Minnesota Required Postings and Forms
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple office locations be sure to post the notices at each location.
- Workers’ Compensation Employee Rights and Responsibilities Notice (English and Spanish).
- Anti-Fraud Notice (English and Spanish)
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- MN FR01 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed and provided to EMPLOYERS within 10 days from notice of a work-related injury or occupational disease when your employee is partially or wholly incapacitated for more than three calendar days. Fatalities must be reported within 48 hours. Late reporting can lead to significant fines imposed by the State of Minnesota. You must use this form to notify EMPLOYERS of every work-related injury or occupational disease suffered by an employee, regardless of severity.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any work-related injury or occupational disease that has caused your employee to be disabled for more than three calendar days.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 14791, Lexington, KY 40512-4791. You should also keep a copy on file for your records.
More Minnesota Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.