Worker's Comp Claim Kit.pdf - Frazee-Vergas Public Schools ...

What to do:
REPORTING A CLAIM
Time is critical when an
injury occurs
• Obtain medical treatment immediately
• Report the injury within 5 days to
BERKLEY RISK ADMINISTRATORS CO.:
• Provide the employee’s name, address & Social Security Number
• Provide the date of the injury
• Provide employer’s full name
• Provide insurer’s name -> Riverport Insurance Company
• Provide details about the accident including any concerns or questions
surrounding the circumstances of the claim
A claim number will be assigned for the claim
• Please include the claim number on all correspondence including
medical bills
• Please let your employee know the claim number
In greater Minnesota
Call (800) 449-7707, Ext. 3461
Within 5 Days of the injury
– OR –
Complete a Form Online: Go to www.berkleyrisk.com
Select Submit FROI -> User ID & Password
(If you already have a User ID and Password setup from MSBA, use it. If not, you can contact Keith Johnson at
KeithHJohnson@BerkleyRisk.com or at 612-766-3841.)
Fax the 1 st Report of Injury to: (800) 593-4578 or (612) 766-3599
Email the 1 st Report of Injury to: bracfroi@berkleyrisk.com
W O R K E R S’ C O M P E N S A T I O N
REVISED 7/2009

Berkley Risk Administrators Company Contacts
For Minnesota Public Schools
Insured by Riverport Insurance Company
Claim Calls or Program Operation Calls:
1-800-449-7707
(Ask for Extension # of Contact Shown Below)
PROGRAM OPERATIONS: PHONE: FAX: EMAIL ADDRESS:
Kin Brenckman
Account Manager
Ext. 3301
612-766-3301
612-766-3399 kbrenckman@berkleyrisk.com
CLAIMS OPERATIONS: PHONE: FAX: EMAIL ADDRESS:
Mike Sternal
Claims Supervisor
Sheryl Hart
Senior Claim Examiner
Lesa Kollodge
Senior Claim Examiner
Dan Ramsland
Senior Claim Examiner
John Stewart
Senior Claim Examiner
Marcia Wiczek
Senior Claim Examiner
Elaine Alexander
Medical Examiner
Ext. 3445
612-766-3445
Ext. 3415
612-766-3415
Ext. 3470
612-766-3470
Ext. 3467
612-766-3467
Ext. 3495
612-766-3495
Ext. 3468
612-766-3468
Ext. 3462
612-766-3462
612-766-3099 msternal@berkleyrisk.com
763-712-1327 shart@berkleyrisk.com
763-241-0550 lkollodge@berkleyrisk.com
952-294-4709 dramsland@berkleyrisk.com
612-766-3099 jstewart@berkleyrisk.com
763-421-0459 mwiczek@berkleyrisk.com
612-766-3099 ealexander@berkleyrisk.com
COPY THE ENCLOSED
FORMS TO REPLENISH YOUR SUPPLY
Berkley Risk Administrators Company, LLC
222 South Ninth Street, #1300, Minneapolis, MN 55402-3332 Revised 7/2009

Minnesota Department of Labor and Industry
Workers’ Compensation Division
PO Box 64221
St. Paul, MN 55164-0221
(651) 284-5030
1. EMPLOYEE SOCIAL SECURITY # 2. OSHA Case #
First Report of Injury
See Instructions on Reverse Side
PRINT IN INK or TYPE
Enter dates in MM/DD/YYYY format.
3. DATE OF CLAIMED INJURY 4. Time of
injury
am
pm
5. Time employee
began work on date
of injury
am
pm
6. EMPLOYEE Name (last, first, middle) 7. Gender
8. Marital Married
M F
Status Unmarried
9. Home Address 10. Home phone # 11. Date of birth
City State Zip Code 12. Occupation 13. Regular department 14. Date hired
15. Average weekly wage 16. Rate per hour 17. Hours per day 18. Days per week 19. Employment
Status
Full time
Seasonal
Part time
Volunteer
20. Weekly value of: Meals Lodging 2 nd Income 21. Apprentice Yes 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.”
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.
25. Did injury occur on employer’s premises?
Yes No
If no, indicate name and address of place of occurrence
24. What tools, equipment, machines, objects, or substances were involved?
Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
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
28. Date employer notified of injury 29. Date employer notified of lost time
30. Return to work date 31. Date of death
32. TREATING PHYSICIAN (name, address, and phone) 33. HOSPITAL/CLINIC (name and address) (if any)
36. EMPLOYER Legal name 37. EMPLOYER DBA name (if different)
34. Emergency Room Visit
Yes No
35. Overnight in-patient
Yes No
38. Mailing address 39. Employer FEIN 40. Unemployment ID#
City State Zip Code 41. Employer’s contact name and phone #
42. Physical address (if different) 43. Witness (name and phone)
City State Zip Code 44. NAICS code 45. Date form completed
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one)
47. Insured legal name 52. CA address
48. Policy # or self-insured certificate # City State Zip Code
49. Insurer FEIN 50. Date insurer received notice 53. CA FEIN 54. Claim #
F R 0 1
DO NOT USE THIS SPACE
Insurer
TPA
MN FR01 (5/08) 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 (651-284-
5731), 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.

SUPERVISOR'S REPORT OF ACCIDENT
(PLEASE READ AND FOLLOW INSTRUCTIONS ON BACK)
EVERY ACCIDENT SHOULD BE INVESTIGATED AND THE CAUSES CORRECTED SO THAT MORE ACCIDENTS WILL NOT OCCUR. DO NOT OVERLOOK
THE SO-CALLED "UNIMPORTANT" CASES, BECAUSE, EXCEPT FOR "CHANCE" THEY COULD ALSO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH
INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED.
NAME OF EMPLOYEE
DATE OF ACCIDENT
HOURS LOST ON DATE OF ACCIDENT
JOB TITLE
TIME
COMPANY
SERVICE WITH THE COMPANY
DEPT.
DID EMPLOYEE LOSE TIME FROM WORK? YES NO
HAS EMPLOYEE RETURNED TO WORK? YES NO
YEARS IN PRESENT JOB
GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO
BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION.
PLEASE ANSWER THE FOLLOWING: CHECK "YES" OR "NO"
1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? ................................... YES NO
2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS?............................................................................................ NO YES
3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) .............................................................. YES NO
4. DID POOR HOUSEKEEPING CONTRIBUTE TO INJURY? ........................................................................................... NO YES
5. DID HORSEPLAY CAUSE THE INJURY? ...................................................................................................................... NO YES
6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS? ................................................................................ NO YES
7. SHOULD A GUARD BE PROVIDED? ............................................................................................................................. NO YES
8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? .............................................................................................. NO YES
9. WAS IT CAUSED BY AN UNSAFE ACT? ....................................................................................................................... NO YES
10. DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY? ............................................... YES NO
ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED, WHO WAS INVOLVED, NATURE OF INJURY, PART OF
BODY AFFECTED.)
WITNESSES' NAMES
UNSAFE ACTS. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?)
UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY, EQUIPMENT, BUILDING OR PREMISES WAS INVOLVED?)
ACTIONS TAKEN. (WHAT DID YOU DO TO CORRECT THE CONDITIONS WHICH CAUSED THIS INJURY?)
REMEDIES. (WHAT SHOULD YOUR ORGANIZATION DO TO PREVENT OTHER INJURIES LIKE THIS?)
MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL? YES NO IF YES, COMPLETE THE FOLLOWING
NAME OF DOCTOR OR HOSPITAL DATE OF INITIAL VISIT
ADDRESS TELEPHONE NUMBER
AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS' COMPENSATION? YES NO
REASONS WHY
REPORT SUBMITTED BY DATE
BRAC 2520 (10/99)

COMPLETION INSTRUCTIONS FOR SUPERVISORS' REPORT OF ACCIDENT (SRA)
The primary purpose of the SRA is to investigate the accident. It is also used to report the accident to the central office where the First Report of Injury is then
completed by administrative personnel. The SRA should be filled out as soon as possible after the accident.
If the SRA is incomplete or delayed, corrective action may also be delayed. A delay in taking corrective action will probably result in the occurrence of a similar
accident.
The initial information asked for at the top of the SRA concerning the injured person's name, occupation, age, job history and loss of time from work is selfexplanatory,
but very necessary for eventual completion of the First Report of Injury.
The following is a line-by-line set of instructions for completing of the SRA by the Supervisor of the injured employee. Concrete examples of important parts of
the form are given for your use. This report should not be completed by the injured employee.
QUESTIONS
1. Was proper instruction given to the employee on how to do the job safely? Supervisors should instruct their employees on how to do the job efficiently and
safely.
2. Referred to in question #1.
3. The supervisor should have told the employee what personal protective equipment is necessary to do the job. Did the employee wear the personal protective
equipment when this job was being done?
4. Was the work area clean and well organized? i.e., scraps on the floor, blocked aisles, wet floor, spilled food, etc.
5. Was there inadequate supervision? Did horseplay or practical jokes contribute to the accident?
6. Was the injured person using equipment that was unsafe and in need of repair? i.e., broken ladder, bad electric cord on drill, etc.
7. Would a guard prevent another accident from happening? i.e., guard around the belts and pulleys, railing properly in place, guard on saw, etc.
8. Did this person have any bodily defects which might have helped cause the accident? i.e., poor vision, previous back injury, etc.
9. Most injuries are caused in part by unsafe acts. An Unsafe Act is something that the injured person or another person did, that he or she should not have
done, which led to the accident. Below is a list of the most common unsafe acts and contributing factors:
1. Operating without authority
2. Failure to warn or secure
3. Operating at unsafe speed
4. Making safety devices inoperative
5. Using equipment, tools, materials or vehicles
unsafely
6 . Using defective equipment, materials, tools or
vehicles
7. Failure to use personal protective equipment
8. Failure to use equipment provided (except
personal protective equipment)
9. Unsafe loading, placing and mixing
10. Unsafe lifting and carrying (including insecure
grip)
11. Taking an unsafe position
10. The accident should have been reported immediately to the supervisor; was it?
12. Adjusting, clearing jams, cleaning
machinery in motion
13. Distracting, teasing
14. Poor housekeeping practices
15. Disregard of instructions
16. Lack of knowledge or skill
17. Act of other than injured
18. Others .................
Accident
1. Describe what the injured was doing at the time of the accident.
2. What happened?
3. Who was involved?
4. What injuries resulted?
Example: John was drilling a hole in the ceiling and chips of plaster fell into his eye. (This answers questions 1 and 2.) John got chips of plaster in his eye,
resulting in a scratch to his eye. John was wearing his prescription glasses. (This answers questions 3 and 4.)
Note the names of witnesses, if any.
Unsafe Act
Refer to question 9 above and examples of Unsafe Acts. Example: John was not wearing proper personal protective equipment.
Unsafe Conditions
1. Defective tools, equipment, substances 5. Improper ventilation
2. Unsafe design or construction 6. Improper dress
3. Hazardous arrangement 7. Poor housekeeping
4. Improper illumination 8. Congested area
9. Other
Action Taken Example: John has been re-instructed to wear proper personal protective equipment such as goggles or face shield when drilling overhead.
Remedy Example: Standard safety policy should be adopted that requires use of personal protective equipment. This policy should be strictly enforced by the
supervisors.
Medical Care: Include all medical information that is known at this time. Do not delay the completion of this form for more complete information.
As supervisor, do you feel that this injury should be covered under workers' compensation benefits? As a general rule, if the employee is injured while at
work, that injury is covered under workers' compensation. However, if you as supervisor, have reason to suspect that the injury did not occur at work, please tell
us. This is only an opinion and by itself will not deny benefits.

Minnesota Workers’ Compensation System Employee Information Sheet
What does workers’ compensation pay for?
• Medical care for the work injury, as long as it is reasonable and necessary
• Wage-loss benefits for part of your lost income (there is a three-calendar-day waiting period before these benefits
start)
• Benefits for permanent damage or loss of function of a body part
• Benefits to your spouse and/or dependents if you die of a work injury
• Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer
How are workers’ compensation benefits paid?
Your worker’s compensation benefits are paid by an insurance company or your employer, if your employer is selfinsured.
State law sets the benefit levels. Please note: pursuant to statute, the insurer can obtain medical information
specific to your work injury without your authorization.
If the insurer accepts your claim for wage loss benefits and you have been disabled for more than
three calendar days.
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating your claim is
accepted.
• The insurer must start paying wage-loss benefits within 14 days of the date your employer knows about your work
injury and lost wages. The insurer must pay benefits on time. Wage-loss benefits are paid at the same intervals as
your work paychecks.
If the insurer denies your claim for wage loss benefits:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating it is denying
primary liability for your claim. The form must clearly explain the facts and reasons why the insurer believes your
injury or illness did not result from your work.
• If you disagree with the denial, you should talk with the insurance claims adjuster who is handling your claim. Your
employer’s insurance company can answer most questions about your claim.
• Insurer name:
Riverport Insurance Company c/o Berkley Risk Administrators Company, LLC
Phone: (612) 766-3000 or (800) 449-7707
• If you are not satisfied with the response you receive from the insurer and still disagree with the denial, you should
contact the Department of Labor and Industry at one of the numbers listed below to see what to do next.
If you have other questions or need more help, call the Minnesota Department of Labor and
Industry Workers’ Compensation Hotline:
Twin Cities and Southern Minnesota: (651) 284-5005 or 1-800-342-5354; TTY (651) 297-4198
Duluth and Northern Minnesota: (218) 733-7810 or 1-800-365-4584
Your call will be answered by experienced workers’ compensation specialists, who can provide instant and accurate
information and assistance.
Additional workers’ compensation information is available on the department’s Web site at:
www.doli.state.mn.us
Your employer is required by law to give you this information. This material can be made available in different
formats, such as large print, Braille or on audiotape, by calling the numbers printed above.
DOLI Updated April 2003 (format-change only). This form may be copied or reproduced electronically. Do not file this form with the department.
BRAC 2535

* Reminder *
Legislative Requirement for
Employers
Law Effective: August 1, 2000
Employers are required to give their employee a copy of the
enclosed Employee Information Sheet at the same time that
the employee is given a copy of their First Report of Injury
form (completed by the employer).
To print a copy of the Employee Information Sheet in English or in Spanish, or for
more information, go to the Minnesota Department of Labor & Industries website:
www.doli.state.mn.us, (Insurer and Self-Insurer Information\Forms). If you
cannot print a copy from the website, you can call DOLI’s department of Benefit
Management and Resolution unit at (651) 284-5005 or 1-800-DIAL-DLI (1-800-
342-5354) to request a copy.
Berkley Risk Administrators Company, LLC
222 South Ninth Street, Stuite 1300, Minneapolis, MN 55402-3332

Minnesota Workers’ Compensation
Employee’s rights and responsibilities
This notice is required by law to be posted in a conspicuous
location wherever the employer is engaged in business.
If you are injured:
• Report any injury to your supervisor as soon as possible, no matter how minor it may appear. You may lose the right to workers’ compensation benefits if
you do not timely report the injury to your employer. The time limit may be as short as 14 days, although under certain circumstances, it may be longer.
• Provide your employer with as much information as possible about your injury so that a proper injury report can be filed.
• Get any necessary medical treatment as soon as possible. If you are not covered by a certified managed care organization (CMCO), you may treat with a
doctor of your choice. Your employer must notify you if you are covered by a CMCO.
• Cooperate with all requests for information concerning your workers’ compensation claim. Please note: the law provides that the workers’ compensation
insurer can obtain medical information specific to your work injury without your authorization, provided you are sent written notification of this request at the
time the request is made.
• Get written confirmation from your doctor on any authorization to be off work.
What does workers’ compensation pay for?
• Medical care for your work injury, as long as it is reasonable and necessary.
• Wage-loss benefits for part of your lost income (There is a three-calendar-day waiting period before these benefits start.)
• Compensation for permanent damage to or loss of function of a body part.
• Benefits to your spouse and/or dependents if you die as a result of a work injury.
• Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer due to your work injury.
What the insurance company must do:
• Investigate your claim promptly.
• Within 14 days of when the claimed injury occurred or when your employer became aware of it, either begin payment of benefits due or file a denial of liability,
explaining why benefits are being denied.
Your employer is insured by the Riverport Insurance Company.
Benefits due to you will be paid by:
PO Box 59143 Minneapolis Minnesota 55459-0143 (612) 766-3000
If the insurer accepts your claim for wage-loss benefits and you have been disabled for more than three calendar-days:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating your claim is accepted.
• The insurer must start paying wage-loss benefits within 14 days of the date your employer knows about your work injury and lost wages. The insurer must
pay benefits on time. Wage-loss benefits are paid at the same intervals as your work paychecks.
If the insurer denies your claim for wage-loss benefits:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating it is denying primary liability for your claim. The form
must clearly explain the facts and reasons why the insurer believes your injury or illness did not result from your work.
• If you disagree with the denial, you should talk with the insurance claims adjuster who is handling your claim. Your employer’s insurance company can
answer most questions about your claim.
• If you are not satisfied with the response you receive from the insurer and still disagree with the denial, you should contact the Department of Labor and
Industry at one of the numbers listed below to discuss your options.
Fraud
Collecting workers’ compensation benefits you are not entitled to is theft. Any theft of more than $500 is a felony.
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.
A suspected fraud can be reported by anyone. If you have reason to suspect someone is committing workers’ compensation fraud, call 1-888-FRAUD MN (1-888-
372-8366). All suspected violations will be investigated.
If you have questions or need more help, call the Minnesota Department of Labor and Industry:
Workers’ Compensation Hotline
1-800-DIAL-DLI
(1-800-342-5354)
8 a.m. to 4:30 p.m.,
Monday-Friday
Department of Labor and Industry
Workers’ Compensation Division
443 Lafayette Road N.
St. Paul, MN 55155
Phone: (651) 284-5032
TDD: (651) 297-4198
Department of Labor and Industry
Workers’ Compensation Division
5 N. Third Ave. W., Suite 400
Duluth, MN 55802
Phone: (218) 733-7810
Toll-free: 1-800-365-4584
Your claim will be answered by experienced workers’ compensation specialists who will provide instant, accurate information and assistance.
Additional workers’ compensation information is available on the department Web site at www.doli.state.mn.us.
August 2003 This document can be made available in alternative formats, such as Braille or audiotape, by calling (651) 284-5042 or (651) 297-4198/TDD. BRAC 2590 (10/03)