Mailing Address: PO Box 64218 St. Paul, MN 55164-0218 WID or SSN STATE OF MINNESOTA OFFICE OF ADMINISTRATIVE HEARINGS WORKERS’ COMPENSATION DIVISION PO Box 64620 St. Paul, MN 55164-0620 (651) 361-7900 L E 0 0 3 2 DO NOT USE THIS SPACE DATE(S) OF CLAIMED INJURY EMPLOYEE VS. EMPLOYER(S) AND Stipulation of Intervention INSURER (S) AND PRINT IN INK or TYPE. Enter dates in MM/DD/YYYY format. Re: dated (Identify dispute you are intervening in, such as a Claim Petition, Medical Request, or Rehabilitation Request) According to the provisions of Minnesota Rules, part 1415.1200, it is stipulated and agreed that (entity filing Motion to Intervene) has sufficient interest to be joined as an intervenor in the above entitled matter. The parties do not dispute that the attached Exhibit A accurately lists the amounts and the dates of services provided by or paid by the intervenor in this case. This exhibit may be amended if additional services are provided or payments made. It is stipulated and agreed by the parties signing this stipulation that the services for which payment is being claimed are related to the alleged injury or condition in dispute and that, if the employee is successful in proving his or her claim, it is agreed that the sum provided in Exhibit A be paid to the intervenor. The intervenor recognizes its obligation to participate in reasonable settlement discussions if such negotiations are initiated by the parties. DATE ATTORNEY FOR EMPLOYEE DATE ATTORNEY FOR EMPLOYER/INSURER DATE ATTORNEY FOR INTERVENOR LE0032 Attachment to MO0001 (9/07) (over) American LegalNet, Inc. www.FormsWorkflow.com WID or SSN DATE(S) OF CLAIMED INJURY STATE OF MINNESOTA COUNTY OF I, } } } AFFIDAVIT OF SERVICE ss. , being first duly sworn, state that on ,I served a true and correct copy of the attached STIPULATION OF INTERVENTON, enclosed in a properly addressed envelope, by depositing the same, with postage prepaid in the United States mail at , Minnesota, addressed as follows: Employee: Employee Attorney: Employer: Employer/Insurer Attorney: Insurer: Other Party (Specify): Other Party (Specify): Other Party (Specify): Subscribed and sworn to before me this day of Signature Notary Public My Commission expires American LegalNet, Inc. www.FormsWorkflow.com