Employees Claim Petition {EC04}

MN EC04 (6/18) (over) WID or SSN Office of Administrative Hearings PO Box 64620, St. Paul, MN 55164-02(651)361-7900PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT DO NOT USE THIS SPACE DATE(S) OF CLAIMED INJURY EMPLOYEE VS. NOTE: File Petition and Affidavit of Service with the Office of Administrative Hearings EMPLOYER(S) AND INSURER (S) AND Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this f orm, will be used to the office of administrative hearings (OAH) and the department of labor and industry 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 urt order; the employer reinsurance association. TO THE OFFICE OF ADMINISTRATIVE HEARINGS The Employee above named, for his/her petition, alleges the following as facts: 1. That his/her address is 2. That the address of the employer is 3. That on the date or dates indicated above he/she sustained a personal injury or occupational disease. 4. That on the date or dates he/she was employed by the above employer. 5. That his/her weekly wage at the time of said alleged injury or disease was 6. That said injury or disease arose out of and in the course of said employment. 7. That the nature of the injury or disease was as follows: 8. That the employer had knowledge or notice of the occurrence of the injury, disease and/or death alleged in paragraph 3. 9. That on the date or dates indicated above the employer was insured against compensation liability by the insurer or insurers indi cated above. 10. That said employer and insurer are liable for the following: DISABILITY BENEFITS a. Temporary Total from to b. Temporary Partial from to c. Permanent Total from to d. Permanent Partial % (Applicable PPD rule citation) MEDICAL BENEFITS Doctor / Hospital / Other Amount e. $ f. $ g. $ REHABILITATION BENEFITS h. Describe OTHER i. Describe 11. NAME and ADDRESS of any third party who has paid disability or medical benefits or income maintenance related to this claim AMOUNT CLAIM NUMBER or POLICY NUMBER 12. American LegalNet, Inc. www.FormsWorkFlow.com The Employee petitions for an award against the of Minnesota. EMPLOYEE SIGNATURE ATTORNEY FOR EMPLOYEE SIGNATURE ADDRESS ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE TELEPHONE ATTORNEY REGISTRATION # TELEPHONE TRIAL DATA: Request is made for a settlement conference. Yes No Estimated hours to present evidence: Requested place of: Pretrial Trial Number of Witnesses: (Attach names and addresses) An Affidavit of Significant Financial Hardship is attached. Yes No If an interpreter is requested for a hearing or conference, specify the language/dialect: If a reasonable accommodation of disability is requested for a hearing or conference, describe: STATE OF MINNESOTA } } ss. AFFIDAVIT OF SERVICE COUNTY OF } I, , being first duly sworn, state that on , I served a true and correct copy of this document, enclosed in a properly addressed envelope, by depositing the same, with post age prepaid, in the United States mail at , Minnesota, addressed as follows: NAMES AND ADDRESSES Subscribed and sworn to before me this day of Signature Notary Public My Commission expires INSTRUCTIONS Failure to properly and fully fill out the claim petition, with appropriate documentation, in accordance practice, shall not be considered proper filing under Minn. Stat. 247 176.291 and 176.305. The Office of Administrative may refuseWID or social security number, or name ofemployer/insurer.If you have more defendants or more injuries than can be listed on the claim petition, it may be modified accordingly.If additional space is required to list all medical benefits claimed, or to list the names, addresses, etc., of third parties making payment ofmedical expenses or disability benefits, or there are other issues you wish to include on the petition, attached a separate sheet containingsuch information to each copy of the petition.provided for thename and address in #11.If the employee has fewer than three days of lost time from work, attach a copy of the First Report of Injury, unless one has already beenfiled.The petitioner must serve a copy of the petition on EACH adverse party (employer(s), insurer(s), the Special Compensation Fund, if appli-cable, and any third party named in #11) by first class mail or personally. 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.ON 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. American LegalNet, Inc. www.FormsWorkFlow.com