Form MN RT01 "Employee or Insurer's Objection to Requested Attorney Fees and/or Costs" - Minnesota

What Is Form MN RT01?

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 June 1, 2018;
  • 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 MN RT01 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 MN RT01 "Employee or Insurer's Objection to Requested Attorney Fees and/or Costs" - Minnesota

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WID or SSN
Office of Administrative Hearings
Workers’ Compensation Division
PO Box 64620
DATE(S) OF CLAIMED INJURY
RT 0 1
St. Paul, MN 55164-0620
(651) 361-7900
DO NOT USE THIS SPACE
EMPLOYEE
VS.
EMPLOYER(S)
Employee or Insurer’s
AND
Objection to Requested
INSURER(S)
Attorney Fees and/or Costs
AND
NAME OF ATTORNEY REQUESTING FEES
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 the department of
labor and industry 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’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.
1. I object to the attorney’s request for (objection may be made to any requested fee or cost):
Attorney fees in the amount of $
Costs in the amount of $
2. The reasons for my objection are:
NOTE: If a compensation judge is required to evaluate the reasonableness of the requested fees, the following factors will be considered.
These factors may be used as a guideline to assist you in agreeing or objecting to the requested fees.
The dollar amount involved;
The time and expense necessary for case preparation;
The responsibility taken by the attorney;
The attorney’s level of experience in and knowledge of workers’ compensation;
How complicated the issues were;
How difficult the case was to prove and what the results were.
3. Do you request a hearing?
No
Yes, on attorney fees
Yes, on costs
If a hearing is held, specify the language/dialect of any needed interpreter:
If a reasonable accommodation of disability is requested for a hearing, describe:
4. On
(date) I mailed a copy of this form to the above-named attorney at the following address:
This form is being filed by
employee
insurer:
SIGNATURE
DATE
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.
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.
MN RT01 (6/18)
Reset
WID or SSN
Office of Administrative Hearings
Workers’ Compensation Division
PO Box 64620
DATE(S) OF CLAIMED INJURY
RT 0 1
St. Paul, MN 55164-0620
(651) 361-7900
DO NOT USE THIS SPACE
EMPLOYEE
VS.
EMPLOYER(S)
Employee or Insurer’s
AND
Objection to Requested
INSURER(S)
Attorney Fees and/or Costs
AND
NAME OF ATTORNEY REQUESTING FEES
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 the department of
labor and industry 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’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.
1. I object to the attorney’s request for (objection may be made to any requested fee or cost):
Attorney fees in the amount of $
Costs in the amount of $
2. The reasons for my objection are:
NOTE: If a compensation judge is required to evaluate the reasonableness of the requested fees, the following factors will be considered.
These factors may be used as a guideline to assist you in agreeing or objecting to the requested fees.
The dollar amount involved;
The time and expense necessary for case preparation;
The responsibility taken by the attorney;
The attorney’s level of experience in and knowledge of workers’ compensation;
How complicated the issues were;
How difficult the case was to prove and what the results were.
3. Do you request a hearing?
No
Yes, on attorney fees
Yes, on costs
If a hearing is held, specify the language/dialect of any needed interpreter:
If a reasonable accommodation of disability is requested for a hearing, describe:
4. On
(date) I mailed a copy of this form to the above-named attorney at the following address:
This form is being filed by
employee
insurer:
SIGNATURE
DATE
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.
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.
MN RT01 (6/18)