Notice Of File Closing {NF01} | Pdf Fpdf Doc Docx | Minnesota

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Notice Of File Closing {NF01} | Pdf Fpdf Doc Docx | Minnesota

Notice Of File Closing {NF01}

This is a Minnesota form that can be used for Workers Comp.

Alternate TextLast updated: 5/9/2006

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N F 0 1 DO NOT USE THIS SPACE Notice of File Closing Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE EMPLOYER INSURER CLAIM NUMBER THIS IS TO NOTIFY YOUR OFFICE THAT ALL PAYMENTS AND OTHER ACTIVITIES HAVE BEEN COMPLETED ON THIS FILE. AS A RESULT, WE ARE NOW CLOSING IT ON OUR SYSTEM. CLAIM REPRESENTATIVE NAME DATE INSURER/SELF-INSURER/TPA AREA CODE PHONE NUMBER ADDRESS Send completed form to: Minnesota Department of Labor and Industry Workers Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4317 This material can be made available in different forms, su ch 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. MN NF01 (8/00)

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