Office of Administrative Hearings Workers222 Compensation Division PO Box 64620 St. Paul, MN 55164-0620 (651) 361-7900 CP03 DO NOT USE THIS SPACE Reset Claim Petition for Dependency Benefits or Payment to Estate NOTE: File Petition and Affidavit of Service with OAH PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers222 compensation dispute. The data will be used by office of administrative hearings (OAH) and the department of labor and industry staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department222s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the workers222 compensation court of appeals; the departments of revenue and health; and the workers222 compensation reinsurance association. TO: THE OFFICE OF ADMINISTRATIVE HEARINGS The Petitioner named above alleges the following facts: 1. That his or her address is 2. That the address of the employer is 3. That on the above-named deceased employee sustained an injury or disease and that his/her death on was related to this injury or disease. 4. That the deceased employee was employed by the above-named employer as a 5. That the deceased employee222s weekly wage at the time of the alleged injury or disease was 6. That the injury or disease arose out of and in the course of the employee222s employment. 7. That the nature of the injury or disease was as follows: 8. That the employer had knowledge or notice of the occurrence of the injury, disease and/or death alleged in paragraph 3. 9. That on the date of injury the employer was insured against compensation liability by the insurer or insurers indicated above. 10. That the hospital and medical expenses made necessary by the injury or disease was the sum of , and that the cost of the funeral and burial was . 11. That the name and address of any third party who has paid benefits or hospital, medical or burial expenses related to this claim is 12. That petitioner is (relationship to deceased employee or dependents) 13. That the following are all of the deceased employee222s living dependent children known to petitioner: Gov222t survivor benefits for which dependent is eligible: Name Address Birth Date Type Amount 14. Other persons dependent on deceased employee (indicate with an * those who are only partially dependent): Gov222t survivor benefits for which dependent is eligible: Name Address Birth Date Type Amount 15. That liability has been denied by said employer and/or insurer and no payment of weekly or other benefits has been made except as follows: MN CP03 (6/18) (over) WID or SSN DATE(S) OF CLAIMED INJURY DATE OF DEATH DECEASED EMPLOYEE BY PETITIONER VS. EMPLOYER(S) AND INSURER(S) AND American LegalNet, Inc. www.FormsWorkFlow.com Based on the facts alleged above, Petitioner asks for an award for such benefits as are in such cases provided for by the Workers222 Compensation Law of Minnesota, as follows: 16. Unpaid benefits payable to employee and now being claimed by dependents 17. Dependency benefits from to 18. Rehabilitation benefits for dependent surviving spouse? Yes No 19. Payment to the estate of the deceased employee under Minn. Stat. 247 176.111, subd. 22? Yes No PETITIONER SIGNATURE ATTORNEY FOR PETITIONER SIGNATURE ADDRESS ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE TELEPHONE ATTORNEY REGISTRATION # TELEPHONE TRIAL DATA: Request is made for a settlement conference. Yes No Estimated hours to present evidence: Requested place of: Pretrial Trial Number of Witnesses: (Attach names and addresses) An Affidavit of Significant Financial Hardship is attached. Yes No If an interpreter is requested for a hearing or conference, specify the language/dialect: If a reasonable accommodation of disability is requested for a hearing or conference, describe: STATE OF MINNESOTA } } ss. AFFIDAVIT OF SERVICE COUNTY OF } I, , being first duly sworn, state that on , I served a true and correct copy of this document, enclosed in a properly addressed envelope, by depositing the same, with postage prepaid, in the United States mail at , Minnesota, addressed as follows: NAMES AND ADDRESSES Subscribed and sworn to before me this day of Signature Notary Public My Commission expires INSTRUCTIONS 1. Failure to properly and fully fill out claim petition, with appropriate documentation, in accordance with workers222 compensation rules of practice, shall not be considered proper filing under Minn. Stat. 247 176.305. OAH may refuse to accept a claim petition that lacks any of the following: employee222s name, date of injury, WID or social security number, or name of employer/insurer. 2. The claim must be presented in terms of the Minnesota Workers222 Compensation Act. 3. If you have more defendants or more injuries than can be listed on the claim petition, it may be modified accordingly. 4. A doctor222s report supporting the claim MUST be filed with the claim petition. 5. In listing dependents, refer to Minn. Stat. 247 176.111, subd. 1, before completing #13. If the child is over 18 years old, indicate the reasons he/she qualified as a dependent. All other dependents, including spouse, should be listed in #14. 6. The relationship of the petitioner to the deceased employee or to the dependents should be stated in #12 (e.g., widow of deceased employee, or father and natural guardian of children of deceased employee). 7. If additional space is required to list all the dependents claimed, or to list the names, addresses, etc., of third parties making payment of benefits, or hospital, medical or burial expenses, attach a separate sheet containing such information. 8. If no third party has made payment of any benefits, or hospital, medical or burial expenses, enter the word 223NONE224 in the blank provided for the name and address. 9. The petitioner must serve a copy of the petition on EACH adverse party (employer(s), insurer(s), the Special Compensation Fund, if applicable, and any third party intervenor named in #11) by first class mail or personally. 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. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS222 COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTI- TLED 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. American LegalNet, Inc. www.FormsWorkFlow.com