Form Mn No0016 "Notice of Appeal to Workers' Compensation Court of Appeals" - Minnesota

Form MN NO0016 is a Minnesota Department of Labor and Industry form also known as the "Notice Of Appeal To Workers' Compensation Court Of Appeals". The latest edition of the form was released in June 1, 2018 and is available for digital filing.

Download a PDF version of the Form MN NO0016 down below or find it on Minnesota Department of Labor and Industry Forms website.

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STATE OF MINNESOTA
Reset
OFFICE OF ADMINISTRATIVE HEARINGS
WORKERS’ COMPENSATION DIVISION
NO0016
PO Box 64620
WID or SSN
St. Paul, MN 55164-0620
(651) 361-7900
DO NOT USE THIS SPACE
DATE(S) OF CLAIMED INJURY
EMPLOYEE
VS.
EMPLOYER(S)
Notice of Appeal
to Workers’ Compensation
AND
INSURER (S)
Court of Appeals
AND
PRINT IN INK or TYPE.
Enter dates in MM/DD/YYYY format.
Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to
process and resolve your workers’ compensation dispute. The data will be used by the office of administrative hearings (OAH) and Workers’
Compensation Court of Appeals staff who have authorized access to the data, and may be used for state investigations and statistics. You may
refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of
the department of labor and industry’s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or
court order; the employer and insurer for your claim; the workers’ compensation court of appeals; the departments of revenue and health; and the
workers’ compensation reinsurance association.
TO THE ABOVE-NAMED PARTIES AND THEIR ATTORNEYS, PLEASE TAKE NOTICE:
, appeals to the Workers’
That the above-named party,
Compensation Court of Appeals from the decision of Compensation Judge
dated the
day of
, 20
, and the following issues are raised in this Notice of Appeal:
Further, that the specific findings and orders appealed from are numbered in the decision as follows:
(give numbers only). If there are other grounds which cannot be raised by reference to the findings,
attach an explanation. (See Minn. Stat. § 176.421.)
DATE SIGNED
SIGNATURE OF PERSON FILING APPEAL
PRINTED NAME AND TITLE
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE
IMPORTANT: The notice of appeal must be served upon each adverse party, and the original, with proof of service, filed with the Office of
Administrative Hearings, together with a $25 filing fee payable to the State Treasurer/OAH. This notice must be served and the original notice
and filing fee received by OAH within 30 days after notice of the Judge’s decision has been served by the Office of Administrative Hearings.
MN NO0016 (6/18)
(over)
STATE OF MINNESOTA
Reset
OFFICE OF ADMINISTRATIVE HEARINGS
WORKERS’ COMPENSATION DIVISION
NO0016
PO Box 64620
WID or SSN
St. Paul, MN 55164-0620
(651) 361-7900
DO NOT USE THIS SPACE
DATE(S) OF CLAIMED INJURY
EMPLOYEE
VS.
EMPLOYER(S)
Notice of Appeal
to Workers’ Compensation
AND
INSURER (S)
Court of Appeals
AND
PRINT IN INK or TYPE.
Enter dates in MM/DD/YYYY format.
Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to
process and resolve your workers’ compensation dispute. The data will be used by the office of administrative hearings (OAH) and Workers’
Compensation Court of Appeals staff who have authorized access to the data, and may be used for state investigations and statistics. You may
refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of
the department of labor and industry’s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or
court order; the employer and insurer for your claim; the workers’ compensation court of appeals; the departments of revenue and health; and the
workers’ compensation reinsurance association.
TO THE ABOVE-NAMED PARTIES AND THEIR ATTORNEYS, PLEASE TAKE NOTICE:
, appeals to the Workers’
That the above-named party,
Compensation Court of Appeals from the decision of Compensation Judge
dated the
day of
, 20
, and the following issues are raised in this Notice of Appeal:
Further, that the specific findings and orders appealed from are numbered in the decision as follows:
(give numbers only). If there are other grounds which cannot be raised by reference to the findings,
attach an explanation. (See Minn. Stat. § 176.421.)
DATE SIGNED
SIGNATURE OF PERSON FILING APPEAL
PRINTED NAME AND TITLE
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE
IMPORTANT: The notice of appeal must be served upon each adverse party, and the original, with proof of service, filed with the Office of
Administrative Hearings, together with a $25 filing fee payable to the State Treasurer/OAH. This notice must be served and the original notice
and filing fee received by OAH within 30 days after notice of the Judge’s decision has been served by the Office of Administrative Hearings.
MN NO0016 (6/18)
(over)
WID or SSN
DATE(S) OF CLAIMED INJURY
STATE OF MINNESOTA
}
PROOF OF SERVICE
}
ss.
COUNTY OF
}
, being first duly sworn, says that on
, (s)he
deposited a true and correct copy of the original NOTICE OF APPEAL TO WORKERS’ COMPENSATION COURT OF APPEALS in the
United States Mail in the City of
, postage prepaid, duly enveloped and stamped, addressed to:
(List opposing attorneys and parties not represented by an attorney with their addresses).
Employee:
Employee Attorney:
Employer:
Employer/Insurer Attorney:
Insurer:
Other Party (Specify):
Other Party (Specify):
COPY TO:
Department of Labor and Industry
PO Box 64221
St. Paul, MN 55164-0221
I declare under penalty of perjury that everything I have stated in this document is true and correct.
DATE
SIGNATURE
NAME
STREET ADDRESS
CITY/STATE/ZIP
TELEPHONE
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