Notice Of Appearance Of Attorney For Employee
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Of Appearance Of Attorney For Employee Form. This is a Minnesota form and can be use in Workers Comp.
Loading PDF...
Tags: Notice Of Appearance Of Attorney For Employee, NA03, Minnesota Workers Comp,
Reset 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 Notice of Appearance of Attorney for Employee PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT N0 A3 DO NOT USE THIS SPACE WID or SSN EMPLOYEE DATE(S) OF CLAIMED INJURY VS. EMPLOYER AND INSURER AND TO THE WORKERS' COMPENSATION DIVISION AND THE ABOVE NAMED INSURER: ATTORNEY NAME ADDRESS CITY ATTORNEY REGISTRATION # PHONE # (include area code) STATE ZIP CODE I have retained the services of the above-named attorney to represent my interests in the above-entitled matter. I hereby authorize the Workers' Compensation Division to release to my attorney any information the attorney may request regarding this injury. It is requested that you make service of all legal documents, notices, etc., upon my attorney. DATE EMPLOYEE SIGNATURE This notice supercedes any and all prior notices of appearance. A copy of the retainer agreement must accompany this notice of appearance. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354/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. MN NA03 (4/12) American LegalNet, Inc. www.FormsWorkFlow.com
