Minnesota > Workers Comp
Employees Request For Administrative Conference EQ05 - Minnesota
| Employees Request For Administrative Conference Form. This is a Minnesota form and can be used in Workers Comp . |
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Employee's Request for Administrative Conference Minn. Stat. ยง 176.239, subd. 2 PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT E0 Q5 DO NOT USE THIS SPACE WID or SSN EMPLOYEE DATE OF INJURY EMPLOYER EMPLOYEE ADDRESS CITY INSURER CLAIM NUMBER STATE ZIP CODE THIS REQUIRES YOUR IMMEDIATE ATTENTION 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' 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 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 for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association. INSURER/SELF-INSURER/TPA 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. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354/Voice or TDD (651) 297-4198. 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: (PLEASE INCLUDE A COPY OF THE NOTICE OF INTENTION TO DISCONTINUE, IF YOU RECEIVED ONE.) In Person Mailing Address Fax Department of Labor and Industry Department of Labor and Industry (651) 284-5731 Workers' Compensation Division Workers' Compensation Division 443 Lafayette Road N. PO Box 64221 St. Paul, MN 55155-4301 St. Paul, MN 55164-0221 Requests will also be accepted by telephone. Call (651) 361-7901 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 (4/12) Questions: Call (651) 284-5032 or 1-800-342-5354 American LegalNet, Inc. www.FormsWorkFlow.com
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