Office of Administrative Hearings P.O. Box 64620 St. Paul, MN 55164 - 0620 OR* Department of Labor and Industry P.O. Box 64221 St. Paul, MN 55164 - 0221 Fax: (651) 284 - 5731 State of Minnesota MO0001 DO NOT USE THIS SPACE Office of Administrative Hearings *Note: Motions to Intervene must be filed with the Office of Administrative Hearings unless applicant intends to intervene in an administrative conference that is pending at the Department of Labor and Industry. WID number Date(s) of claimed injury Employee vs. Employer (s) and Insurer (s) and 1. The applicant is filing this Motion to Intervene in the following disputes(s): Claim Petition dated Rehabilitation Request * dated Medical Re quest* dated Re quest for Formal Hearing dated 2. T he applicant, (name of entity filing this Motion to Intervene) , has provided services or paid benefits to or on behalf of the employee and has a statutory right to intervene under Minnesota Statu t es 247 176.361. 3. Attached to this Motion to Intervene is an e xhibit(s) itemizing the charge s for services provided or payments made to or on behalf of the employee by the a pplicant from (date) to (date). The claim to - date is $ . Upon request of a party or to present evidence of the interventio n claim at hearing, the applicant acknowledges it will provide additional documentation, records and reports as required by law. 4. A determination in this case may affect the ability of the applicant to obtain payment from any source for the services provided or payments made to or on behalf of the employ ee as itemized in the attached e xhibit(s). 5. , who has authority to settle on behalf of the applicant, (p rint name and title), can be contacted at (phone number) and (email address). 6. Therefore, the applicant requests it be allowed to intervene as a party in the above - captioned proceeding and that payment for services provided or benefits paid be made, plus appropriate statutory interest. Date signed Signature of person filing motion Printed name and title Mailing address Email ad d ress City State ZIP code Telephone MN MO0001 (6/18) (over) Motio n to Intervene Print in ink or type. Enter dates in MM/DD/YYYY format. American LegalNet, Inc. www.FormsWorkFlow.com WID n umber Date(s) of claimed injury State of County of } } } ss. Proof of s ervice I, state that on I served a true and correct copy of the attached Motion to Intervene , by placing it in a properly stamped and addressed envelope , in the United States mail at , , addressed as follows . Employee Employee a ttorney Employer Employer/I nsurer attorney Insurer Other party (specify) Other party (specify) Other party (specify) I declare under penalty of perjury that everything I have stated in this document is true and correct. Dated Signature Name Address City/State/ZIP Telephone American LegalNet, Inc. www.FormsWorkFlow.com