The Minnesota EC04 form serves as a vital document for employees seeking to file a claim related to workplace injuries or occupational diseases. This form facilitates the petition process, allowing employees to formally present their claims against employers and insurers. Understanding its requirements is crucial for ensuring a smooth filing process and obtaining the benefits entitled under Minnesota's Workers' Compensation Law.
To begin your claim, fill out the Minnesota EC04 form by clicking the button below.
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The Minnesota EC04 form is a critical document for employees seeking to file a claim for workers' compensation benefits. However, several other forms and documents are often used in conjunction with the EC04 to ensure a comprehensive claim process. Below is a list of these related documents, each serving a specific purpose in the workers' compensation system.
Understanding these forms and their purposes can significantly enhance the effectiveness of a workers' compensation claim. Properly completing and submitting all necessary documentation ensures that the process runs smoothly and increases the likelihood of receiving the benefits owed.
What is the Minnesota EC04 form used for?
The Minnesota EC04 form is a Claim Petition used in the workers' compensation process. It allows employees to formally request a hearing with a compensation judge when there is a dispute regarding their claim. This typically occurs when an insurer denies liability for a claim or accepts liability but disputes the benefits owed, such as wage loss or medical expenses. Completing this form accurately is essential for resolving disputes related to workplace injuries or occupational diseases.
What information do I need to provide on the EC04 form?
When filling out the EC04 form, you must include key information about yourself, your employer, and the details of your claim. This includes your name, address, and Social Security Number or Worker Identification Number (WID). You will also need to provide the employer's information, the date of your injury, and a description of the injury or occupational disease. Additionally, you should list the benefits you are claiming, such as temporary total disability or medical benefits, along with any unpaid medical bills and the names of third parties who may have paid benefits related to your claim.
What happens if I don’t provide all the required information?
If you fail to complete the EC04 form properly, it may be rejected by the Workers' Compensation Division. Essential information, such as your name, date of injury, and the employer's details, must be included. Incomplete submissions can lead to delays in processing your claim or even denial of your benefits. It’s crucial to ensure that all sections are filled out accurately and that supporting documentation is attached when necessary.
How do I submit the EC04 form?
You should mail the completed EC04 form to the Minnesota Department of Labor and Industry at the address provided on the form. Make sure to keep copies of the petition and any attachments for your records. Additionally, you must serve a copy of the petition to each party involved in the claim, including your employer and any insurers. This can be done by first-class mail or in person. If you have questions about the submission process, you can contact the Alternative Dispute Resolution Unit for assistance.
Filling out the Minnesota EC04 form can be a straightforward process, but many people make common mistakes that can delay their claims. One frequent error is failing to provide complete identifying information. The form requires specific details about the employee, employer, and the nature of the claim. Omitting any of these key pieces of information, such as the employee’s name, date of injury, or the employer's name, can result in the form being rejected or returned for corrections.
Another common mistake is not adhering to the required date format. The form specifies that dates should be entered in the MM/DD/YYYY format. If someone writes the date incorrectly, it can create confusion and lead to processing delays. It’s essential to double-check this detail to ensure that all dates are formatted correctly before submitting the form.
Additionally, many individuals overlook the importance of supporting documentation. The EC04 form requires that a doctor’s report supporting the claim be filed alongside the petition. Without this crucial documentation, the claim may not be considered valid. It’s advisable to gather all necessary medical records and attach them to the form to strengthen the case and avoid unnecessary complications.
Lastly, some people neglect to serve copies of the petition to all relevant parties. The instructions clearly state that a copy of the petition must be sent to each adverse party, including the employer, insurer, and any third party involved. Failing to do so can result in delays and may even jeopardize the claim. It is important to keep track of all parties involved and ensure that they receive their copies promptly.
The Minnesota EC04 form shares similarities with the Employee's Claim Petition, a document used in various states to initiate a workers' compensation claim. Like the EC04, the Employee's Claim Petition requires detailed information about the employee, employer, and specifics of the injury. Both forms serve the purpose of formally notifying the appropriate workers' compensation division of a claim, allowing for the resolution of disputes regarding benefits. Additionally, they both necessitate the inclusion of supporting documentation, such as medical records, to substantiate the claim being made.
Another document akin to the Minnesota EC04 is the First Report of Injury (FROI). This form is often the initial step in the workers' compensation process, documenting the circumstances surrounding the injury. Similar to the EC04, the FROI collects essential information about the injured employee, the employer, and the nature of the injury. The FROI must be filed promptly to ensure that the claim is recognized and processed in a timely manner, paralleling the EC04's requirement for timely submission to avoid delays in benefits.
In addition to understanding the procedural aspects of various workers' compensation forms, families considering homeschooling in California should also be aware of the necessary documentation involved in that process. The California Homeschool Letter of Intent is crucial as it officially communicates the parents' decision to the local school district, ensuring compliance with state regulations. For more information on this important document, you can visit https://homeschoolintent.com/editable-california-homeschool-letter-of-intent, which provides an editable version to simplify the submission process.
The Amended Claim Petition functions similarly to the Minnesota EC04 by allowing parties to modify their claims after the initial submission. This document is used when there are changes to the parties involved or the date of injury, just as the EC04 can be amended to reflect new information. Both documents aim to keep the workers' compensation division informed of any updates, ensuring that the case remains current and accurately reflects the circumstances surrounding the claim.
The Affidavit of Service is another document that aligns with the EC04 in its procedural function. This affidavit confirms that all parties involved in the claim have been properly notified of the petition. Like the EC04, it requires specific information about the parties and must be completed in accordance with legal standards. This ensures transparency and proper communication throughout the claims process, which is crucial for the resolution of disputes.
Lastly, the Notice of Appeal serves a similar role to the Minnesota EC04 in the context of workers' compensation claims. When a party disagrees with a decision made regarding their claim, they may file a Notice of Appeal to contest that decision. Both documents require detailed information about the parties and the issues at hand. They also both initiate formal proceedings within the workers' compensation system, allowing for a review of the case and potential changes to the outcome based on new arguments or evidence presented.
WID or SSN
DATE(S) OF CLAIMED INJURY
Minnesota Department of Labor and Industry
Workers’ Compensation Division
PO Box 64221, St. Paul, MN 55164-0221
(651) 284-5032 or 1-800-342-5354
EC04
Fax: 651-284-5731
DO NOT USE THIS SPACE
PRINT IN INK or TYPE
ENTER DATES in MM/DD/YYYY FORMAT
EMPLOYEE
VS.
EMPLOYER(S)
AND
INSURER (S)
Employee’s Claim Petition
NOTE: File Petition and Affidavit of Service with the Division
Amended Claim Petition
(to amend a party/date of injury to the claim)
Amendment to the Claim Petition
(to amend issues(s) relating to this claim)
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 pro- cess and resolve your workers’ compensation dispute. The data will be used by department of labor and industry (department) staff who have author- ized 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 department’s 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 office of administrative hearings; the workers’ compensation court of appeals; the departments of revenue and health; and the workers’ compensation reinsurance association.
TO THE WORKERS’ COMPENSATION DIVISION, DEPARTMENT OF LABOR AND INDUSTRY
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 said date he/she was in the employ of 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 said injury or disease was as follows:
8.That said employer had knowledge or due notice of the occurrence of the injury, disease and/or death alleged in paragraph 3.
9.That on said date the employer was insured against compensation liability by the insurer or insurers indicated above.
10.That said employer and insurer are liable for the following:
DISABILITY BENEFITS
a. Temporary Total from
to
b. Temporary Partial from
c. Permanent Total from
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. That employee’s date of birth is
MN EC04 (4/12)
(over)
WHEREFORE, Employee petitions for an award against said Employer and Insurer for such benefits as provided for by the Workers’ Com- pensation Law of Minnesota.
EMPLOYEE SIGNATURE
ATTORNEY FOR EMPLOYEE SIGNATURE
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE
ATTORNEY REGISTRATION #
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.
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 postage 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
1.Failure to properly and fully fill out the claim petition, with appropriate documentation, in accordance with workers’ compensation rules of practice, shall not be considered proper filing under Minn. Stat. § 176.291 and 176.305. The Workers’ Compensation Division may refuse to accept a claim petition that lacks any of the following: employee’s name, date of injury, WID or social security number, or name of em- ployer/insurer.
2.The claim must be presented in terms of the Minnesota Workers’ Compensation Act.
3.If you have more defendants or more injuries than can be listed on the claim petition, it may be modified accordingly.
4.A doctor’s report supporting the claim MUST be filed with the claim petition.
5.If additional space is required to list all medical benefits claimed, or to list the names, addresses, etc., of third parties making payment of medical expenses or disability benefits, or there are other issues you wish to include on the petition, attached a separate sheet containing such information to each copy of the petition.
6.If no third party has made payment of any disability, rehabilitation or medical benefits, enter the word “NONE” in the space provided for the name and address in #11.
7.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 been filed with the Department of Labor and Industry.
8.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/Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ 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 SEN- TENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
443 Lafayette Road N. St. Paul, Minnesota 55155 www.dli.mn.gov
(651)284-5005
1-800-DIAL-DLI
TDD: (651) 297-4198
Instructions for Completing a Claim Petition Form
Use a Claim Petition if you want a hearing with a compensation judge to resolve a dispute where the insurer has denied primary liability for a claim or where the workers’ compensation insurer has accepted liability for the claim but is denying wage loss, permanency, and any medical or rehabilitation benefits.
Since the issues typically claimed on the Claim Petition may be complex, you may want to retain the services of an attorney to file the Claim Petition and represent you in the hearing. You will be able to find a workers’ compensation attorney by checking the Yellow Pages of your local phone directory or contacting the bar association in your county, which usually have referral services to direct you to an appropriate attorney.
#1-9 and 12 on the front of the form. Complete identifying information about employee, employer and the workers’ compensation claim itself.
10a-i. List the workers’ compensation benefits being claimed on the Claim Petition:
10a-d. List the wage loss and/or permanent partial disability benefits to which you feel that you are entitled to. Temporary total disability benefits are wage loss benefits you receive when you are off work completely due to the work injury. Temporary partial disability benefits are wage loss benefits you receive when you return to work at a lower wage, due to your injury. Permanent total disability benefits are wage loss benefits you get when you are permanently unable to return to work. Permanent partial disability benefits are monetary benefits you receive to compensate you for a permanent disability (when your doctor gives you a “rating”). Don’t worry about the monetary amounts being claimed; just try to list the dates you feel the benefits should have been paid. Attach supporting information, such as an off-work slip from your doctor or a Health Care Provider Report listing the percentage of disability to the whole body, in support of your claim.
10e-g. List any medical bills that are unpaid. Attach copies of the bills and supporting medical documentation. Attach additional sheets if necessary to list all the medical providers involved.
10h. Fill out this section if you are requesting the services of a Qualified Rehabilitation Consultant (QRC) to help you return to work.
11.If your medical treatment has been paid for by a health insurer or you have received short- or long- term disability benefits or unemployment compensation, list them here.
On the back of the form, put in your name, address and telephone number, complete with area code. If you are represented by an attorney, the attorney also gives his or her name, address, telephone number and registration number.
Trial Data section. Fill out this section to the best of your ability. Most hearings take 1/2 day. Specify where the hearing should be held - hearings are usually held in St. Paul, Duluth and Detroit Lakes. A settlement conference would be appropriate if you are interested in settling your claim through a process of negotiation. Witnesses, while not required, usually include the injured worker, co-workers who may have witnessed the workers’ compensation injury, QRC or vocational experts.
Affidavit of Significant Hardship. You may complete a form indicating that you have a significant financial hardship and are requesting an expedited hearing.
Instructions for MN EC04 (4/12)
Affidavit of Service section. Fill out the names and addresses of all the parties to the claim including employer(s), insurer(s), health care providers, any third party that has paid benefits under #11, etc. Fill out and sign the rest of this section in the presence of a Notary Public, who will stamp the form and attest to the true and correct nature of the copy sent through the U.S. mail.
Make a copy of the Claim Petition and each attachment for each of the parties indicated on the back of the form and mail it to each party. Keep a copy for yourself. Mail the original to the Department of Labor and Industry at the address listed on the top of the front of the form.
Additional instructions appear on the bottom of the back page.
If you have questions about how to complete the form, you may call the Alternative Dispute Resolution Unit at: (651) 284-5032 in the Minneapolis/St. Paul metropolitan area, or toll free at 1-800 342-5354 statewide.
Filling out the Minnesota EC04 form is an important step in the workers' compensation process. Here are some key takeaways to keep in mind: