Claim Petition For Dependency Benefits Or Payment To Estate {CP03}

MN CP0 - CLAIM PETITION FOR DEPENDENCY BENEFITS OR PAYMENT TO ESTATE. This form is used in Minnesota’s Workers’ Compensation system when a dependent or estate of a deceased employee seeks benefits following a work-related injury, illness, or death. This form is filed with the Court of Administrative Hearings and provides detailed information about the employee, employer, insurer, cause of death, wages, medical and funeral expenses, and any benefits already paid. It also requires the petitioner to identify all dependents of the deceased, including children and other family members, along with any government survivor benefits they may receive. The petitioner requests workers’ compensation benefits such as unpaid wages owed, dependency benefits for surviving family members, or payment directly to the estate. Supporting documentation, including a doctor’s report, must be attached, and the petition must be served on all involved parties, such as the employer, insurer, and any third-party payers. www.FormsWorkflow.com