Department of Labor & Industry Workers' Compensation Division Instructions for Completing Claim Petition Use a Claim Petition if you want a hearing with a compensation judge to resolve a dispute where the insurer has denied primary liability for a claim or where the workers' compensation insurer has accepted liability for the claim but is denying wage loss, permanency, and any medical or rehabilitation benefits. Since the issues typically claimed on the Claim Petition may be complex, you may want to retain the services of an attorney to file the Claim Petition and represent you in the hearing. You will be able to find a workers' compensation attorney by checking the Yellow Pages of your local phone directory or contacting the bar association in your county, which usually have referral services to direct you to an appropriate attorney. #1-9 and 12 on the front of the form. Complete identifying information about employee, employer and the workers' compensation claim itself. 10a-i. List the workers' compensation benefits being claimed on the Claim Petition: 10a-d. List the wage loss and/or permanent partial disability benefits to which you feel that you are entitled to. Temporary total disability benefits are wage loss benefits you receive when you are off work completely due to the work injury. Temporary partial disability benefits are wage loss benefits you receive when you return to work at a lower wage, due to your injury. Permanent total disability benefits are wage loss benefits you get when you are permanently unable to return to work. Permanent partial disability benefits are monetary benefits you receive to compensate you for a permanent disability (when your doctor gives you a "rating"). Don't worry about the monetary amounts being claimed; just try to list the dates you feel the benefits should have been paid. Attach supporting information, such as an off-work slip from your doctor or a Health Care Provider Report listing the percentage of disability to the whole body, in support of your claim. 10e-g. List any medical bills that are unpaid. Attach copies of the bills and supporting medical documentation. Attach additional sheets if necessary to list all the medical providers involved. 10h. Fill out this section if you are requesting the services of a Qualified Rehabilitation Consultant (QRC) to help you return to work. 11. If your medical treatment has been paid for by a health insurer or you have received short- or long-term disability benefits or unemployment compensation, list them here. On the back of the form, put in your name, address and telephone number, complete with area code. If you are represented by an attorney, the attorney also gives his or her name, address, telephone number and registration number. Trial Data section. Fill out this section to the best of your ability. Most hearings take 1/2 day. Specify where the hearing should be held - hearings are usually held in St. Paul, Duluth and Detroit Lakes. A settlement conference would be appropriate if you are interested in settling your claim through a process of negotiation. Witnesses, while not required, usually include the injured worker, co-workers who may have witnessed the workers' compensation injury, QRC or vocational experts. Affidavit of Significant Hardship. You may complete a form indicating that you have a significant financial hardship and are requesting an expedited hearing. Affidavit of Service section. Fill out the names and addresses of all the parties to the claim including employer(s), insurer(s), health care providers, any third party that has paid benefits under #11, etc. Fill out and sign the rest of this section in the presence of a Notary Public, who will stamp the form and attest to the true and correct nature of the copy sent through the U.S. mail.
Instructions for MN EC04 (9/07)
Make a copy of the Claim Petition and each attachment for each of the parties indicated on the back of the form and mail it to each party. Keep a copy for yourself. Mail the original to the Department of Labor and Industry at the address listed on the top of the front of the form. Additional instructions appear on the bottom of the back page. If you have questions about how to complete the form, you may call the Department's Workers' Compensation Division's Benefit Management and Resolution Unit Hotline at (651) 284-5032 in the Minneapolis/St. Paul metropolitan area; (800) 365-4584 in the Duluth area; or (800) 342-5354 statewide.