Get Motion Application To Intervene Minnesota Form

Filling out the Motion Application To Intervene Minnesota Form online can be straightforward with the right guidance. This document allows applicants to request participation in a workers' compensation proceeding, and this guide provides step-by-step instructions for successfully completing the form.

Follow the steps to fill out the Motion Application To Intervene Minnesota Form online.

1. Click ‘Get Form’ button to obtain the form and open it in a digital format.
2. Begin by entering the date or dates of the claimed injury in the designated section. Use the MM/DD/YYYY format for clarity.
3. Identify the parties involved in the application by filling in the applicant's name, the employer, and the insurer(s) in the relevant fields.
4. In the 'Re:' section, provide a brief description of the dispute you are intervening in, such as a Claim Petition, Medical Request, or Rehabilitation Request.
5. Specify the services provided or benefits paid to the employee in the appropriate section. This information is crucial for your request.
6. Attach an itemization of all charges for services provided or benefits paid related to the worker's compensation injury as Exhibit A. Clearly note the total claim amount.
7. If applicable, gather and attach any necessary medical or rehabilitation records as Exhibit B.
8. State your statutory right to intervene under Minn. Stat. § 176.361 in the designated area.
9. Provide your contact information for any discussions regarding settlements, including a phone number.
10. Use the signature section to sign and date the form, including your printed name and title, and your complete address.
11. Complete the affidavit of service section, noting the parties served and where the documents were sent.
12. Once all sections are filled out, review your entries for accuracy, and then save the changes, download the form, print, or share as necessary.

Complete your documents online today to take the next steps in your workers' compensation proceedings.