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Employee's Request for Administrative Conference Minn. Stat. § 176.239, subd. 2
PRINT IN INK or TYPE. Enter dates in MM/DD/YYYY format.

E Q

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DO NOT USE THIS SPACE DATE OF INJURY

WID or SSN

EMPLOYEE

EMPLOYER

THIS REQUIRES YOUR IMMEDIATE ATTENTION

EMPLOYEE ADDRESS

Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers' CITY STATE ZIP CODE compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and INSURER CLAIM NUMBER INSURER/SELF-INSURER/TPA statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION for your claim and may be supplied to: anyone BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, who has access to the file or the data by MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL authorization or court order; the employer and insurer for your claim; the office of administraBE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. tive hearings; the workers' compensation court of appeals; the departments of revenue and This material can be made available in different forms, such as large print, Braille or on a tape. health; and the workers' compensation reTo request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. insurance association.

INSTRUCTIONS TO EMPLOYEE DO NOT COMPLETE THIS FORM IF YOU AGREE THAT YOUR WEEKLY WORKERS' COMPENSATION BENEFITS MAY BE STOPPED OR CHANGED. HOWEVER, IF YOU DISAGREE THAT YOUR BENEFITS MAY BE STOPPED OR CHANGED, YOU MAY BE ENTITLED TO AN ADMINISTRATIVE CONFERENCE. At the conference, a decision can be made about your right to further weekly benefits. TO REQUEST A CONFERENCE, MAIL OR DELIVER THIS COMPLETED FORM TO: DEPARTMENT OF LABOR AND INDUSTRY WORKERS' COMPENSATION DIVISION PO BOX 64218 ST PAUL, MN 55164-0218 Requests will also be accepted by telephone. Call (651) 361-7912 or 1-800-342-5354 TIME LIMIT TO REQUEST A CONFERENCE IF BOX 1 OR 2 is checked on the Notice of Intention to Discontinue Workers' Compensation Benefits, your request for a conference must be received by the Workers' Compensation Division WITHIN 30 DAYS AFTER YOU RETURNED TO WORK. IF BOX 3 is checked on the Notice of Intention to Discontinue Workers' Compensation Benefits, your request for a conference must be received WITHIN 12 DAYS AFTER A COPY OF THE NOTICE OF INTENTION TO DISCONTINUE WORKERS' COMPENSATION BENEFITS IS RECEIVED BY THE WORKERS' COMPENSATION DIVISION. EMPLOYEE'S REQUEST FOR ADMINISTRATIVE CONFERENCE 1. 2. BOX (check one) 1 2 3 is checked on the Notice of Intention to Discontinue Workers' Compensation Benefits.

My weekly benefits should not be changed/stopped because:

(attach separate sheet if more room is needed)

EMPLOYEE SIGNATURE

EMPLOYEE PHONE # (include area code)

DATE

ATTORNEY (if you have one)

ATTORNEY #

ATTORNEY PHONE # (include area code)

QRC (if you have one)

MN EQ05 (5/08)

QUESTIONS: Call (651) 284-5032 Toll free within Minnesota 1-800-342-5354

ASK FOR BENEFIT MANAGEMENT AND RESOLUTION