. Be sure all required documents
have been sent to the department before filing this form.


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Section 7

The timely filing of these forms is important for several reasons:

• Filing of the FROI starts the statute of limitations.

• Employees are informed of their rights and benefits quickly.

• Parties can avoid penalties for late filing.

First Report of Injury (FROI)

July 2007 Basic Adjusters’ Training Guide

3. DATE OF CLAIMED INJURY 4. Time of am 5. Time employee am

30. Return to work date 31. Date of death

38. Mailing address 39. Employer FEIN 40. Unemployment ID#

48. Policy # or self-insured certificate # City State Zip Code

SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT

SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM

INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER

How are workers’ compensation benefits paid?

If the insurer denies your claim for wage loss benefits:

Insurer name: Phone :

Notice of Insurer’s Primary Liability Determination (NOPLD)

The NOPLD form is used to notify the employee (or heirs/dependents of an

• the first payment of wage loss benefits;

• acceptance of liability, but denial of initial wage loss benefits;

• a denial of primary liability.

Note: This form is not to be used to report a resumption of wage-loss payments

How to Complete the Form

• Check Box 1, 2, or 3. Only one box should be checked.

July 2007 Basic Adjusters’ Training Guide

Basic Adjusters’ Training Guide July 2007

July 2007 Basic Adjusters’ Training Guide

INSURER CLAIM NUMBER

1. Your claim is ACCEPTED and wage loss benefits will be paid.

Full wage continuation by the employer under M.S. § 176.221, subd. 9.

C. Other reason (include legal and factual basis):

PLEASE KEEP A COPY OF THIS NOTICE FOR YOUR RECORDS

Instructions to Insurer/Claims Administrator

Notice of Intention to Discontinue Workers’ Compensation

Always attach an “Employee’s Request for Administrative Conference” form to the

1) when the employee returns to work at full wage;

2) when the employee returns to work at reduced wage; or

3) for reasons other than a return to work.

176.238 Notice of Discontinuance of Compensation. (1995)

Basic Adjusters’ Training Guide July 2007

176.239 Administrative Decision Concerning Discontinuance of

When an administrative conference is conducted under circumstances in which

How to Complete the Form

• Check one box for reason for discontinuance.

• #1 for return to work at full wage

• #2 for return to work at reduced wage

• #3 other - supply specific reason and supporting documentation

• TTD/PTD, TPD, and Retraining benefits:

• Each period of TTD/PTD should be listed separately on the form (or an

• Each period of TPD should be listed separately on the form (or an

• Permanent Partial Disability:

• Enter the percent of PPD.

• Enter the weeks, rate if applicable, and total.

• Attorney Fee Expenses:

• Enter the amounts on the appropriate lines.

• Enter the amounts on the appropriate lines.

Basic Adjusters’ Training Guide July 2007

July 2007 Basic Adjusters’ Training Guide

Enter dates in MM/DD/YYYY format. DO NOT USE THIS SPACE

CITY STATE ZIP CODE

INSURER CLAIM NUMBER