Employees Request For Administrative Conference {EQ05}

Employee222s Request for Administrative Conference on Discontinuance of Workers222 Compensation Benefits Mail or deliver this form to the Office of Administrative Hearings at one of the addresses listed at the bottom of this form. Print in ink or type. Enter dates in MM/DD/YYYY format. Reset EQ0 5 DO NOT USE THIS SPACE WID number or SSN Date of injury Employee Employer Employee address City State ZIP code Insurer claim number Insurer/self-insurer/TPA 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 workers222 compensation dispute. The data will be used by the office of administrative hearings (OAH) and the department of labor and industry staff members 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 department222s 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 Workers222 Compensation Court of Appeals; the Department of Revenue; the Department of Health; and the Workers222 Compensation Reinsurance Association. THIS REQUIRES YOUR IMMEDIATE ATTENTION Do not complete this form if you agree that your weekly workers222 compensation benefits may be stopped or changed. If you disagree that your benefits may be stopped or changed, you may request an administrative conference. A decision can be made at the conference about your weekly benefits. If box 1 or 2 is checked on the Notice of Intention to Discontinue Workers222 Compensation Benefits form, your request for a conference must be received by the Office of Administrative Hearings within 30 days after you returned to work. If box 3 is checked on the Notice of Intention to Discontinue Workers222 Compensation Benefits form, your request for a conference must be received by the Office of Administrative Hearings within 12 days after a copy of the Notice of Intention to Discontinue Workers222 Compensation Benefits form is received by the Department of Labor and Industry. Complete this section to request a conference by mail or in person (You do not need to complete this section to request a conference by phone) Box (check one) 1 2 3 is checked on the Notice of Intention to Discontinue Workers222 Compensation Benefits form. My weekly benefits should not be stopped or changed because (Attach a separate sheet if needed) If an interpreter is needed for conference, specify the language/dialect Employee signature Employee phone number (include area code) Date Attorney (if you have one) Attorney phone number (include area code) To request a conference, take one of the following actions: Call Mail this form Deliver this form (651) 361-7900 Office of Administrative Hearings Office of Administrative Hearings Workers222 Compensation Division Workers222 Compensation Division P.O. Box 64620 600 N. Robert Street St. Paul, MN 55164-0620 St. Paul, MN 55101 This document can be given to you in Braille, large print or audio. To request, call (651) 284 - 5032 or 1 - 800 - 342 - 5354. Any person who, with intent to defraud, receives workers222 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 Minnesota Statutes 247 609.52, subdivision 3. American LegalNet, Inc. www.FormsWorkFlow.com MN EQ05 (6/18) American LegalNet, Inc. www.FormsWorkFlow.com