Loading
Form preview picture

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..

How It Works

captioned rating
4.8Satisfied
27 votes

How to fill out and sign alleges online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Business, legal, tax and other electronic documents need higher of protection and compliance with the law. Our templates are regularly updated in accordance with the latest amendments in legislation. Plus, with our service, all of the information you provide in your Motion Application To Intervene Minnesota Form is well-protected from loss or damage via top-notch encryption.

The tips below will help you fill in Motion Application To Intervene Minnesota Form quickly and easily:

  1. Open the form in our full-fledged online editor by hitting Get form.
  2. Complete the required boxes that are colored in yellow.
  3. Click the arrow with the inscription Next to jump from one field to another.
  4. Use the e-autograph solution to e-sign the document.
  5. Insert the relevant date.
  6. Look through the whole e-document to ensure that you have not skipped anything.
  7. Hit Done and download the new template.

Our service enables you to take the whole process of submitting legal documents online. Consequently, you save hours (if not days or even weeks) and get rid of extra costs. From now on, submit Motion Application To Intervene Minnesota Form from your home, workplace, or even while on the move.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Norton logo picture

    Norton Secured

    The highest level of recognition among eCommerce customers.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.