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WID or SSN Minnesota Department of Labor and Industry Workers' Compensation Division PO Box 64218 St. Paul, MN 55164-0218 (651) 284-5030 1-800-342-5354 (DIAL-DLI)

N A 0 3

DATE(S) OF CLAIMED INJURY

DO NOT USE THIS SPACE

EMPLOYEE VS. EMPLOYER AND INSURER AND

Notice of Appearance of Attorney for Employee
PRINT IN INK or TYPE. Enter dates in MM/DD/YYYY format.

TO THE WORKERS' COMPENSATION DIVISION AND THE ABOVE NAMED INSURER:

ATTORNEY NAME

ATTORNEY REGISTRATION #

ADDRESS

PHONE # (include area code)

CITY

STATE

ZIP CODE

I have retained the services of the above-named attorney to represent my interests in the above-entitled matter. I hereby authorize the Workers' Compensation Division to release to said attorney any information the attorney may request regarding this injury. It is requested that you make service of all legal documents, notices, etc., upon said attorney.

DATE

EMPLOYEE SIGNATURE

This notice supercedes any and all prior notices of appearance. A copy of the retainer agreement must accompany this notice of appearance.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

MN NA03 (5/08)