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MINNESOTA (National American Insurance Company)

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MN FR01 (12/12) Employer: Send copies to Insurer (or Workers’ Compensation Division if no insurer), employee, and employee’s union (if applicable)
MN Department of Labor and Industry
Workers’ Compensation Division
PO Box 64221
St. Paul, MN 55164-0221
(651) 284-5032 or 1-800-342-5354
Fax: (651) 284-5731
First Report of Injury
See Instructions on Reverse Side
PRINT IN INK or TYPE
ENTER DATES IN MM/DD/YYYY FORMAT
1. EMPLOYEE SOCIAL SECURITY #
2. OSHA case #
3. Time employee began
work on date of injury
am
pm
4. DATE OF CLAIMED INJURY
5. Time
of injury
am
pm
6. Date of death
is related to injury)
7. EMPLOYEE Name (last, suffix, first, middle)
8. Gender
M F
9. Marital
status
Married
Unmarried
10. Home address
11. Home phone #
12. Date of birth
13. Date hired
City State Zip Code
14. Occupation
15. Regular department
16. Apprentice
Yes No
17. Average weekly wage
18. Rate per
hour
19. Hours per
day
20. Days per
week
Normal work schedule Sun - Sat
S M T W T F S
21. Employment
status (check all
that apply)
Full time
Seasonal
Part time
Volunteer
22. Tell us how the injury/illness occurred, what the employee was doing before the incident (give details), and what the injury/illness was. Examples: “Worker was driving
lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”
23. What was the injury or illness (include the part(s) of body)? Examples:
chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.
24. What tools, equipment, machines, objects, or substances were involved?
Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
25. Did injury occur on employer’s premises?
Yes No
Name and address of the place of the occurrence
26.
First date of any lost time 27. Employer paid for lost time on day of injury (DOI)
Yes No No lost time on DOI
28. Date employer notified of injury
29. Date employer notified of lost time
30. Return to work date
31. RTW same employer
Yes No
32. RTW with restrictions
Yes No
33. Treating physician (name)
34. Extent of medical treatment (check all that apply)
None Minor on-site by employer’s medical staff Minor clinic/hospital
Emergency room Hospitalization more than 24 hours
Future major medical anticipated
35. Certified Managed Care Organization (if any)
36. EMPLOYER Legal name
37. EMPLOYER DBA name (if different)
38. Mailing address
39. Employer FEIN
40. Unemployment ID #
City State Zip Code
41. Employer’s contact name and phone #
42. Physical address (if different)
43. Witness (name and phone) - if more than 1 attach a separate sheet
City State Zip Code
44. NAICS code
45. Date form completed
46. INSURER name
51. CLAIMS ADMIN COMPANY (CA) name (check one)
Insurer
TPA
47. Insured legal name and FEIN
52. CA address
48. Policy # (including effective dates) or self-insured certificate #
City State Zip Code
49. Insurer FEIN
50. Date insurer received notice
53. CA FEIN
54. CA claim #
55. To be completed
by the CA:
Claim type code: Type of loss code: Late reason code: Salary paid in lieu of comp? Death result of injury?
FR0 1
DO NOT USE THIS SPACE
Reset
GENERAL INSTRUCTIONS TO THE EMPLOYER
Employers, not employees, are responsible for completing this form. The information is needed to determine liability and entitlement
to benefits. You must file this form with your insurer, and give a copy to the employee and the employee’s local union office. You are
required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department of Labor and
Industry’s web site at www.dli.mn.gov
.
Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work-
related injury or illness that requires medical care or where lost time from work has occurred. If the claimed injury wholly or partially
incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within
ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. It is important to file
this form quickly to allow your insurer time to investigate the claim. Your insurer will report the injury to the Department of Labor and
Industry (Department), when necessary. Self-insured employers have 14 days to report the injury to the Department, when necessary.
If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer
within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-
5731), or personal notice. The initial notice must be followed by the filing of this form with the Department within seven days of the
occurrence.
SEND THIS FORM TO YOUR INSURER IMMEDIATELY – DO NOT WAIT FOR THE DOCTOR’S REPORT
SPECIFIC INSTRUCTIONS TO THE EMPLOYER ON COMPLETING THIS FORM
• Item 2: OSHA case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301.
• Items 17-21: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week
wage statement so your insurer can calculate the appropriate average weekly wage. Attach a separate sheet giving the weekly
value of any meals, lodging, or 2nd income paid to the employee.
• Item 20: Fill in the average number of days per week that the employee works. Also include their normal work schedule, Sunday -
Saturday, by checking the appropriate boxes. If the employee’s work schedule fluctuates from week-to-week, leave the boxes blank.
• Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.),
and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved.
• Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the
employee for the lost time.
• Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time.
• Item 28: Fill in the date you first became aware of the injury or illness.
• Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury.
• Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to
work, fill in the date and answer the questions in Items 31 and 32. Notify your insurer if the employee misses time due to this injury
after that date.
• Item 34: Check all the boxes that apply AT the time you file this form.
• Item 39: Fill in your Federal Employer Identification Number (FEIN). For information, see
www.usa.gov/Business/Business-
Gateway.shtml and click on “Get an Employer ID Number”.
• Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code, which
are both assigned by the Minnesota Unemployment Insurance Program (651-296-6141).
• Items 46-54: Your insurer or claims administrator will complete this information if you do not have it available.
INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR
The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s
name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the
First Report will be rejected and returned to you (see Minn. Stat. § 176.275). Providing the name of the third party administrator does
not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting
period or potential PPD, the form does NOT need to be filed with the Department.
• Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self-
insured company or group.
• Items 47-48: Fill in the legal name and Federal Employer Identification Number (FEIN) of the employer who purchased the policy
from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number.
• Item 49: Fill in the insurer’s FEIN.
• Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be
sure to mark either the “Insurer” or “TPA” box.
• Item 53-54: Fill in the claims administrator’s FEIN and claim number.
• Item 55: These items apply only to FROIs electronically submitted by the claim administrator.
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 Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED 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.
This notice is required by law to be posted in a conspicuous
location wherever the employer is engaged in busi ness.
If you are injured:
• Report any injury to your supervisor as soon as possible, no matter how minor it may appear. You may lose the right to workers’
compensation benefi ts if you do not timely report the injury to your employer. The time limit may be as short as 14 days, although under
certain circumstances, it may be longer.
• Provide your employer with as much information as possible about your injury so that a proper injury report can be fi led.
• Get any necessary medical treatment as soon as possible. If you are not covered by a certifi ed managed care organization (CMCO), you may
treat with a doctor of your choice. Your employer must notify you if you are covered by a CMCO.
• Cooperate with all requests for information concerning your workers’ compensation claim. Please note: the law provides that the
workers’ compensation insurer can obtain medical information specifi c to your work injury with out your authorization, provided you are sent
written notifi cation of this request at the time the request is made.
• Get written confi rmation from your doctor on any authorization to be off work.
What does workers’ compensation pay for?
• Medical care for your work injury, as long as it is reasonable and necessary;
• Wage-loss benefi ts for part of your lost income (there is a three-calendar-day waiting period before these benefi ts start);
• Compensation for permanent damage to or loss of function of a body part;
• Benefi ts to your spouse and/or dependents if you die as a result of a work injury;
• Vocational rehabilitation services if you cannot return to your pre-injury job or to your pre-injury employer due to your work injury.
What the insurance company must do:
• Investigate your claim promptly;
• Within 14 days of when the claimed injury occurred or when your employer became aware of it, either begin payment of benefi ts due or fi le
a denial of liability, explaining why benefi ts are being denied.
Minnesota Workers’ Compensation
Employee rights and responsibilities
Minnesota Workers’ Compensation
Employee rights and responsibilities
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If the insurer accepts your claim for wage-loss benefi ts and you have been disabled for more than three calendar-days:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating your claim is accepted.
• The insurer must start paying wage-loss benefi ts within 14 days of the date your employer knows about your work injury and lost wages.
The insurer must pay benefi ts on time. Wage-loss benefi ts are paid at the same intervals as your work paychecks.
If the insurer denies your claim for wage-loss benefi ts:
• The insurer will send you a copy of the Notice of Insurer’s Primary Liability Determination form stating it is denying primary liability
for your claim. The form must clearly explain the facts and reasons why the insurer be lieves your injury or illness did not result from your
work.
• If you disagree with the denial, you should talk with the insurance claims adjuster who is handling your claim. Your employer’s insurance
company can answer most questions about your claim.
• If you are not satisfi ed with the response you receive from the insurer and still disagree with the denial, you should contact the Department
of Labor and Industry at one of the numbers listed below to discuss your options.
Fraud
Collecting workers’ compensation benefi ts you are not entitled to is theft. Any theft of more than $500 is a felony.
Any person who, with intent to defraud, receives workers’ compensation benefi ts to which the person is not entitled 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.
A suspected fraud can be reported by anyone. If you have reason to suspect someone is committing workers’ compensation fraud, call
1-888-FRAUD MN (1-888-372-8366). All suspected violations will be investigated.
This document can be made available in alternative formats, such as Braille or audio, by calling (651) 284-5042 or (651) 297-4198/TDD.
If you have questions or need more help, call the Minnesota Department of Labor and Industry:
Workers’ Compensation Hotline
1-800-DIAL-DLI
(1-800-342-5354)
8 a.m. to 4:30 p.m.,
Monday-Friday
Department of Labor and Industry
Workers’ Compensation Di vi sion
P.O. Box 64221
St. Paul, MN 55164-0221
Phone: (651) 284-5032
TDD: (651) 297-4198
Department of Labor and Industry
Workers’ Compensation Di vi sion
525 Lake Ave. S., Suite 330
Duluth, MN 55802-2368
Phone: (218) 733-7810
Toll-free: 1-800-342-5354
Your call will be answered by experienced workers’ compensation specialists who will provide instant, accurate information
and assistance. Additional workers’ compensation in for ma tion is available on the department Web site at www.dli.mn.gov.
September 2008
Insurer name:
Phone number:
Seguro de compensación a trabajadores por accidentes en el
trabajo de Minnesota. Derechos y responsabilidades de los empleados
Minnesota Workers' Compensation Employee's rights and responsibilities (Spanish)
La ley requiere que este aviso se coloque en un lugar visible
dondequiera que una empresa lleve a cabo actividades comerciales
Si usted se lesiona:
• Infórmele a su supervisor cualquier lesión que sufra tan pronto como sea posible, independientemente de cuán leve parezca ser. Es
posible que pierda su derecho a recibir beneficios del seguro de compensación a trabajadores por accidentes en el trabajo si no le
informa oportunamente a su empleador que sufrió una lesión. Es posible que el plazo límite para informar sea sólo 14 días, aunque
puede ser más largo bajo ciertas circunstancias.
• Proporciónele a su empleador la mayor cantidad de información que sea posible acerca de su lesión, de manera que pueda hacerse
el informe de lesión correspondiente.
• Obtenga cualquier tratamiento médico que sea necesario tan pronto como sea posible. Si no tiene cobertura bajo una organización
certificada de atención administrada (certified managed care organization - CMCO), puede acudir a cualquier médico de su elección
para recibir el tratamiento. Su empleador debe notificarle si está cubierto bajo una organización CMCO.
• Coopere con todas las solicitudes de información acerca de su reclamación de compensación a trabajadores. Tome nota: la ley
estipula que la compañía de seguro de compensación a trabajadores podrá obtener información médica relacionada específicamente
con su lesión en el trabajo sin la autorización suya, siempre y cuando le envíe un aviso por escrito de dicha solicitud al momento de
hacerla.
• Obtenga confirmación por escrito de su médico de cualquier autorización para ausentarse del trabajo.
¿Qué le paga su seguro de compensación?
• Atención médica por su lesión en el trabajo, siempre y cuando la misma sea razonable y necesaria.
• Beneficios parciales por pérdida de ingresos. (Hay un período de espera de tres días civiles antes de que comiencen estos beneficios.)
• Compensación por daños permanentes o por la pérdida del funcionamiento de una parte del cuerpo.
• Beneficios a su cónyuge y/o sus dependientes si usted fallece como resultado de una lesión en el trabajo.
• Servicios de rehabilitación vocacional si, a causa de una lesión en el trabajo, usted no puede regresar al trabajo que tenía o a la
empresa para la que trabajaba antes de sufrir dicha lesión.
Lo que debe hacer la compañía de seguro:
• Investigar su reclamación de manera puntual.
• Comenzar a pagarle los beneficios, o presentar un rechazo de responsabilidad que explique por qué le están negando la solicitud de
beneficios, dentro de un plazo de 14 días de usted haber sufrido la lesión por la cual hizo la reclamación o de que su empleador se
haya enterado de la misma.
Nombre del asegurador:
Número telefónico:
Este documento está disponible en formatos alternativos como Braille o audiocinta llamando al (651) 284-5042 o al (651) 297-4198/TDD.
Si tiene preguntas o necesita más ayuda, llame al Departamento del Trabajo y la Industria de Minnesota:
Línea directa de compensación
a trabajadores
1-800-DIAL-DLI
(1-800-342-5354)
de 8 a.m. a 4:30 p.m.,
de lunes a viernes
Departamento del Trabajo y la Industria
División de Compensación a Trabajadores
por Accidentes en el Trabajo
P.O. Box 64221
St. Paul, MN 55164-0221
Teléfono: (651) 284-5032
TDD: (651) 297-4198
Departamento del Trabajo y la Industria
División de Compensación a Trabajadores
por Accidentes en el Trabajo
525 Lake Ave. S., Suite 330
Duluth, MN 55802-2368
Teléfono: (218) 733-7810
Línea gratuita: 1-800-342-5354
Especialistas en compensación a trabajadores con experiencia responderán a su reclamación y le proveerán información
y asistencia instantáneas y precisas. Hay información adicional acerca de la compensación a trabajadores por
accidentes en el trabajo disponible en el sitio de Internet del departamento en www.dli.mn.gov.
September 2008
Si el asegurador acepta su reclamación de beneficios por pérdida de ingresos y usted ha estado incapacitado por más de
tres días civiles:
• El asegurador le enviará una copia del formulario de Aviso de Determinación de Responsabilidad Principal del Asegurador (Notice of
Insurer’s Primary Liability Determination) indicando que aceptó su reclamación.
• El asegurador deberá comenzar a pagarle los beneficios por pérdida de ingresos dentro de un plazo de 14 días desde que su
empleador se haya enterado de su lesión en el trabajo y de su pérdida de ingresos. El asegurador deberá pagar los beneficios de
manera puntual. Los beneficios por pérdida de ingresos se pagan a los mismos intervalos de tiempo que sus cheques de nómina.
Si el asegurador rechaza su reclamación de beneficios por pérdida de ingresos:
• El asegurador le enviará una copia del formulario de Aviso de Determinación de Responsabilidad Principal del Asegurador (Notice of
Insurer’s Primary Liability Determination) indicando que está rechazando la responsabilidad principal por su reclamación. El
formulario debe explicar claramente los hechos y los motivos por los cuales el asegurador cree que su lesión o enfermedad no resultó
de su trabajo.
• Si usted no está de acuerdo con el rechazo, debe hablar con el tasador de reclamaciones de seguro que esté encargado de su
reclamación. La compañía de seguros de su empleador podrá responder a la mayoría de sus preguntas acerca de su reclamación.
• Si no está satisfecho con la respuesta que reciba del empleador y aún no está de acuerdo con el rechazo, debe comunicarse con el
Departamento del Trabajo y la Industria llamando a uno de los números que se indican a continuación para hablar acerca de sus
opciones.
Fraude
Cobrar beneficios de compensación a trabajadores por accidentes en el trabajo si usted no tiene derecho a los mismos constituye robo.
Cualquier robo de más de $500 constituye un delito grave.
Cualquier persona que, con la intención de defraudar, reciba beneficios de compensación a trabajadores por accidentes en el trabajo a
los que la misma no tiene derecho, haciendo declaraciones falsas o inexactas, u ocultado cualquier hecho substancial, es culpable de
robo y recibirá una sentencia de conformidad con la sección 609.52, subdivisión 3.
Cualquier persona puede informar una sospecha de fraude. Si usted tiene algún motivo de sospechar que alguien está cometiendo
fraude de compensación a trabajadores por accidentes en el trabajo, llame al 1-888-FRAUD MN (1-888-372-8366). Se investigará toda
sospecha de infracción.
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Completed 29 July 2021

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