Request For Formal Hearing {RF03}

MN RF03 (6/18) (over) Office of Administrative Hearings PO Box 64620 St. Paul, MN 55164-02(651)361-7900 Request for Formal Hearing (under M.S. 176.106 or 176.305) PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT DO NOT USE THIS SPACE WID or SSN DATE(S) OF CLAIMED INJURY EMPLOYEE VS. EMPLOYER AND INSURER AND ADDITIONAL PARTIES (INCLUDING INTERVENORS) 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 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 n or court order; the compensation reinsurance association. TO THE ABOVE NAMED PARTIES AND THEIR ATTORNEYS: The above - named party, , requests a formal hearing. An administrative decision on the issues was previously issued by: (Name) . The decision was served and filed on: (date). The specific issues in dispute and the specific reason(s) for disputing the decision are as follows: American LegalNet, Inc. www.FormsWorkFlow.com Copies of this request have been served on all parties and their attorneys who are listed with addresses and attorney registration numbers as follows: (attach additional sheet if necessary) Employee: Employee Attorney: Employer: Employer/Insurer Attorney: Insurer: Other Party (Specify): REQUESTOR SIGNATURE ATTORNEY FOR PARTY SIGNATURE REQUESTOR PRINTED NAME ADDRESS DATE CITY STATE ZIP CODE ATTORNEY REGISTRATION # PHONE # (include area code) INSTRUCTIONS ffice of dministrative earings within 30 days after the date the decision was served and filed. Issues and reasons for the request must be specifically listed. For example, a general disputed issues. All requests will be referred to the Office of Administrative Hearings for a formal hearing bef 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.ENEFITS 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