February 11, 2008

STATE OF MINNESOTA WORKERS’ COMPENSATION BARCODE FORMS

Name of Form Barcode ID Revision ID Pages/Sides

Affidavit of Significant Financial Hardship AS01 MN AS01 (6/04) 2
Annual Claim for Reimbursement of Supplementary Benefits AC03 MN AC03 (8/03) 3
Annual Claim for Reimbursement from the Second Injury Fund AR04 MN AR04 (8/03) 2
Benefit Addendum BA01 MN BA01 (8/04) 1
Claim Petition for Dependency Benefits CP03 MN CP03 (6/04) 2
Disability Status Report DS01 MN DS01 (5/03) 1
Employee and Insurer Response to Attorney Fees RT01 MN RT01 (8/04) 1
Employee’s Claim Petition EC04 MN EC04 (3/04) 2
Employee’s Objection to Discontinuance ED02 MN ED02 (6/04) 2
Employee’s Request for Administrative Conference (Minn. Stat. EQ05 MN EQ05 (8/04) 1
176.239, Subd. 2)
First Report of Injury FR01 MN FR01 (5/03) 2
Health Care Provider Report HC01 MN HC01 (8/04) 2
Interim Status Report IS03 MN IS03 (8/04) 2
Medical Request MQ03 MN MQ03 (8/04) 2
Medical Response MR03 MN MR03 (8/04) 2
Notice of Appearance of Attorney for Employee NA03 LI-23011-03 (7/01) 1
Notice of Benefit Payment NB01 MN NB01 (8/04) 2
Notice of Benefit Reinstatement NC01 MN NC01 (8/04) 1
Notice of Discontinuance of Workers’ Compensation Benefits BD02 MN BD02 (8/04) 2
Upon Death of Employee
Notice of Discontinuance of Workers’ Compensation Dependency DB02 MN DB02 (8/04) 2
Benefits
Notice of File Closing NF01 MN NF01 (8/04) 1
Notice of Insurer’s Primary Liability Determination NL01 MN NL01 (6/03) 2
Notice of Intention to Claim Reimbursement From the Second RS05 MN RS05 (8/03) 2
Injury Fund
Notice of Intention to Discontinue Workers’ Compensation Benefits ND01 MN ND01 (8/04) 2
M.S. 176.238
On the Job Training JA04 MN JA04 (4/03) 2
Permanent Total Disability Agreement PA04 MN PA04 (8/03) 2
Petition for Disputed or Excess Attorney’s Fees and/or Non- PF04 LI-23042-04 (7/01) 3
Reimbursed Disbursements
Petition for Taxation of Actual and Necessary Disbursements PT03 MN PT03 (8/04) 2
Plan Progress Report PR01 MN PR01 (12/02) 1
R-2 Rehabilitation Plan RE01 MN RE01 (3/03) 2
R-3 Rehabilitation Plan Amendment RP01 MN RP01 (12/02) 1
R-8 Notice of Rehabilitation Plan Closure NR01 MN NR01 (12/02) 1
Rehabilitation Consultation Report RC01 MN RC01 (12/02) 1
Rehabilitation Request RQ03 MN RQ03 (8/04) 2
Rehabilitation Response RR03 MN RR04 (8/04) 2
Rehabilitation Rights and Responsibilities of the Injured Worker IW05 MN IW05 (1/04) 2
Report of Work Ability RW01 MN RW01 (8/04) 2
Request for Extension QE03 MN QE03 (8/04) 1
Request for Formal Hearing or Commissioner Review Conference RF03 LI-20505-03 (7/01) 2
(Under Minn. Stat. 176.106 or 176.305)
Retraining Plan EP04 MN EP04 (4/03) 2
Small Claims Court Statement of Claim SC01 LI-20324-01 (7/01) 2
Statement of Attorney Fees SA04 MN SA04 (8/04) 2

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