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About the forms

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

The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.

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Online submission options

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

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

Form name Version date Notes
Affidavit of Significant Financial Hardship (AS01) June 2018 Legislative changes
Annual Claim for Reimbursement From the Second Injury Fund (AR04) September 2015 New fax number
Annual Claim for Reimbursement of Supplementary Benefits (AC03)
  -- Addendum to Annual Claim for Reimbursement of Supplementary Benefits
September 2015 New fax number
Certificate of Compliance; Minnesota Workers' Compensation Law (MN LIC 04) -- more information November 2016 Form overhaul
Claim Petition for Dependency Benefits of Payment to Estate (CP03) June 2018 Legislative changes
Disability Status Report (DS01) September 2012  
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (SF0138) May 2018 Made fillable
Election to Exclude Relatives of Managers of a Limited Liability Company (SF0137) May 2018 Made fillable
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01) June 2018 Legislative changes
Employee's Claim Petition (EC04) June 2018 Legislative changes
Employee's Objection to Discontinuance (ED02) June 2018 Legislative changes
Employee's Request for Administrative Conference (EQ05) -- more information June 2018 Legislative changes
Excess Fee Exhibit (PF04) June 2018 Legislative changes

First Report of Injury (FR01) -- more information

Amended rules effective for first reports of injury filed on or after Jan. 1, 2014:  5220.2530, 5220.2820, 5220.2830

March 2016 Instruction changes
Health Care Provider Report (HC01) -- more information April 2017 Format changes
Interim Status Report (IS03) -- more information July 2010  
Medical Request (MQ03) June 2018 Legislative changes
Medical Response (MR03) June 2018 Legislative changes
Notice of Appearance of Attorney for Employee (NA03) April 2012 New mailing address
Notice of Benefit Payment (NB01) -- more information April 2017 Format changes
Notice of Benefit Reinstatement (NC01) -- more information September 2015 Format changes
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) -- more information May 2018 Format changes
Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) -- more information February 2010 New phone number
Notice of Insurer's Primary Liability Determination (NL01) -- more information February 2010 New phone number
Notice of Intention to Claim Reimbursement From the Second Injury Fund (RS05) September 2015 New fax number
Notice of Intention to Discontinue Workers' Compensation Benefits (ND01) -- more information January 2017 Format, instruction changes
Objection to Penalty Assessment (CE0003) May 2008 New mailing address
On-the-job Training Plan (JA04) September 2008 New mailing address
Permanent Total Disability Agreement (PA04) September 2015 New fax number
Petition for Taxation of Actual and Necessary Disbursements (PT03) June 2018 Legislative changes
Plan Progress Report (PR01)
-- Spanish version (informational, do not file)
January 2014
November 2014
 
R-2 Rehabilitation Plan (RE01) -- more information August 2015 Format changes
R-3 Rehabilitation Plan Amendment (RP01) -- more information August 2015 Format changes
R-8 Notice of Rehabilitation Plan Closure (NR01) November 2013 Statute/law change

Rehabilitation Consultation Report (RC01)

-- Spanish version (informational, do not file)

May 2016

May 2016

Format changes
Rehabilitation Request (RQ03) July 2018 Corrections to legislative changes update
Rehabilitation Response (RR03) June 2018 Legislative changes

Rehabilitation Rights and Responsibilities of the Injured Worker (IW05)

-- Spanish version (informational, do not file)

October 2013

May 2016

Form overhaul

First time translated

Report of Work Ability (RW01) -- more information May 2017 Format changes
Request for Extension (QE03) -- more information July 2010  
Request for Formal Hearing (RF03) June 2018 Legislative changes
Retraining Plan (EP04) January 2014  
Statement of Attorney Fees and Costs (SA04) June 2018 Legislative changes

 

Miscellaneous form

 

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

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

 

Rehabilitation provider forms

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

 

More information