This is one of the official Workers' Compensation forms for the state of Minnesota.
Minneapolis Minnesota Medical Request for Workers' Compensation
Category:
State:
Minnesota
City:
Minneapolis
Control #:
MN-MQ03-WC
Format:
PDF;
Rich Text
Instant download
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Public form
Description
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FAQ
The first day of disability is the first day of the waiting period. Any disability (claimed lost time or wages), including a fraction of a day of disability, is considered the first day of disability regardless of whether the employee is paid in full by the employer for that day.
Within 14 days ? If you tell your employer within 14 days after your injury, your notice is on time. The employer cannot deny your workers' compensation claim because you gave late notice of the injury.
Two Years is the Standard Time Limit for Minnesota Personal Injury Lawsuits.
176.151 TIME LIMITATIONS. (a) Actions or proceedings by an injured employee to determine or recover compensation, three years after the employer has made written report of the injury to the commissioner of the Department of Labor and Industry, but not to exceed six years from the date of the accident.
How much does workers' compensation insurance cost in Minnesota? Estimated employer rates for workers' compensation in Minnesota are $1 per $100 in covered payroll. Your cost is based on a number of factors, including: Payroll.
If notice of a work injury is not provided within 180 days, a claim may be denied unless the employee was unable to give notice due to mental or physical incapacity or where the employer has engaged in fraud or misrepresentation.
In Minnesota, TPD benefits are two-thirds of the difference between your pre-injury and post-injury wages (up to the same maximum amount as for TTD). For example, if you used to earn $1,200 in weekly wages, but you now can only earn $600, you would get $400 in TPD benefits ($1,000-$600 = $600; 0.6666 x $600 = $400).
There is a law in Minnesota that prevents employers from firing employees for seeking workers compensation benefits. The law also states that an employer cannot intentionally obstruct an employee from seeking workers compensation benefits.
In Minnesota, the workers' compensation waiting period starts on the first day of any lost time and is three calendar-days long. Wage-loss benefits for an injured worker are not paid for the waiting period unless the disability continues for 10 calendar-days or longer.
More info
Save copies of all claim-related documents, letters, forms, benefit checks and medical bills, especially the First Report of Injury form. Fill out an incident report as soon as you safely can.Report the injury as soon as it occurs. It does not matter if the injury seems minor, not reporting it means possibly losing compensation rights. Speak to an attorney about your claim, we offer free consultations within our law firm. The Minnesota Health Records Act is in Minnesota Statutes 144.291-. Claiming or attempting to claim workers' compensation benefits. (Minn. Stat. You will need to fill out your part of the C-4 form the first time you visit a medical provider for treatment of your work injury. NOTE: Before filing this form, call the workers' compensation insurer. If you're injured on the job, there's a chance your health insurance provider could deny the claim, leaving you with expensive medical bills.