Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5083 or 1-800-342-5354 www.dli.mn.gov R-24 Qualified Rehabilitation Consultant Firm Application Initial registration Renewal Firm registration # ____________ Expiration date _______________ (check one) Print in ink or type Legal business name. Except for individuals and partnerships doing business under their own true full legal first and last name(s), all businesses and assumed names (DBA) must be registered with the Office of the Secretary of State. Business address (where certified mail can be delivered) City Business telephone number State ZIP code Contact person's name Contact person's telephone number Contact person's email address FOR INITIAL REGISTRATION APPLICATIONS ONLY Have you previously applied for registration as a rehabilitation provider in Minnesota or any other state? Yes No If yes, provide your registration number and identify the state if other than Minnesota: Any data or information to support your application for registration as a qualified rehabilitation consultant (QRC) firm should be attached to this application. Examples include your resume, list of activities or license/certification information. THE FOLLOWING INFORMATION IS REQUIRED FOR INITIAL REGISTRATION AND RENEWAL APPLICATIONS Provide the following information for ALL management staff members, which shall consist of at least one employee who is registered as a qualified rehabilitation consultant (Minnesota Rules 5220.1600, subp. 1). Use additional sheet(s) if necessary. Attach resumes of those hired from outside your organization since last registration approval. Name Office address Name Office address Job title Job title Email Phone Email Phone Provide the following information for ALL non-management staff members. Use additional sheet(s) if necessary. Name Office address Name Office address Name Office address Job title Job title Job title Email Phone Email Phone Email Phone MN R-24 (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING INFORMATION IS REQUIRED FOR INITIAL REGISTRATION AND RENEWAL APPLICATIONS You must complete 1 or 2 below. 1 ­ Workers' compensation insurance policy information Insurance company name (not the insurance agent) Policy number Effective date Insurer's NAIC number Expiration date 2 ­ Reason for exemption from workers' compensation insurance If you have questions regarding the need to obtain workers' compensation coverage, including exemptions, call (651) 2845032 or 1-800-342-5354. I have no employees (see Minnesota Statutes § 176.011, subd. 9, for the definition of an employee). I am self-insured for workers' compensation (attach a copy of the authorization to self-insure from the Minnesota Department of Commerce). I have employees but they are not covered by the workers' compensation law (see Minn. Stat. § 176.041 for a list of excluded employees). Explain why your employees are not covered: _____________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________ Other: Note: You must notify the department if there is any change to your workers' compensation insurance information or employee status. Payment Information: Enclose a check or money order for $200 payable to the "Minnesota Department of Labor and Industry". Send all application documents and fees to the department's Financial Services unit at the address indicated on the front of this form. I authorize the Workers' Compensation Division, Department of Labor and Industry, to make any appropriate investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection of this application or denial of registration. I agree to be bound by all statutes, rules and orders as established by the commissioner and realize that violations may result in the denial or revocation of registration. I understand that Minnesota Rules 5220.1250 prohibits any ownership or financial relationship of any kind between any registered rehabilitation vendor and qualified rehabilitation consultant firm, qualified rehabilitation consultant or qualified rehabilitation consultant intern. I agree to notify the department within two weeks of the occurrence of any change in the employment status of staff who provide direct services to injured workers under a rehabilitation plan or of staff members who directly supervise those persons. Any branch office openings or closings, as well as any change in the firm address, telephone number or contact person, must be reported to the department within two weeks of the occurrence (Minn. Rules 5220.1600, subp. 1). I certify that the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify that I am authorized to sign on behalf of the business. MN R-24 (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com Notice: The information you as an individual provide in this application will be used by Department of Labor and Industry (department) staff members who require the information to determine if you meet the department's registration/renewal requirements. Minnesota Statutes § 270C.72, subd. 4, requires you to provide your Social Security number and Minnesota tax identification number on this application. The other information is being requested for purposes of processing your application. With the exception of your Social Security number and Minnesota tax identification number, you are not legally required to supply the data requested on this application. However, failure to provide the requested information may delay the processing of your application or result in the denial of the same. The application data will be made part of the department's file for your registration/renewal. Except for your name and the address you designated to receive correspondence from the department, the information you provide on this application is private data while the application is pending. Once you are registered, the application data may become public except for your Social Security number and Minnesota tax identification number. However, disclosure of private or nonpub