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Get Motion Application To Intervene Minnesota Form

Mailing Address PO Box 64221 St. Paul MN 55164-0218 STATE OF MINNESOTA OFFICE OF ADMINISTRATIVE HEARINGS WORKERS COMPENSATION DIVISION 651 361-7900 WID or SSN M 0001 O DO NOT USE THIS SPACE DATE S OF CLAIMED INJURY EMPLOYEE VS. Motion/Application to Intervene AND INSURER S PRINT IN INK or TYPE. Enter dates in MM/DD/YYYY format. Being first duly sworn state that on served a true and correct copy of the attached MOTION/APPLICATION TO INTERVENE enclosed in a properly addressed envelope by depositing the same with postage prepaid in the United States mail at Minnesota addressed as follows Employee Employee Attorney Employer/Insurer Attorney Insurer Other Party Specify Subscribed and sworn to before me this day of Notary Public My Commission expires Signature. Re dated Identify dispute you are intervening in such as a Claim Petition Medical Request or Rehabilitation Request TO THE WORKERS COMPENSATION DIVISION AND THE ABOVE-NAMED PARTIES Applicant for its Motion to Intervene in the above-entitled matter states and alleges as follows 1. That applicant has provided services or paid benefits to the employee as follows 2. That attached to this Motion as Exhibit A is an itemization of all charges for services provided or benefits paid by the applicant regarding the workers compensation injury or injuries. The total claim is for services provided or payment made from date. to 3. That a determination in this case may affect the ability of the applicant to obtain payment from any source for services provided or benefits paid as itemized in Exhibit A. 4. In support of this Motion attached as Exhibit B are if applicable medical records/reports or rehabilitation records/reports. name and title 6. That in the event settlement is discussed by the parties applicant requests that phone regarding authority to settle on behalf of applicant. be contacted at Therefore applicant requests that it be allowed to intervene as a party in the above-captioned proceeding and that payment for its services provided or benefits paid be made plus appropriate statutory interest. DATE SIGNED SIGNATURE OF PERSON FILING MOTION PRINTED NAME AND TITLE ADDRESS CITY MN MO0001 5/08 STATE over ZIP CODE TELEPHONE COUNTY OF I AFFIDAVIT OF SERVICE ss. Re dated Identify dispute you are intervening in such as a Claim Petition Medical Request or Rehabilitation Request TO THE WORKERS COMPENSATION DIVISION AND THE ABOVE-NAMED PARTIES Applicant for its Motion to Intervene in the above-entitled matter states and alleges as follows 1. That applicant has provided services or paid benefits to the employee as follows 2. That attached to this Motion as Exhibit A is an itemization of all charges for services provided or benefits paid by the applicant regarding the workers compensation injury or injuries. That applicant has provided services or paid benefits to the employee as follows 2. That attached to this Motion as Exhibit A is an itemization of all charges for services provided or benefits paid by the applicant regarding the workers compensation injury or injuries. The total claim is for services provided or payment made from date. to 3. That a determination in this case may affect the ability of the applicant to obtain payment from any source for services provided or benefits paid as itemized in Exhibit A.

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