Form R-22 "Rehabilitation Vendor Application" - Minnesota

What Is Form R-22?

This is a legal form that was released by the Minnesota Department of Labor and Industry - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Minnesota Department of Labor and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form R-22 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Labor and Industry.

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Download Form R-22 "Rehabilitation Vendor Application" - Minnesota

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Minnesota Department of Labor and Industry
Financial Services
R-22
443 Lafayette Road N.
St. Paul, MN 55155
(651) 284-5083 or
Rehabilitation Vendor Application
1-800-342-5354
www.dli.mn.gov
(check one)
Initial registration
Renewal
Vendor registration # ____________ Expiration date ______________
Print in ink or type
Legal business name.
Except for individuals and partnerships doing business under their own true full legal first and last name(s), all businesses and
assumed names (DBA) must be registered with the Office of the Secretary of State.
Business address (where certified mail can be delivered)
Contact person’s name
Contact person’s telephone number
City
State
ZIP code
Contact person’s email address
Business telephone number
FOR INITIAL REGISTRATION APPLICATIONS ONLY
Have you previously applied for registration as a rehabilitation provider in Minnesota or any other state?
Yes
No
If yes, provide your registration number and identify the state if other than Minnesota:
Any data or information to support your application should be described below or attached. Examples include your resume,
list of activities or license/certification information.
THE FOLLOWING INFORMATION IS REQUIRED FOR INITIAL REGISTRATION AND RENEWAL APPLICATIONS
List the name and job title of ALL staff members. Use an additional sheet if necessary.
Name
Job title
Name
Job title
Name
Job title
Name
Job title
Name
Job title
Name
Job title
MN R-22 (07/2015)
Reset
Minnesota Department of Labor and Industry
Financial Services
R-22
443 Lafayette Road N.
St. Paul, MN 55155
(651) 284-5083 or
Rehabilitation Vendor Application
1-800-342-5354
www.dli.mn.gov
(check one)
Initial registration
Renewal
Vendor registration # ____________ Expiration date ______________
Print in ink or type
Legal business name.
Except for individuals and partnerships doing business under their own true full legal first and last name(s), all businesses and
assumed names (DBA) must be registered with the Office of the Secretary of State.
Business address (where certified mail can be delivered)
Contact person’s name
Contact person’s telephone number
City
State
ZIP code
Contact person’s email address
Business telephone number
FOR INITIAL REGISTRATION APPLICATIONS ONLY
Have you previously applied for registration as a rehabilitation provider in Minnesota or any other state?
Yes
No
If yes, provide your registration number and identify the state if other than Minnesota:
Any data or information to support your application should be described below or attached. Examples include your resume,
list of activities or license/certification information.
THE FOLLOWING INFORMATION IS REQUIRED FOR INITIAL REGISTRATION AND RENEWAL APPLICATIONS
List the name and job title of ALL staff members. Use an additional sheet if necessary.
Name
Job title
Name
Job title
Name
Job title
Name
Job title
Name
Job title
Name
Job title
MN R-22 (07/2015)
THE FOLLOWING INFORMATION IS REQUIRED FOR INITIAL REGISTRATION AND RENEWAL APPLICATIONS
You must complete 1 or 2 below.
1 – Workers’ compensation insurance policy information
Insurer’s NAIC number
Insurance company name (not the insurance agent)
Policy number
Effective date
Expiration date
2 – Reason for exemption from workers’ compensation insurance
If you have questions regarding the need to obtain workers’ compensation coverage, including exemptions, call (651) 284-
5032 or 1-800-342-5354.
I have no employees (see Minnesota Statutes § 176.011, subd. 9, for the definition of an employee).
I am self-insured for workers’ compensation (attach a copy of the authorization to self-insure from the Minnesota
Department of Commerce).
I have employees but they are not covered by the workers’ compensation law (see Minn. Stat. § 176.041 for a list of
excluded employees). Explain why your employees are not covered:
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
Other:
Note: You must notify the department if there is any change to your workers’ compensation insurance information or
employee status.
Payment information: Enclose a check or money order for $200 payable to the “Minnesota Department of Labor and
Industry”. Send all application documents and fees to the department’s Financial Services unit at the address indicated on
the front of this form.
I authorize the Workers’ Compensation Division, Department of Labor and Industry, to make any appropriate investigation
of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection
of this application or denial of registration.
I agree to be bound by all statutes, rules and orders as established by the commissioner and realize that violations may
result in the denial or revocation of registration.
I understand that Minnesota Rules 5220.1250 prohibits any ownership or financial relationship of any kind between any
registered rehabilitation vendor and qualified rehabilitation consultant firm, qualified rehabilitation consultant or qualified
rehabilitation consultant intern.
I further understand that registered rehabilitation vendors shall not employ or otherwise engage the services of qualified
rehabilitation consultants (Minn. Rules 5220.1700, subp. 5).
Any change in the firm address, telephone number or contact person must be reported to the department within two
weeks of the occurrence (Minn. Rules 5220.1700, subp. 1).
I certify that the information provided on this form is accurate and complete. If I am signing on behalf of a business, I
certify that I am authorized to sign on behalf of the business.
MN R-22 (07/2015)
Notice: The information you as an individual provide in this application will be used by Department of Labor and Industry
(department) staff members who require the information to determine if you meet the department’s registration/renewal
requirements. Minnesota Statutes § 270C.72, subd. 4, requires you to provide your Social Security number and
Minnesota tax identification number on this application. The other information is being requested for purposes of
processing your application. With the exception of your Social Security number and Minnesota tax identification number,
you are not legally required to supply the data requested on this application. However, failure to provide the requested
information may delay the processing of your application or result in the denial of the same. The application data will be
made part of the department’s file for your registration/renewal. Except for your name and the address you designated to
receive correspondence from the department, the information you provide on this application is private data while the
application is pending. Once you are registered, the application data may become public except for your Social Security
number and Minnesota tax identification number. However, disclosure of private or nonpublic information to others may
occur as authorized or required by law, including but not limited to the Attorney General’s Office, the Department of
Revenue, the Office of Administrative Hearings, upon court order, and/or for the purpose of verification, state
investigations and statistics.
Print applicant’s name (must be owner, officer or manager) Title
Applicant’s Social Security number
Minnesota tax ID number (if applicable)
Applicant signature
Date
Notary signature
Date
My commission expires
This form is located at www.dli.mn.gov/WC/Wcforms.asp. The form can be made available in different formats, such as
large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354.
MN R-22 (07/2015)
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