Minnesota > Workers Comp
Application For Registration Or Renewal As Organization Approved For Employment Of Qualified Rehabilitation Consultant Or Independent R-24 - Minnesota
| Application For Registration Or Renewal As Organization Approved For Employment Of Qualified Rehabilitation Consultant Or Independent Form. This is a Minnesota form and can be used in Workers Comp . |
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Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5459 or 1-800-342-5354 (DIAL DLI) www.dli.mn.gov R-24 Application for: (check one) Registration Renewal of Registration As Organization Approved for the Employment of Qualified Rehabilitation Consultant/Independent Please PRINT or TYPE. See Minn. Rules 5220.1600, Subp. 2.D. QRC FIRM NAME ADDRESS (where certified mail can be delivered) CITY STATE ZIP CODE TELEPHONE NUMBER CHIEF EXECUTIVE OFFICER OR MANAGER NAME QRC FIRM NUMBER (for renewal applications only) EXPIRATION DATE Check all that apply: public private profit nonprofit corporation incorporated (date) (state) private individual not incorporated M.S. ยง 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation coverage requirement. The following information is therefore required. WORKERS' COMPENSATION INSURANCE CARRIER NAME POLICY NUMBER (or) I am not required to have workers' compensation liability coverage because: (CHECK ONLY ONE OF THE FOLLOWING) I have no employees. I am self insured (include permit to self insure). I have no employees who are covered by the Workers' Compensation Law. (These include: spouse, parents, children.) MN R-24 (3/12) (over) American LegalNet, Inc. www.FormsWorkFlow.com (FOR NEW APPLICATIONS FOR REGISTRATION ONLY) 1. Have you previously applied for registration as a Rehabilitation Provider in Minnesota or any other state? If yes, indicate your identification number Yes No 2. State what experience and qualifications you have in workers' compensation vocational rehabilitation as it relates to the services you provide. Attach any supportive data, resume, list of activities or other information that may assist in evaluating this application for registration as a Qualified Rehabilitation Consultant (QRC) Firm. 3. If currently licensed, certified, approved or accredited by any public or private body, indicate name, address, licensure number if appropriate, expiration date; if more than one certification or accreditation, list them all: THE FOLLOWING INFORMATION IS REQUIRED OF BOTH NEW AND RENEWAL APPLICATIONS. 1. List names and titles of management staff. (Attach resumes of those hired from outside your organization since last registration approval.) 2. List ALL office addresses and telephone numbers of each branch of the QRC firm. (Attach additional sheets if necessary.) 3. List alphabetically the names and job titles of ALL personnel at each address. (Attach additional sheets if necessary.) 4. Complete the attached Tax Notice form. 5. Enclose a check or money order for $220.00 payable to the Commissioner of the Department of Labor and Industry. (This includes the 10% surcharge pursuant to 2009 Laws, Chapter 101, Article 2, Section 59.) Send all application documents and fees to the Department's Financial Services Section at the address indicated on the front of this form. I have read Minn. Rules 5220.1600, subp. 1 regarding the criteria for approval as a QRC Firm. I authorize the Workers' Compensation Division, Department of Labor and Industry, to make any appropriate investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection or revocation of registration. I understand that Minn. Rules 5220.1250 prohibits any ownership or financial relationship of any kind with a Registered Rehabilitation Vendor. I hereby agree to be bound by all statutes, rules and orders as established by the Commissioner, and realize that violations may result in revocation of registration. APPLICANT NAME APPLICANT SIGNATURE NOTARY SIGNATURE TITLE DATE MY COMMISSION EXPIRES American LegalNet, Inc. www.FormsWorkFlow.com Form SP:C1 License Applicant Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information. 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest. 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchanges of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following information and return it along with your application to the agency issuing the license. DO NOT RETURN IT TO THE DEPARTMENT OF REVENUE. LICENSE BEING APPLIED FOR OR RENEWED: Qualified Rehabilitation Consultant Firm LICENSING AUTHORITY: Minnesota Department of Labor and Industry LICENSE RENEWAL DATE: PERSONAL INFORMATION: (Chief Executive Officer or Manager of QRC Firm) NAME RESIDENCE SOCIAL SECURITY NUMBER CITY STATE ZIP CODE BUSINESS INFORMATION: BUSINESS NAME BUSINESS ADDRESS MINNESOTA TAX IDENTIFICATION NUMBER CITY FEDERAL TAX IDENTIFICATION NUMBER STATE ZIP CODE If a Minnesota Tax Identification number is not required, please explain on the reverse side. SIGNATURE TITLE DATE This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5459 or 1-800-342-5354/Voice or TDD (651) 297-4198. American LegalNet, Inc. www.FormsWorkFlow.com
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