Get Workers' Compensation Forms - Minnesota Department Of Labor And ...

Completing the Workers' Compensation Forms through the Minnesota Department of Labor and Industry is essential for individuals seeking an extension of time for temporary total disability benefits. This guide will provide you with clear, step-by-step instructions to ensure your forms are filled out accurately and submitted properly.

Follow the steps to successfully complete the Workers' Compensation Forms.

1. Click the 'Get Form' button to access the Workers' Compensation Form. This will open the form for you to begin filling it out.
2. Fill in your WID or Social Security Number at the top of the form, ensuring the accuracy of the information, as it is crucial for processing your request.
3. Enter the date of injury in the MM/DD/YYYY format. This is necessary to establish the timeline of your claim.
4. Provide the names of the employee and employer in the designated fields. Make sure these names are spelled correctly to avoid any processing delays.
5. Indicate the name of the insurer, self-insurer, or third-party administrator (TPA) along with the corresponding claim number. This helps identify where the claims are managed.
6. Document the first day of lost time for this new period of temporary total disability, also in MM/DD/YYYY format.
7. Record the date the employer received notice of the additional lost time. This is important for the timeline and processing of the extension request.
8. In the section requesting reasons for the extension, clearly specify whether the investigation is incomplete, if medical reports are unavailable, or any other applicable reason.
9. Write the name and phone number of the claim representative associated with your case. It is vital to ensure this contact information is accurate for any follow-up.
10. Indicate the date this form was served to the employee to ensure proper record-keeping.
11. After filling out all sections accurately, review the entire form for any missing information or errors.
12. Save your changes to the form. You can then download, print, or share the completed document as necessary.

Complete your Workers' Compensation Forms online today to ensure timely processing of your claim.