Get Mn Mn Nl01 2017-2025

Filling out the MN MN NL01 form is essential for reporting primary liability determinations by insurers in Minnesota. This guide will provide you with clear, step-by-step instructions to help you navigate the online version of this form effectively.

Follow the steps to complete the MN MN NL01 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the required information in the designated fields. Start with the WID number or Social Security Number (SSN) followed by the date of injury, ensuring the date format is MM/DD/YYYY.
3. Fill in the employee's name, including last name, first name, and middle initial, as well as the employer's name, and the insurer or self-insurer's information.
4. Record the insurer claim number and the first date of any lost time from work. Additionally, input the date the employer was notified of this lost time and the initial return-to-work date.
5. Enter the average weekly wage at the date of injury. If there was a new period of lost time after the initial return to work, complete the additional fields regarding that period of lost time.
6. Indicate whether your claim is accepted and specify the type of benefits being received, such as Temporary Total, Temporary Partial, Permanent Total, or Dependency. Provide the relevant payment details, including dates and amounts.
7. If applicable, check the boxes that apply regarding full wage continuation, the type of payment made for Temporary Partial Disability, or details concerning fatality claims.
8. If your claim is accepted but wage loss benefits will not be paid, check the reason that applies and provide an explanation if necessary.
9. If primary liability is denied, check the relevant boxes and detail the reasons for denial, including legal and factual bases.
10. Fill in the name and contact information of the person making the determination, date served, and ensure all relevant distributions are selected.
11. Review all entered information for accuracy and completeness, then save your changes. You can download, print, or share the form as needed.

Complete your MN MN NL01 document online today for efficient processing.