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The Minnesota EC04 form plays a critical role within the frame of workers' compensation proceedings, serving as a vital document for individuals seeking to assert their rights to benefits following a workplace injury or illness. At its heart, this form functions as a Claim Petition, designed to facilitate the resolution of disputes over workers' compensation, whether arising from an insurer's denial of primary liability or disagreements over the extent and coverage of benefits claimed by an employee. The detailed structure of the form demands comprehensive information, including personal identifiers, employer and insurer details, specifics of the claimed injury or illness, as well as the nature and extent of benefits sought, ranging from disability to medical and rehabilitation benefits. Significantly, its sections underscore the critical step of establishing the basis for claims to wage loss, permanency, and medical or rehabilitation support, backed by documentary evidence such as medical reports. Instructions embedded within the document elucidate procedures for filing, emphasizing the value of legal representation in navigating the complexities of workers’ compensation claims. Moreover, the form alerts filers to the legal implications of fraudulent claims, incorporating preventative warnings in alignment with Minnesota law. This document not only stands as a tool for initiating legal action but also functions within the broader system of workers' compensation to ensure equitable resolution of disputes, underscoring the state's commitment to protecting workers while promoting a clear and effective process for addressing their compensation claims.

Minnesota Ec04 Example

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)

AND

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

 

 

 

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. 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

 

 

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

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:

No

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.

↓ Minnesota Ec04 File

Form Characteristics

Fact Name Description
Purpose of the EC04 Form The Minnesota EC04 form is used for employees to file a claim petition with the Workers' Compensation Division for disputes involving denial of liability for a claim or denial of benefits like wage loss, permanency, and medical or rehabilitation benefits.
Governing Law The form and claims are governed by the Workers' Compensation Law of Minnesota, which outlines the benefits workers are entitled to and the procedure for disputes.
Required Information Employees must provide detailed information including personal identification, employer and insurer information, details of the claimed injury or occupational disease, and the benefits being claimed.
Benefits Claimed The form allows for the claim of various benefits including temporary total disability, temporary partial disability, permanent total disability, permanent partial disability, medical benefits, and rehabilitation benefits.
Affidavit of Service A completed affidavit of service is necessary to confirm that a copy of the claim petition has been served to all relevant parties as required by the Workers’ Compensation Division’s rules.
Privacy Notice The form advises that private or confidential data supplied will be used for processing the workers’ compensation dispute and may be shared with authorized parties as per state investigations and statistics.
Filing Procedures Properly completing and filing the EC04 form according to the prescribed instructions, including attaching necessary documentation like the doctor's report, is essential for the proper filing of a claim.
Penalty for Fraud Misrepresenting, misstating, or failing to disclose any material fact for receiving workers' compensation benefits fraudulently is considered theft and is subject to legal penalties under Minnesota law.

Steps to Writing Minnesota Ec04

When you've decided to proceed with a workers' compensation claim in Minnesota due to a dispute over denied benefits or disagreements about the benefits received, the EC04 form is a crucial step in the process. This form is your way to officially present your side to the Minnesota Department of Labor and Industry. You're advocating for yourself, asking for a resolution that aligns with your needs and rights under workers' compensation law. Completing this form clearly and thoroughly is your first step in the process toward a hearing that could adjust your compensation.

Here’s how to methodically fill out the EC04 form:

  1. Start by writing your Worker Identification (WID) or Social Security Number (SSN) at the top of the form, along with the date(s) of the claimed injury.
  2. Fill in sections 1 through 9, and 12 on the front of the form. Include your personal address, the address of your employer, details of the injury or occupational disease, your employment status, weekly wage at the time of injury, and the nature of the injury or disease. Also, include information that your employer was aware of the injury, the employer’s insurance details, and your date of birth.
  3. Under the section for DISABILITY BENEFITS (items 10a to 10d), list the types and periods of wage loss or permanent disability benefits you believe you are entitled to, but do not worry about specifying monetary amounts here.
  4. For MEDICAL BENEFITS (items 10e to 10g), list any medical treatments received and their associated costs that have not been reimbursed by the insurer.
  5. Under REHABILITATION BENEFITS (item 10h), describe any vocational rehabilitation services you need or are receiving. If additional space is needed for any section, attach a separate sheet.
  6. If applicable, under OTHER (item 10i), detail any additional benefits or aspects of your claim not covered in previous sections.
  7. In section 11, name any third party that has paid for disability, medical benefits, or income maintenance related to your claim. If no third party payments have been made, write "NONE".
  8. On the back of the form, complete your personal contact information. If you have legal representation, your attorney should also fill in their contact details and registration number.
  9. In the TRIAL DATA section, provide information about your request for a settlement conference or trial, including estimated duration, preferred location, and the number of witnesses you might present.
  10. If necessary, complete the AFFIDAVIT OF SIGNIFICANT FINANCIAL HARDSHIP to request an expedited hearing due to financial difficulties.
  11. In the AFFIDAVIT OF SERVICE section, list the names and addresses of everyone who needs to receive a copy of this form—including employer(s), insurer(s), and any third parties mentioned in section 11. Sign this section in the presence of a Notary Public. The Notary will validate your signature and apply their official seal.
  12. Make a copy of the completed form and any attachments for your records, as well as for each party listed in the AFFIDAVIT OF SERVICE. Send the original form to the Department of Labor and Industry at the address provided on the form, and mail copies to all other parties.

Once the EC04 form is filled out and submitted along with any necessary attachments, your claim petition will be reviewed by the Department of Labor and Industry. Keep a close eye on any correspondence from them, as it may contain important information about your claim or requests for additional information. Accuracy and thoroughness in completing this form can significantly contribute to the efficient processing of your claim.

Listed Questions and Answers

  1. What is the purpose of the Minnesota EC04 form?

    The Minnesota EC04 form is used to file a worker’s compensation claim petition with the Minnesota Department of Labor and Industry. This form is necessary when an injured worker seeks a hearing with a compensation judge because their workers’ compensation insurer has either denied primary liability for the claim or accepted liability but is denying benefits like wage loss, permanency, and medical or rehabilitation benefits. Filling out this form accurately helps in presenting your case for the benefits you believe you are entitled to due to a work-related injury or illness.

  2. Who needs to fill out the Minnesota EC04 form?

    This form should be filled out by employees who have sustained a personal injury or occupational disease that they believe is related to their job and their claim has been disputed or partially denied by their employer’s workers’ compensation insurer. If you are in this situation and want to have your dispute heard by a compensation judge, filling out and submitting the EC04 form starts that process.

  3. What information do I need to complete the EC04 form?

    To properly fill out the EC04 form, you will need to provide detailed information about yourself (the employee), your employer, and the insurer. This includes your full name, address, the dates of the claimed injury or disease, details of your employment at the time of the injury (such as wages), and the nature of your injury or disease. Additionally, you must provide a breakdown of the workers’ compensation benefits you are claiming, including disability, medical, and rehabilitation benefits. If your medical treatment was covered by another insurer or you received any disability benefits from another source, these details should also be included. It’s also crucial to attach any relevant documentation, such as medical reports and bills, to support your claim.

  4. How and where do I submit the completed EC04 form?

    Once you have completed the EC04 form and attached any necessary documentation, you must serve a copy of the petition on each adverse party. This includes your employer(s), their insurer(s), any third parties named in section 11 of the form, and possibly the Special Compensation Fund, if applicable. Each party should receive the petition either by first class mail or in person. After serving the petition to all necessary parties, mail the original document to the Minnesota Department of Labor and Industry Workers' Compensation Division at the address provided on the top of the form. Remember to keep a copy of the form and all attachments for your records. For additional assistance or if you have questions about completing the form, you may contact the Alternative Dispute Resolution Unit using the provided phone numbers.

Common mistakes

  1. Not providing complete identifying information on the form, specifically items #1-9 and #12. It's crucial to include full details about the employee, employer, and the workers’ compensation claim, such as the employee's name, date of injury, WID or social security number, and the name of the employer/insurer.

  2. Failure to detail the workers' compensation benefits being claimed in sections 10a-i of the form. Many individuals forget to list the wage loss and/or permanent partial disability benefits to which they believe they are entitled, along with attaching supporting documents, such as an off-work slip from a doctor or a Health Care Provider Report listing the percentage of disability.

  3. Omitting unpaid medical bills in section 10e-g, which requires specifics about any medical expenses incurred but not yet paid. It's essential to attach copies of these bills and any supporting medical documentation, yet this step is often overlooked.

  4. Incorrectly filling out section 11, which is meant for stating any third party that has paid disability or medical benefits. Some petitioners incorrectly leave this blank or do not include the name and address of the third party, if applicable, which can cause delays.

  5. Failing to properly complete the Affidavit of Service section on the back of the form. This includes not listing all parties to the claim, such as employers, insurers, and health care providers, or not correctly signing the section in the presence of a Notary Public. This mistake can result in the form being incorrectly processed or not accepted at all.

These common mistakes can lead to the refusal of the claim by the Workers’ Compensation Division or significantly delay the process. Therefore, attention to detail and thorough review before submission is paramount to prevent these errors.

Documents used along the form

When navigating through the process of a workers' compensation claim in Minnesota, it's important to be aware of the different forms and documents that might be involved alongside the Minnesota EC04 form, commonly known as the Employee's Claim Petition. These documents vary in purpose, from providing detailed medical information to formalizing the claimant's appeal against decisions related to their case. Being familiar with these additional documents ensures a more comprehensive understanding of the case and assists in a smoother claims process.

  • First Report of Injury (FROI): This document initiates the claim process. It details the when, where, and how the injury occurred, providing the workers' compensation insurer with initial notification.
  • Health Care Provider Report: Medical professionals complete this form to offer a detailed account of the employee's injury or illness, including diagnosis and forecasted treatment plans.
  • Rehabilitation Request: If an injured employee needs help returning to work, this document requests assistance from a Qualified Rehabilitation Consultant (QRC).
  • Notice of Intention to Discontinue Benefits (NOID): Employers or insurers use this form to notify an employee of the intent to stop their workers' compensation benefits.
  • Objection to Discontinuance: If an employee disagrees with the decision to discontinue benefits, they can file this form to challenge the termination.
  • Employee's Wage Statement: This document is necessary for calculating compensation benefits, requiring details on the employee's earnings before the injury.
  • Dependency Benefit Application: In cases of fatal injuries, dependents use this form to claim death benefits from the workers' compensation coverage.
  • Request for Formal Hearing: If an employee or their representative disagrees with any decisions or needs to resolve disputes related to their claim, this document formally requests a hearing before a workers' compensation judge.

Understanding and gathering the necessary forms and documents is a critical step in successfully navigating a workers' compensation claim. Each document serves a specific role in the process, offering a structured way to present evidence, disclose medical information, and dispute or appeal decisions. Familiarity with these forms ensures that all relevant information is accurately conveyed, aiding all parties involved in reaching an appropriate resolution.

Similar forms

The EC04 form, primarily utilized in the workers' compensation domain within Minnesota, shares similarities with the First Report of Injury (FROI) form that employers must submit immediately after an employee's injury or occupational disease is reported. Both documents are pivotal in the initial stages of a claim, providing essential details about the incident, such as the date of injury, employee information, and the employer's details. The key similarity lies in their role in kickstarting the workers’ compensation process by officially documenting the incident, thereby notifying relevant parties, including insurance providers and state departments, about the occurrence of a workplace injury.

Another document closely related to the EC04 form is the Application for Mediation Services. This application is crucial when disputes arise regarding the claim, such as disagreements over benefits due. Like the EC04, it necessitates detailed information about the claim, but its focus shifts towards resolving disputes through mediation instead of litigation. Both documents require precise information about the injury and the parties involved, working towards the goal of benefit resolution, but through different mechanisms—litigation for the EC04 and mediation for the Application for Mediation Services.

The Affidavit of Service, a component embedded within the EC04 form itself, is a standalone document integral to many legal processes. It serves a crucial function across different legal filings, confirming that documents have been properly served to all relevant parties. Although it is just a part of the EC04, detailing how the claim petition was delivered, its presence underscores the importance of procedural correctness in legal processes. By ensuring documents are correctly served, it upholds the integrity and efficacy of the legal proceedings, mirroring its role in other legal contexts outside workers' compensation.

Lastly, the Request for Formal Hearing is akin to the EC04 form in its utility for escalating workers' compensation issues to a formal setting where disputes can be adjudicated. Whereas the EC04 form may initiate the claim process or amend it, a Request for Formal Hearing seeks a judicial venue to resolve disputes that could not be settled through initial claims or mediation. Both documents prepare the groundwork for bringing unresolved issues before a judge, although they are utilized at different stages of the dispute resolution process.

Dos and Don'ts

Filling out the Minnesota EC04 form correctly is essential for a smooth process in resolving workers' compensation disputes. To assist with this, here is a list of things you should and shouldn't do when completing the form:

  • Do print in ink or type to ensure that all information is clear and legible.
  • Do enter dates in the MM/DD/YYYY format, as this is crucial for the accuracy of your claim.
  • Do ensure that the claim is presented in terms of the Minnesota Workers' Compensation Act, reflecting an understanding of the law.
  • Do attach a doctor’s report supporting the claim, as this is a necessary piece of documentation.
  • Don't leave any required fields blank. If a question does not apply to your situation, enter "NONE" to indicate this.
  • Don't forget to attach a separate sheet if additional space is needed for medical benefits claimed or to list third parties.
  • Don't neglect to attach a copy of the First Report of Injury if the employee has fewer than three days of lost time from work, unless already filed with the Department of Labor and Industry.
  • Don't fail to serve a copy of the petition on each adverse party, as proper notification is key to the legal process.

Ensuring all sections are completed accurately and adhering to these guidelines can help avoid delays or issues with your workers' compensation claim. Remember, it's also beneficial to consult with a legal professional if you have any questions or concerns about filling out the form.

Misconceptions

There are several misconceptions about the Minnesota EC04 form, which is vital in the workers' compensation claims process. Understanding these misconceptions can help ensure that employees correctly navigate their claims, leading to a smoother resolution of their disputes. Below are six common misunderstandings and clarifications regarding the EC04 form:

  • It is only for initial claims. The Minnesota EC04 form is not solely for initial workers' compensation claims. It can also be used for amended claims if there's a need to update party information or injury dates, and for amending issues related to the claim, making it an integral part of ongoing claims management.
  • Filling out the form secures benefits immediately. Simply completing and submitting the EC04 form does not guarantee immediate eligibility for workers' compensation benefits. The claim undergoes evaluation, and benefits are awarded based on the merits of the case and the evidence provided.
  • The form can be submitted without detailed medical information. Contrary to this belief, the effectiveness of the claim partly hinges on the completeness of the medical information provided. A doctor’s report and other supporting documentation play crucial roles in substantiating the claim.
  • Personal details are optional. Every piece of personal and injury-related information requested on the form is crucial. The form requires comprehensive details to process and resolve your workers' compensation dispute effectively. Omitting details can lead to delays or denial of the claim.
  • The form is only necessary for disputed claims. While it's true the form is often used in the context of disputes, it's equally important for claims where liability is accepted but certain benefits are denied. The EC04 form allows for a structured process to present the claim for various benefits, including disputed ones.
  • There's no follow-up required after submission. After submitting the EC04 form, the claimant must remain proactive. This may involve attending hearings, providing additional documentation, or following up on the claim's status. It’s a continuous process that may require further actions from the employee.

Understanding these key aspects of the Minnesota EC04 form is essential for a proper approach to workers' compensation claims. Employees should ensure the completeness and accuracy of the information they provide and follow up on their claims process, possibly with the assistance of a legal professional, to navigate the complexities of workers' compensation successfully.

Key takeaways

Filling out the Minnesota EC04 form correctly is crucial for employees seeking to resolve workers' compensation disputes. Here are seven key takeaways for successfully completing and using this form:

  • Accuracy and Completeness: Make sure all information is accurate and complete. Missing details such as the employee’s name, date of injury, WID or Social Security Number, and name of employer/insurer could lead to the claim petition being rejected.
  • Attachments: Include all necessary attachments, like a doctor’s report supporting the claim, to substantiate the benefits being claimed. If additional space is needed for any section, attach separate sheets with the required information.
  • Claim Presentation: Present the claim in accordance with the Minnesota Workers’ Compensation Act. This means listing the workers' compensation benefits being claimed and providing evidence to support these claims.
  • Notice of Third Party Payments: If a third party has made payments for disability, medical, or rehabilitation benefits, their details must be included in the form. If no third party payments have been made, enter "NONE" where applicable.
  • Service of Petition: It's essential to serve a copy of the petition on each adverse party, including employers, insurers, and any third parties named in the petition. This can be done via first-class mail or in person.
  • Seek Legal Advice: Given the complexities involved in workers' compensation claims, consider consulting with an attorney. Attorneys can help ensure that the form is filled out correctly and represent you in hearings.
  • Keep Records: Make copies of the filled-out EC04 form and all attachments for your records and for each party involved in the claim. Mail the original form to the Department of Labor and Industry.

Remember, the EC04 form is a crucial document for pursuing workers' compensation claims in Minnesota. Taking the time to accurately and thoroughly complete the form and adhering to the procedural requirements can help streamline the resolution process.

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