The forms on this page are PDFs that can be viewed or printed. The forms have been converted to fill-in PDFs that allow users to type directly into the form and then print it. The free Adobe Acrobat Reader software does not allow users the option of saving data that is typed into the fill-in PDF; for the option to save, visit www.adobe.com for more information about Adobe Acrobat software.
Experience faster data entry for dates, phone numbers and Social Security number by entering numbers only. The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.
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The Spanish forms, denoted by "[Spanish]" are to be used for communication purposes only; they should not be filed with the department.
| Form name | Last update | Notes* |
| Affidavit of Significant Financial Hardship (AS01) | April 2012 | PO |
| Annual Claim for Reimbursement From the Second Injury Fund (AR04) | May 2008 | PO; WID |
|
Annual Claim for Reimbursement of Supplementary Benefits (AC03) -- Addendum to Annual Claim for Reimbursement of Supplementary Benefits |
December 2009 | PO; WID; addendum separated |
| Certificate of Compliance Minnesota Workers' Compensation Law (MN LIC 04) -- [more info] | March 2009 | |
| Claim Petition for Dependency Benefits or Payment to Estate (CP03) | April 2012 | PO |
| Disability Status Report (DS01) | May 2008 | PO; WID |
| Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (CSI02) | February 2011 | |
| Election to Exclude Relatives of Managers of a Limited Liability Company (CSI01) | February 2011 | |
| Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01) | April 2012 | PO |
| Employee's Claim Petition (EC04) | April 2012 | PO |
| Employee's Objection To Discontinuance (ED02) | April 2012 | PO |
| Employee's Request for Administrative Conference (EQ05) -- [more info] | April 2012 | PO |
| Excess Fee Exhibit (PF04) | April 2012 | PO |
| First Report of Injury (FR01) -- [more info] | May 2008 | PO |
| Health Care Provider Report (HC01) -- [more info] | July 2010 | DLI |
| Interim Status Report (IS03) -- [more info] | July 2010 | DLI |
| Medical Request (MQ03) | April 2012 | PO |
| Medical Response (MR03) | April 2012 | PO |
| Notice of Appearance of Attorney for Employee (NA03) | April 2012 | PO |
| Notice of Benefit Payment (NB01) -- [more info] | February 2010 | PH |
| Notice of Benefit Reinstatement (NC01) -- [more info] | July 2010 | DLI |
| Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) -- [more info] | February 2010 | PH |
| Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) -- [more info] | February 2010 | PH |
| Notice of Insurer's Primary Liability Determination (NL01) -- [more info] | February 2010 | PH |
| Notice of Intention to Claim Reimbursement From the Second Injury Fund (RS05) | May 2008 | PO; WID |
| Notice of Intention to Discontinue Workers' Compensation Benefits (ND01) -- [more info] | August 2010 | PH |
| Objection to Penalty Assessment (CE0003) | May 2008 | PO; WID |
| On-the-Job Training Plan (JA04) | September 2008 | PO; TENN; WID |
| Permanent Total Disability Agreement (PA04) | May 2008 | PO; WID |
| Petition for Taxation of Actual and Necessary Disbursements (PT03) | May 2008 | PO; WID |
| Plan Progress Report (PR01) -- [Spanish] | February 2012 | Technical changes |
| R-2 Rehabilitation Plan (RE01) -- [more info] | February 2012 | Technical changes |
| R-3 Rehabilitation Plan Amendment (RP01) -- [more info] | February 2012 | Technical changes |
| R-8 Notice of Rehabilitation Plan Closure (NR01) | March 2012 | Technical changes |
| Rehabilitation Consultation Report (RC01) -- [Spanish] | February 2012 | Technical changes |
| Rehabilitation Request (RQ03) | April 2012 | PO |
| Rehabilitation Response (RR03) | May 2008 | PO; TENN; WID |
| Rehabilitation Rights and Responsibilities of the Injured Worker (IW05) -- [Spanish] | February 2012 | Technical changes |
| Report of Work Ability (RW01) -- [more info] | July 2010 | DLI |
| Request for Extension (QE03) -- [more info] | July 2010 | DLI |
| Request for Formal Hearing (RF03) | May 2008 | PO; TENN; WID |
| Retraining Plan (EP04) | September 2008 | PO; TENN; WID |
| Statement of Attorney Fees (SA04) | April 2012 | PO |
| *Notes: DLI = department
information updated; PH = phone number
change; PO = new mailing address; TENN =
Tennessen warning; WID = worker identification (number)** **Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used. |
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