N F 0 1 DO NOT USE THIS SPACE Notice of File Closing PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format. WID or SSN DATE OF INJURY EMPLOYEE EMPLOYER INSURER CLAIM NUMBER THIS IS TO NOTIFY YOUR OFFICE THAT ALL PAYMENTS AND OTHER ACTIVITIES HAVE BEEN COMPLETED ON THIS FILE. AS A RESULT, WE ARE NOW CLOSING IT ON OUR SYSTEM. CLAIM REPRESENTATIVE NAME DATE ADDRESS INSURER/SELF-INSURER/TPA CITY Send completed form to: STATE ZIP CODE PHONE NUMBER (include area code) Minnesota Department of Labor and Industry Workers’ Compensation Division PO Box 64221 St. Paul, MN 55164-0221 This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1 800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. MN NF01 (5/08) American LegalNet, Inc. www.FormsWorkflow.com