Workers' Compensation Division. Minnesota Department of Labor and Industry.ARTICLE 15 - LEAVE BENEFITS AND WORKERS COMPENSATION BENEFITS . Protect your legal rights for workers comp benefits. There are deadlines, limits on benefits and guidelines which must be followed. Employee(s), Faculty and Faculty Member . Notification of claim for dependent's benefits fatality . 625, Saint Paul, Minnesota, as defined in Minnesota. Immediately upon receiving notice of injury, fill in the information above and give this form to the employee.
You must not delay in filing a claim if you believe a claim is justified for your employee; if a worker is injured or killed by their employer. Notice of Claim for dependent's benefits. NOTE: You may submit this form electronically using the link Employer(s) Name Employer Address of Work Phone Number of Owner/President City State Zip Code of County of Work State (if applicable) of Workers' Compensation Report Employee Information: Employee's Full Name, Full Address, Phone Number, Address of the Driver's License or Social Security Card, Date of Loss or Injury, Occupational Status, Type of Labor, Occupational Field, and Employee's Signature (if applicable). Filled out correctly, you will be issued Employer's Claim Number. Employer(s) may also provide you with a Proof Of Claim to use in the lawsuit. Employer(s) Information. Employer does not have to provide this information to Minnesota Department of Labor and Industry.
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