Fill and Sign the Small Claims Court 497312902 Form

                                         Indemnity Benefits (temporary total, temporary partial, permanent total, permanent partial)       Rehabilitation Benefits Other                         Date:       16.       17.       1. Employee's Social Security Number See Instructions on Reverse Side 2. Date(s) of Claimed Injury (mm/dd/yyyy) 3. Claim No. Minnesota Department of Labor and Industry Workers' Compensation Division 443 Lafayette Road North St Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) S C 0 1 DO NOT USE THIS SPACE Private or confidential data which you supply on this form will be used to process your workers' compensation file. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers' Compensation Reinsurance Association. It may also be used in workers' compensation hearings and for state investigations and statistics. 4. VS. 5. and , Employee Small Claims Court Statement of Claim 6. , Employer, and Original Claim and Affidavit of Service NOTE - File with Division 7. , Insurer, STATEMENT OF CLAIM 8. 9. Medical Benefits 10. 11 . 12. Brief statement of issue(s) in dispute: 13. Brief statement of Defense(s) to the claim 14. Potential Interveners: All parties must agree to submit to the jurisdiction of the Small Claims Court without right to appeal for this matter by signing below: 15 . Employee Insurer, or Self-insured Employer LI-20324-01 (7/01) Instructions Complete the Statement of Claim form including Social Security Number, all dates of injury relevant to this claim, and a brief explanation of issues in dispute. A doctor's report supporting the claim should be attached unless the claim involves only non-medical issues. Other information in support of the claim may likewise be attached to the form. All parties must sign the form agreeing to the jurisdiction of the Small Claims Court with no right to appeal any decision which might be rendered by the Small Claims Court. If other parties have paid benefits to the employee as a result of the work-related injury, indicate the name and address of such parties in the space entitled ''possible third party interveners'' Companies, Medicare, Unemployment Benefit agencies, state rehabilitation agencies, etc.) (e.g., Health Insurance Serve or mail a copy of the Small Claims Court Statement of Claim to each party and to each possible third-party intervener. File the Original Statement of Claim with the Department of Labor and Industry. 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.