Section 1 Workers’ Compensation Overview

Workers’ compensation is a no-fault system designed to provide benefits to employees injured as a result of their employment activities and to limit the liability of employers. Because it is a no-fault system, the employee does not need to prove negligence on the part of the employer in order to establish liability. It also means that the employer can not use negligence on the part of the employee as a defense to a claim. A work-related injury can be any condition that is caused, aggravated, or accelerated by employment activities. This includes traumatic injuries, gradual injuries, or occupational diseases. The employee needs to show only that the employment activities were a substantial contributing factor to the disability and/or need for medical care.

Basic Benefits
Workers’ compensation provides four basic types of benefits: • • • • wage loss compensation for the loss of use of a part of the body medical benefits vocational rehabilitation services

Each of the four types of benefits is discussed in more detail later.

Controlling Events
The Minnesota workers’ compensation statutes have undergone many revisions since the first law was enacted in 1913. It is very important for you to remember that the date of injury or death controls. This means the law in effect on the date of injury or death governs the type and amount of benefits that are payable to the employee or dependents of the employee. The wage on the date of injury also controls. This means the compensation rate is based on the gross weekly wage at the time of the injury and does not include any wage increases the employee might receive in the future. For example, an employee is injured on August 30 with earnings of $400.00 per week. A labor agreement allows employees a cost-of-living increase on November 1 of an additional $1.00 per hour. Calculate the compensation rate by using the wage of $400.00 per week, as that is the employee’s gross weekly wage at the time of injury.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

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Workers’ Compensation Overview

First Report of Injury (FROI)
The FROI is the reporting document for all work-related injury claims. It provides basic information necessary to start the claim. Deaths and serious injuries must be reported to the department within 48 hours. This can be done via telephone, facsimile, or electronic transmission, to be followed by the FROI. For all other injuries, where claimed disability exceeds three calendar days, the employer must get the FROI to their insurance company within 10 days of the first day of disability or the date they were aware of disability, whichever is later. Likewise, the insurance company must file the FROI with the department within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later. For self-insured employers, the FROI must be filed with the department within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later. The employee must be given a copy of the FROI along with the employee information sheet. Employees are not responsible for completing the FROI. The form should be completed accurately, completely, legibly, and timely by the employer. Again, it is very important that the FROI be submitted timely to avoid unnecessary penalties.

Other Time Requirements
For injuries with claimed disability extending more than three calendar days, the insurer must make a determination regarding liability within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later. This means the insurer must pay or deny a claim within 14 days. Failure to pay or deny within 14 days can result in penalties. Penalties regarding late filings, late payments, and late denials are discussed in the penalty section of the workbook. Once payment of wage loss benefits has begun, they can not be stopped without giving notice to the employee. The insurer must advise the employee of the specific type of benefit that they are proposing to discontinue, the reason for the discontinuance, and the facts (including medical reports) that support the reason. This is done by filing a Notice of Intention to Discontinue benefits form (NOID) or a Petition to Discontinue. Exception: If the insurer begins to pay benefits and then determines soon afterward that the injury is not compensable, the insurer may deny primary liability and discontinue benefits by filing a Notice of Insurer’s Primary Liability Determination (NOPLD) form within 60 days from the first day of disability or the date the employer was aware of disability, whichever is later. If more than 60 days have elapsed, the insurer must file an NOID to discontinue the benefits when denying primary liability.

Recovery of Overpayments
Overpayments of compensation are discussed in Minnesota Statutes §176.179. Under current law, if voluntary payments to an employee or an employee’s dependents are received in good faith, the insurer is not entitled to a refund if it is later determined the payments were made under a mistake of fact or law. If further benefits are owed for the same injury, the insurer is entitled to take a partial credit
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against future periodic benefits. The credit can not exceed 20% of the amount of the future benefits that otherwise would be payable. Future periodic benefits from which the insurer can take a credit include, but are not limited to, temporary total disability, temporary partial disability, economic recovery compensation, permanent partial disability, and permanent total disability. In situations where the employee is entitled to a lump sum payment, the insurer can take a credit for the entire overpayment from the lump sum due to the employee. If a compensation judge or the commissioner determines the compensation paid by mistake was not received in good faith, they may order reimbursement of the compensation. These instances occur if the payments are received by fraudulent means or if the employee knew the compensation was paid under mistake of fact or law. (See Minnesota Statutes §45.0135 and 60A.951 for the laws concerning fraud.) The insurer can not take a credit against medical expenses or penalty amounts payable to the employee.

Maximum Medical Improvement (MMI)
MMI is defined in Minnesota Statutes §176.011, Subd. 25. It is the date after which no further significant recovery from or lasting improvement to a personal injury can be reasonably anticipated, regardless of subjective complaints. Once the date of MMI has been validly determined, the insurer does not need to request any further determinations of MMI unless the employee becomes medically unable to continue working [see Minnesota Statutes §176.101, Subd. 1(e)(2)]. For purposes of commencement or recommencement of temporary total disability benefits only, a new period of maximum medical improvement begins when the employee becomes medically unable to continue working due to the injury. MMI determinations are important because the employee’s entitlement to future benefits can cease 90 days after the insurer serves a written report of MMI on the employee or as otherwise described in Minnesota Statutes §176.101, Subd. 1(e) to (l).

Waiting Period
Statutory Language
Below is the statutory language which defines the waiting period. 176.121 Commencement of Compensation. In cases of temporary total or temporary partial disability no compensation is allowed for the three calendar days after the disability commenced, except as provided by Minnesota Statutes §176.135, nor in any case unless the employer has actual knowledge of the injury or is notified thereof within the period specified in Minnesota Statutes §176.141. If the disability continues for ten calendar days or longer, the compensation is computed from the
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commencement of the disability. Disability is deemed to commence on the first calendar day or fraction of a calendar day that the employee is unable to work.

Waiting Period Application
Here are the important elements in applying the waiting period: • • • The waiting period is counted in consecutive calendar days, not work days. The first day of disability is the first day of the waiting period. Any disability (claimed lost time or wages), including a fraction of a day of disability, is considered the first day of disability regardless of whether the employee is paid in full by the employer for that day. Temporary partial disability, including time lost from work to obtain medical treatment for a work related injury, is considered a day in which there is disability. If there is disability on the 10th calendar day or beyond (from the first day of disability), compensation is owed from the first day of disability. If the only disability beyond the waiting period is for non-scheduled work days, generally no compensation is owed for those non-work days. Counting the waiting period and paying benefits for the disability are separate issues. The claim must be reported to the department and action taken within the time frames previously described if the claimed disability exceeds the waiting period, even if the insurer is not making payment for the disability.

• • •

Waiting Period Examples:
For the following examples, the employee works Monday through Friday. • First day of disability is Friday, March 4, 2005, and return to work date without disability is March 7, 2005. The waiting period is March 4th through March 6th. The FROI does not need to be filed with the department and the insurer does not owe compensation, as the only disability occurred within the waiting period. First day of disability is Friday, March 4, 2005, and return to work date without disability is March 9, 2005. The waiting period is March 4th through March 6th, so the FROI needs to be filed with the department and timely payment or denial must occur. Compensation might be due for March 7th and March 8th. First day of disability is March 1, 2005, and return to work date without disability is March 15, 2005. The FROI needs to be filed with the department and timely payment or denial must occur. Compensation for the entire period from March 1st through March 14th might be due, as there is disability on or after the 10th calendar day from March 1st (March 10th).

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First day of disability is March 1, 2005, and return to work date without disability is March 2, 2005. The employee again has disability beginning on March 7, 2005, and another return to work date without disability on March 10, 2005. The FROI needs to be filed with the department and timely payment or denial must occur as the disability extends beyond the waiting period, March 1st through March 3rd. Compensation might be due for March 7th through March 9th. First day of disability is March 1, 2005, and return to work date without disability is March 3, 2005. The employee again has disability beginning March 10, 2005, and another return to work date without disability on March 15, 2005. The FROI needs to be filed with the department and timely payment or denial must occur as the disability extends beyond the waiting period, March 1st through March 3rd. Both periods of disability (March 1st and March 2nd and March 10th through March 14th) might be due, as there is disability on or after the 10th calendar day from March 1st (March 10th).

For the following example, the employee only works Saturdays and Sundays. • First day of disability is Saturday, March 5, 2005, and return to work date without disability is Saturday, March 12, 2005. The waiting period is March 5th through March 7th. The FROI needs to be filed with the department and timely action must occur even though compensation is probably not due as March 8th through March 11th are non-work days.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

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Waiting Period – Exercise 1A
1. An employee who works Monday through Friday was injured on February 7, 2005. The employee lost one hour from work on the date of injury and remained off work through February 15, 2005. The employee returned to work on February 16, 2005. What are the dates of the waiting period?

2.

An employee who works Monday through Friday was injured on March 4, 2005. The first day of disability was March 7, 2005, and the employee returned to work without disability on March 10, 2005. What are the dates of the waiting period? Are you required to report this claim to the department?

3.

An employee who works Monday through Friday was injured on April 8, 2005, and lost one hour of work on that date. The employer paid the employee full wages for the date of the injury. The employee returned to work without disability on April 14, 2005. For which dates do you possibly owe compensation?

4.

An employee who works Monday through Thursday was injured on May 5, 2005. The first day of disability wasn’t until May 16, 2005. The employee returned to work without disability on May 23, 2005. Disability began again on May 26, 2005, with a return to work without disability on May 30, 2005. All dates of disability were authorized by the treating doctor. What are the dates of the waiting period? Should the waiting period be paid?

5.

An employee who works Monday through Friday was injured on April 15, 2005, and lost three hours of work on the date of injury. The employer paid full wages for the date of the injury. The employee returned to work without disability on April 25, 2005. All disability was authorized by the treating doctor. What are the dates of the waiting period? Should the waiting period be paid?

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Liability Determinations
The NOPLD form is used to notify the employee (or heirs/dependents of an employee), the employer, and the department of the insurer’s position regarding primary liability on the claim, including specific details of the accepted or denied claim. It is important to remember that this form could be completed several different times on the same claim to reflect changes in the insurer’s position or changes in the specific details of the claim. These subsequent filings of the form would be considered amended NOPLD forms. In addition, this form outlines the employee’s rights and responsibilities. The NOPLD form is used to convey to all parties on all claims (with claimed disability that exceeds the waiting period) what action the insurer is initially taking on the claim. In most situations it is filed only once on a claim. However in certain circumstances it can be filed multiple times. The following are some of the examples where this might occur: • • When the insurer initially denies primary liability, but later accepts liability. When the insurer initially accepts a claim and pays wage loss benefits, but later denies primary liability within 60 days per Minnesota Statutes §176.221, Subd. 1. When the insurer accepts a claim on which there are no wage loss benefits initially paid, but later pays wage loss benefits voluntarily.

Investigation Tips
An investigation or a good faith effort to attempt an investigation of the claim must be done on each claim before an informed decision can be made regarding acceptance or denial of liability. What is considered an adequate investigation can vary depending upon the type of injury, whether it was witnessed, and if the injury was caused, accelerated, or aggravated by the work activities. At times it is not necessary to talk to the employee prior to making a determination. Other times it might not be necessary to reach the employee’s supervisor prior to making a determination.

Acceptance of Liability
(with payment of wage loss benefits) After completing an investigation, if the injury and the claimed wage loss benefits are determined to be compensable, the insurer checks Box 1 on the NOPLD form. The payment must be made within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later, to be considered timely. Complete all boxes that are applicable to the injury. If payments are continuing, indicate the day of the week that further checks will be issued and how often. Be sure to include the dates the payment covers, not just the amount of time covered. For example, state the period is May 2, 2005, through May 8, 2005, not one week.
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Workers’ Compensation Overview

Partial Acceptance of Liability
(without payment of wage loss benefits) For injuries where there is no claimed disability beyond the waiting period, the FROI and NOPLD are not required to be filed with the department. An exception to this occurs when the FROI showing possible disability beyond the waiting period has already been filed with the department. In these situations, Box 2A should be used on the NOPLD form to explain that liability for the injury is accepted but that the disability did not exceed the waiting period. For injuries where there is claimed disability beyond the waiting period, if the insurer has determined that an injury is compensable but they are denying responsibility for the wage loss benefits, an NOPLD must be filed with the department. This is frequently called a partial denial of liability and the insurer checks Box 2C on the NOPLD form. The NOPLD must be served within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later, to be considered timely. The reason given for denying payment of the wage loss must be specific and not frivolous. Again, remember that this is a denial of liability and it must be in compliance with all applicable statutes, rules, and case law.

Denial of Primary Liability
A primary denial of liability is a determination that the injury is not compensable under Minnesota workers’ compensation statutes and rules. It informs the employee and the department that the insurer is not voluntarily paying any benefits because they do not believe the circumstances surrounding the injury indicate the claim is compensable. Before a determination is made, the insurer must complete or at least attempt to complete an investigation of the claim. There can be many questions that need to be considered, two of which are: • • Did something happen at work and/or is it work related? Is it covered under Minnesota workers’ compensation statutes and rules?

If the insurer is denying primary liability, an NOPLD form must be filed with the department, for any claim where the employee has claimed disability that exceeds the waiting period. The insurer checks Box 3 on the NOPLD form. The NOPLD must be served within 14 days of the first day of disability or the date the employer was aware of disability, whichever is later, to be considered timely. Denials must meet the criteria in the statutes and rules in order to avoid being considered non-specific or frivolous. The insurer must attach supporting documentation, as necessary. If the denial is based on medical information, the insurer must attach a copy of the medical report. If the medical information was obtained over the telephone, in addition to stating the substance of the conversation, the name of the health care provider, along with the date the telephone information was obtained, should be stated on the form.
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In order for a denial to be considered specific, the reasons for the denial must be clear and state a specific reason in language easily readable to a person of average intelligence and education. Remember both the employee and the department must be able to easily understand why the claim was denied. In order for a denial not to be considered frivolous, the reason for denial must state a legal basis and provide an accurate statement of facts concerning the claimed injury. It must also show that an investigation has been completed or that a good faith effort to investigate has been attempted. Presently, the department reviews denials for: • • • • • proper wording inclusion of reported facts surrounding the injury extent of the investigation performed by the insurer a legal basis for the denial as stated by the insurer inclusion of supporting documentation, as necessary

Failure to give a specific and non-frivolous reason for the denial or failure to investigate or attempt to investigate a claim can be grounds for assessment of frivolous1 and/or non-specific denial2 penalties. Minnesota statutes and rules outline some basic information regarding what are considered frivolous and nonspecific denials.

Statutory Language and Rule Cites
For additional information regarding liability determinations see Minnesota Statutes §176.194, Subd. 3(4) and Subd. 4, 176.221, Subd. 3a, and 176.225, Subd. 1. Also see Minnesota Rules Parts 5220.2570, Subp. 10B, 5220.2540, Subp. 4, 5220.2760, Subp. 1C, and 5220.2770, Subp. 2E.

1

Frivolous Denials Minnesota Rules Part 5220.2570, Subp. 10B defines a frivolous denial as one which: (1) does not state facts indicating that an investigation has been completed or that a good faith effort to investigate has been attempted; or (2) states a basis which is a clearly inaccurate statement of fact or the applicable law.

2

Non-specific denials Minnesota Rules Part 5220.2570, Subp. 2E gives information regarding what is not considered a specific denial. In part the rule states: ... A denial which states only that the injury did not arise out of and in the course and scope of employment or that the injury was denied for lack of a medical report, for example, is not specific within the meaning of this item; ...

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Workers’ Compensation Overview

Liability Determination – Exercise 1B
Part 1 See the FROI for Susan Jones. The employee normally works Monday through Friday. You have been unable to reach the employee. Upon contacting the employer, you are told that the injury was witnessed and the supervisor took the employee to a local hospital for immediate medical attention. The employer also states that the employee has not returned to work yet and according to medical information, should stay off work at least until the follow-up appointment on February 11th. 1. Should liability be accepted or denied? Why?

2.

What forms need to be filed?

3.

What boxes need to be checked on the NOPLD?

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Part 2 See the FROI for Sam Smith. This claim has been assigned to you. 1. What steps do you need to take to determine if the claim is compensable?

2.

What questions should you ask of the employer/employee?

3.

If the treating doctor said she had been treating the employee since he hurt his back three weeks ago lifting a refrigerator at home, would this affect your investigation and determination of liability?

4.

Based on your determination, what box needs to be checked on the NOPLD?

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Workers’ Compensation Overview

Part 3 See the FROI for Andrew Anderson. You have tried on three occasions to reach the employee and left messages twice. The employee hasn’t called you back. The employer tells you the employee was returning from a work-related training seminar when the vehicle accident occurred. The employee was taken from the scene of the accident by ambulance. You contact the treating doctor listed on the FROI. The doctor tells you the records have not been transcribed yet. 1. Should primary liability be accepted to denied? Why?

2.

What boxes should be checked on the NOPLD?

3.

After paying benefits for four weeks, the employee tells you he stopped at his parent’s house on his way back from training. The police report verifies that the accident occurred two blocks from his parent’s home. What should you do?

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Basic Adjusters’ Training Guide MN Department of Labor and Industry

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4305 (651) 284-5030

First Report of Injury
See Instructions on Reverse Side PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. 2. OSHA Case #
F R 0 1

1. EMPLOYEE SOCIAL SECURITY #

DO NOT USE THIS SPACE
5. Time employee began work on date 7 :30 of injury 7. Gender 8. Marital Status 10. Home phone # M F

555-55-5555 02/03/2005

01
am am pm Married Unmarried 11. Date of birth

3. DATE OF CLAIMED INJURY 4. Time of injury 6. EMPLOYEE Name (last, first, middle)

8:30

pm

JONES, SUSAN M
9. Home Address

1600 MAIN ST
City State Zip Code

(651) 666-6666
12. Occupation

02/12/1969
13. Regular department 14. Date hired

HOMETOWN
15. Average weekly wage

MN
16. Rate per hour

55155

MACHINE OPERATO MOLDING
18. Days per week

07/01/1992
Full time Seasonal Part time Volunteer No

17. Hours per day

$400.00
20. Weekly value of: Meals

$10.00
Lodging

8.00
2 Income
nd

5

19. Employment Status 21. Apprentice

Yes

22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: “Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”

Caught left hand in molding machine

23. What was the injury or illness (include the part(s) of body)? Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.

Amputation of left index finger
25. Did injury occur on employer’s premises? Yes No If no, indicate name and address of place of occurrence

Molding machine
26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOI) Yes No No lost time on DOI

02/03/2005
28. Date employer notified of injury

29. Date employer notified of lost time

02/03/2005
30. Return to work date 31. Date of death

02/03/2005

32. TREATING PHYSICIAN (name, address, and phone)

33. HOSPITAL/CLINIC (name and address) (if any)

34. Emergency Room Visit Yes 35. Overnight in-patient Yes No No

REGIONS HOSPITAL ER ST PAUL, MN

36. EMPLOYER Legal name

37. EMPLOYER DBA name (if different)

ABC MACHINE
38. Mailing address 39. Employer FEIN 40. Unemployment ID#

2000 RIVER ST
City State Zip Code 41. Employer’s contact name and phone #

HOMETOWN
42. Physical address (if different)

MN

55155

JOHN JOHNSON, SAFETY OFFICE
43. Witness (name and phone)

(651) 444-4444 (651) 333-3333

MIKE SMITH
City State Zip Code 44. NAICS code

45. Date form completed

02/03/2005
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one) Insurer TPA 52. CA address

YOUR INSURANCE COMPANY
47. Insured legal name

48. Policy # or self-insured certificate #

City

State

Zip Code

49. Insurer FEIN

50. Date insurer received notice

53. CA FEIN

54. Claim #

02/08/2005
MN FR01 (02/06)

123123
Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)

GENERAL INSTRUCTIONS TO THE EMPLOYER Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a workrelated injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary. If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-2845731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence. Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employee’s local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department’s web site at www.doli.state.mn.us. Employees are not responsible for completing this form. SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM • • • • • • • • • • • Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301. Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved. Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. Item 28: Fill in the date you first became aware of the injury or illness. Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury. Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to work, fill in the date and notify your insurer if the employee misses time due to this injury after that date. Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on Employer ID Number under Business. Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are both assigned by the Minnesota Unemployment Insurance Program (651-296-6141). Items 46-54: Your insurer or claims administrator will complete this information. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn. Stat. § 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department. • Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public selfinsured company or group. • Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number. • Item 49: Fill in the insurer’s Federal Employment ID number (FEIN) number. • Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the “Insurer” or “TPA” box. • Item 53-54: Fill in the claims administrator’s FEIN and claim number. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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 SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4305 (651) 284-5030

First Report of Injury
See Instructions on Reverse Side PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. 2. OSHA Case #
F R 0 1

1. EMPLOYEE SOCIAL SECURITY #

DO NOT USE THIS SPACE
5. Time employee began work on date of injury 7. Gender 8. Marital Status 10. Home phone # M F

666-66-6666
3. DATE OF CLAIMED INJURY 4. Time of injury am pm am pm Married Unmarried 11. Date of birth

03/02/2005

6. EMPLOYEE Name (last, first, middle)

SMITH, SAMUEL S
9. Home Address

320 1ST AVE S
City State Zip Code

(651) 777-7777
12. Occupation

08/08/1955
13. Regular department 14. Date hired

HOMETOWN
15. Average weekly wage

MN
16. Rate per hour

55155

LABORER
18. Days per week

BOX DEPT

06/22/1975
Full time Seasonal Part time Volunteer No

17. Hours per day

$600.00
20. Weekly value of: Meals

$15.00
Lodging

10.00
2 Income
nd

4

19. Employment Status 21. Apprentice

Yes

22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: “Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”

Normal job duties, complained last week or so

23. What was the injury or illness (include the part(s) of body)? Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.

Lower back pain
25. Did injury occur on employer’s premises? Yes No If no, indicate name and address of place of occurrence 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOI) Yes No No lost time on DOI

03/03/2005
28. Date employer notified of injury

29. Date employer notified of lost time

03/03/2005
30. Return to work date 31. Date of death

03/03/2005

32. TREATING PHYSICIAN (name, address, and phone)

33. HOSPITAL/CLINIC (name and address) (if any)

34. Emergency Room Visit Yes 35. Overnight in-patient Yes No No

DR JOHNSON

HEALTHPARTNERS HOMETOWN, MN

36. EMPLOYER Legal name

37. EMPLOYER DBA name (if different)

DO BOX US IN
38. Mailing address 39. Employer FEIN 40. Unemployment ID#

555 SOMEWHERE
City State Zip Code 41. Employer’s contact name and phone #

ST PAUL
42. Physical address (if different)

MN

55155

I M SAFETY, CONTROLLER
43. Witness (name and phone)

(651) 888-8888

NONE
City State Zip Code 44. NAICS code 45. Date form completed

03/10/2005
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one) Insurer TPA 52. CA address

YOUR INSURANCE COMPANY
47. Insured legal name

48. Policy # or self-insured certificate #

City

State

Zip Code

49. Insurer FEIN

50. Date insurer received notice

53. CA FEIN

54. Claim #

03/15/2005
MN FR01 (02/06) Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)

GENERAL INSTRUCTIONS TO THE EMPLOYER Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a workrelated injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary. If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-2845731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence. Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employee’s local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department’s web site at www.doli.state.mn.us. Employees are not responsible for completing this form. SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM • • • • • • • • • • • Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301. Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved. Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. Item 28: Fill in the date you first became aware of the injury or illness. Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury. Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to work, fill in the date and notify your insurer if the employee misses time due to this injury after that date. Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on Employer ID Number under Business. Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are both assigned by the Minnesota Unemployment Insurance Program (651-296-6141). Items 46-54: Your insurer or claims administrator will complete this information. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn. Stat. § 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department. • Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public selfinsured company or group. • Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number. • Item 49: Fill in the insurer’s Federal Employment ID number (FEIN) number. • Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the “Insurer” or “TPA” box. • Item 53-54: Fill in the claims administrator’s FEIN and claim number. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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 SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4305 (651) 284-5030

First Report of Injury
See Instructions on Reverse Side PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. 2. OSHA Case #
F R 0 1

1. EMPLOYEE SOCIAL SECURITY #

DO NOT USE THIS SPACE
5. Time employee began work on date of injury 7. Gender 8. Marital Status 10. Home phone # M F

444-44-4444
3. DATE OF CLAIMED INJURY 4. Time of injury am am pm Married Unmarried 11. Date of birth

04/26/2005

3:00

pm

6. EMPLOYEE Name (last, first, middle)

ANDERSON, ANDREW A
9. Home Address

1 MAIN ST
City State Zip Code

(612) 999-9999
12. Occupation

04/15/1950
13. Regular department 14. Date hired

MINNEAPOLIS
15. Average weekly wage

MN
16. Rate per hour

AUDITOR
17. Hours per day 18. Days per week

01/01/1988

$2,000.00
20. Weekly value of: Meals Lodging 2 Income
nd

5

19. Employment Status 21. Apprentice

Full time Seasonal Yes

Part time Volunteer No

22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: “Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”

Vehicle accident

23. What was the injury or illness (include the part(s) of body)? Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.

Fractured left leg, neck pain, bruises
25. Did injury occur on employer’s premises? Yes No If no, indicate name and address of place of occurrence 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOI) Yes No No lost time on DOI

04/26/2005
28. Date employer notified of injury

29. Date employer notified of lost time

HWY 394 & HWY 100

04/27/2005
30. Return to work date 31. Date of death

04/27/2005

32. TREATING PHYSICIAN (name, address, and phone)

33. HOSPITAL/CLINIC (name and address) (if any)

34. Emergency Room Visit Yes 35. Overnight in-patient Yes No No

METHODIST HOSPITAL ST LOUIS PARK, MN

36. EMPLOYER Legal name

37. EMPLOYER DBA name (if different)

XYZ ENTERPRISES
38. Mailing address 39. Employer FEIN 40. Unemployment ID#

1234 ANY PL
City State Zip Code 41. Employer’s contact name and phone #

ST PAUL
42. Physical address (if different)

MN

NEIL NUMBERS, OWNER
43. Witness (name and phone)

(651) 999-9999

UNKNOWN
City State Zip Code 44. NAICS code 45. Date form completed

05/02/2005
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one) Insurer TPA 52. CA address

YOUR INSURANCE COMPANY
47. Insured legal name

48. Policy # or self-insured certificate #

City

State

Zip Code

49. Insurer FEIN

50. Date insurer received notice

53. CA FEIN

54. Claim #

05/05/2005
MN FR01 (02/06) Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)

GENERAL INSTRUCTIONS TO THE EMPLOYER Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a workrelated injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary. If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-2845731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence. Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employee’s local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department’s web site at www.doli.state.mn.us. Employees are not responsible for completing this form. SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM • • • • • • • • • • • Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301. Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved. Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. Item 28: Fill in the date you first became aware of the injury or illness. Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury. Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to work, fill in the date and notify your insurer if the employee misses time due to this injury after that date. Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on Employer ID Number under Business. Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are both assigned by the Minnesota Unemployment Insurance Program (651-296-6141). Items 46-54: Your insurer or claims administrator will complete this information. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn. Stat. § 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department. • Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public selfinsured company or group. • Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number. • Item 49: Fill in the insurer’s Federal Employment ID number (FEIN) number. • Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the “Insurer” or “TPA” box. • Item 53-54: Fill in the claims administrator’s FEIN and claim number. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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 SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.