Fillable state of minnesota Motion to Intervene form

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state of minnesota Motion to Intervene form

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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 _______________________
Medical Request* dated ____________________
2. The 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 Statutes § 176.361.
3. Attached to this Motion to Intervene is an exhibit(s) itemizing the charges for services provided or payments made
to or on behalf of the employee by the applicant from __________________ (date) to __________________
(date). The claim to-date is $________________. Upon request of a party or to present evidence of the
intervention 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 employee as itemized in the attached exhibit(s).
5. The applicant’s representative, who has authority to settle on behalf of the applicant,
________________________ (print 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 address
City
State
ZIP code
Telephone
MN MO0001 (6/18)
(over)
Motion to Intervene
Print in ink or type.
Enter dates in MM/DD/YYYY format.
Reset
WID number
Date(s) of claimed injury
State of _______________________
County of _______________________
}
}
} ss.
Proof of service
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 attorney
Employer
Employer/Insurer 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.
Date
d ________________________________________ Signature ________________________________________
Name ___________________________________________
Address _________________________________________
City/State/ZIP _____________________________________
Telephone________________________________________
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state of minnesota Motion to Intervene form

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Completed 15 January 2020

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