Minnesota Employee's Claim PetitionMinnesota Employee's Claim PetitionMinnesota Employee's Claim Petition
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WID or SSN

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
Fax: 651-284-5731

DATE(S) OF CLAIMED INJURY

EC04

DO NOT USE THIS SPACE

PRINT IN INK or TYPE
ENTER DATES in MM/DD/YYYY FORMAT

EMPLOYEE

Reset
VS.

EMPLOYER(S)
AND
INSURER (S)

Employee’s Claim Petition
NOTE: File Petition and Affidavit of Service with the Division

Amended Claim Petition

AND

(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 process and resolve your workers’ compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if yo