Employees Claim Petition {EC04}

MN EC04 - EMPLOYEE’S CLAIM PETITION. This form is used in Minnesota’s workers’ compensation system when an injured worker requests benefits through the Court of Administrative Hearings. This form allows the employee to provide detailed information about the injury or occupational disease, including the date, nature, and circumstances of the injury, the employee’s wages at the time, and whether the employer had knowledge of the injury. The petition identifies the employer, insurer, and any third parties who may have paid benefits, and specifies the types of benefits being claimed, such as temporary or permanent disability payments, medical expenses, rehabilitation services, or other compensation under Minnesota law. The employee or their attorney must also attach a supporting doctor’s report and serve a copy of the petition on all adverse parties. By filing this form, the employee asks the court to determine the employer’s and insurer’s liability and to order payment of benefits as required under the Minnesota Workers’ Compensation Act. www.FormsWorkflow.com