Get Report - Minnesota Department Of Labor And Industry

This guide will assist users in completing the Report required by the Minnesota Department of Labor and Industry for workers' compensation claims. Following these steps will ensure that all necessary information is submitted accurately and efficiently.

Follow the steps to complete your report online.

1. Press the ‘Get Form’ button to access the report and open it in your browser.
2. Begin by filling in the employee's social security number in the designated field (Item 1). Ensure accuracy to avoid any processing delays.
3. In Item 2, provide the OSHA case number, which is found on the OSHA 300 log. This is essential for compliance purposes.
4. For Items 3 and 4, enter the date and time of the claimed injury. Use the MM/DD/YYYY format for dates.
5. Complete Item 5 by noting the time the employee began work on the date of the injury to provide context for the incident.
6. In Item 6, fill in the employee's full name (last, first, middle) to clearly identify the individual involved.
7. Record the employee's date of birth in Item 11 and their home address in Item 9. Accurate personal information is crucial.
8. For Items 15-20, provide comprehensive wage information, including average weekly wage, rate per hour, and other related fields.
9. Details about how the injury occurred should be entered in Item 22. Be thorough, providing as much information as possible.
10. In Item 26, indicate the date of the first day of any lost time related to the injury.
11. Conclude by reviewing all information for accuracy, then save your changes, and use the options to download, print, or share the completed form as needed.

Submit your completed Report online to ensure timely processing of your workers' compensation claim.