Department of Labor: WC Batg 1

Section 1
Workers’ Compensation Overview

Workers’ compensation is a no-fault system designed to provide benefits to
employees injured as a result of their employment activities and to limit the liability
of employers. Because it is a no-fault system, the employee does not need to
prove negligence on the part of the employer in order to establish liability. It also
means that the employer can not use negligence on the part of the employee as a
defense to a claim.
A work-related injury can be any condition that is caused, aggravated, or

accelerated by employment activities. This includes traumatic injuries, gradual
injuries, or occupational diseases. The employee needs to show only that the
employment activities were a substantial contributing factor to the disability and/or
need for medical care.
Basic Benefits
Workers’ compensation provides four basic types of benefits:
• wage loss
• compensation for the loss of use of a part of the body
• medical benefits
• vocational rehabilitation services
Each of the four types of benefits is discussed in more detail later.
Controlling Events
The Minnesota workers’ compensation statutes have undergone many revisions
since the first law was enacted in 1913. It is very important for you to remember
that the date of injury or death controls. This means the law in effect on the date
of injury or death governs the type and amount of benefits that are payable to the
employee or dependents of the employee. The wage on the date of injury also
controls. This means the compensation rate is based on the gross weekly wage at
the time of the injury and does not include any wage increases the employee might
receive in the future.
For example, an employee is injured on August 30 with earnings of $400.00 per

week. A labor agreement allows employees a cost-of-living increase on November
1 of an additional $1.00 per hour. Calculate the compensation rate by using the
wage of $400.00 per week, as that is the employee’s gross weekly wage at the time
of injury.
Basic Adjusters’ Training Guide July 2007

MN Department of Labor and Industry 1-1
First Report of Injury (FROI)

The FROI is the reporting document for all work-related injury claims. It provides
basic information necessary to start the claim. Deaths and serious injuries must be
reported to the department within 48 hours. This can be done via telephone,
facsimile, or electronic transmission, to be followed by the FROI. For all other
injuries, where claimed disability exceeds three calendar days, the employer must
get the FROI to their insurance company within 10 days of the first day of disability
or the date they were aware of disability, whichever is later. Likewise, the
insurance company must file the FROI with the department within 14 days of the
first day of disability or the date the employer was aware of disability, whichever is
later. For self-insured employers, the FROI must be filed with the department
within 14 days of the first day of disability or the date the employer was aware of
disability, whichever is later. The employee must be given a copy of the FROI
along with the employee information sheet.
Employees are not responsible for completing the FROI. The form should be
completed accurately, completely, legibly, and timely by the employer. Again, it is
very important that the FROI be submitted timely to avoid unnecessary penalties.
Other Time Requirements

For injuries with claimed disability extending more than three calendar days, the
insurer must make a determination regarding liability within 14 days of the first day
of disability or the date the employer was aware of disability, whichever is later.
This means the insurer must pay or deny a claim within 14 days. Failure to pay or
deny within 14 days can result in penalties. Penalties regarding late filings, late
payments, and late denials are discussed in the penalty section of the workbook.
Once payment of wage loss benefits has begun, they can not be stopped without
giving notice to the employee. The insurer must advise the employee of the
specific type of benefit that they are proposing to discontinue, the reason for the
discontinuance, and the facts (including medical reports) that support the reason.
This is done by filing a Notice of Intention to Discontinue benefits form (NOID) or a
Petition to Discontinue. Exception: If the insurer begins to pay benefits and then
determines soon afterward that the injury is not compensable, the insurer may deny
primary liability and discontinue benefits by filing a Notice of Insurer’s Primary
Liability Determination (NOPLD) form within 60 days from the first day of disability
or the date the employer was aware of disability, whichever is later. If more than 60
days have elapsed, the insurer must file an NOID to discontinue the benefits when
denying primary liability.
Recovery of Overpayments
Overpayments of compensation are discussed in Minnesota Statutes §176.179.
Under current law, if voluntary payments to an employee or an employee’s
dependents are received in good faith, the insurer is not entitled to a refund if it is
later determined the payments were made under a mistake of fact or law. If further
benefits are owed for the same injury, the insurer is entitled to take a partial credit
July 2007 Basic Adjusters’ Training Guide

1-2 MN Department of Labor and Industry
against future periodic benefits. The credit can not exceed 20% of the amount of
the future benefits that otherwise would be payable. Future periodic benefits from
which the insurer can take a credit include, but are not limited to, temporary total
disability, temporary partial disability, economic recovery compensation, permanent
partial disability, and permanent total disability. In situations where the employee is
entitled to a lump sum payment, the insurer can take a credit for the entire
overpayment from the lump sum due to the employee.
If a compensation judge or the commissioner determines the compensation paid by

mistake was not received in good faith, they may order reimbursement of the
compensation. These instances occur if the payments are received by fraudulent
means or if the employee knew the compensation was paid under mistake of fact or
law. (See Minnesota Statutes §45.0135 and 60A.951 for the laws concerning
fraud.)
The insurer can not take a credit against medical expenses or penalty amounts
payable to the employee.
Maximum Medical Improvement (MMI)

MMI is defined in Minnesota Statutes §176.011, Subd. 25. It is the date after which
no further significant recovery from or lasting improvement to a personal injury can
be reasonably anticipated, regardless of subjective complaints. Once the date of
MMI has been validly determined, the insurer does not need to request any further
determinations of MMI unless the employee becomes medically unable to continue
working [see Minnesota Statutes §176.101, Subd. 1(e)(2)]. For purposes of
commencement or recommencement of temporary total disability benefits only, a
new period of maximum medical improvement begins when the employee becomes
medically unable to continue working due to the injury.
MMI determinations are important because the employee’s entitlement to future

benefits can cease 90 days after the insurer serves a written report of MMI on the
employee or as otherwise described in Minnesota Statutes §176.101, Subd. 1(e) to
(l).
Waiting Period
Statutory Language
Below is the statutory language which defines the waiting period.
176.121 Commencement of Compensation.

In cases of temporary total or temporary partial disability no compensation is
allowed for the three calendar days after the disability commenced, except as
provided by Minnesota Statutes §176.135, nor in any case unless the
employer has actual knowledge of the injury or is notified thereof within the
period specified in Minnesota Statutes §176.141. If the disability continues for
ten calendar days or longer, the compensation is computed from the

commencement of the disability. Disability is deemed to commence on the first

calendar day or fraction of a calendar day that the employee is unable to work.
Waiting Period Application

Here are the important elements in applying the waiting period:
• The waiting period is counted in consecutive calendar days, not work days.
• The first day of disability is the first day of the waiting period.
• Any disability (claimed lost time or wages), including a fraction of a day of

disability, is considered the first day of disability regardless of whether the
employee is paid in full by the employer for that day.
• Temporary partial disability, including time lost from work to obtain medical
treatment for a work related injury, is considered a day in which there is
disability.
• If there is disability on the 10th calendar day or beyond (from the first day of
disability), compensation is owed from the first day of disability.
• If the only disability beyond the waiting period is for non-scheduled work days,
generally no compensation is owed for those non-work days.
• Counting the waiting period and paying benefits for the disability are separate
issues. The claim must be reported to the department and action taken within
the time frames previously described if the claimed disability exceeds the
waiting period, even if the insurer is not making payment for the disability.
Waiting Period Examples:

For the following examples, the employee works Monday through Friday.
• First day of disability is Friday, March 4, 2005, and return to work date without
disability is March 7, 2005. The waiting period is March 4th through March 6th.
The FROI does not need to be filed with the department and the insurer does
not owe compensation, as the only disability occurred within the waiting period.
• First day of disability is Friday, March 4, 2005, and return to work date without
disability is March 9, 2005. The waiting period is March 4th through March 6th,
so the FROI needs to be filed with the department and timely payment or
denial must occur. Compensation might be due for March 7th and March 8th.
• First day of disability is March 1, 2005, and return to work date without
disability is March 15, 2005. The FROI needs to be filed with the department
and timely payment or denial must occur. Compensation for the entire period
from March 1st through March 14th might be due, as there is disability on or
after the 10th calendar day from March 1st (March 10th).

disability is March 2, 2005. The employee again has disability beginning on
March 7, 2005, and another return to work date without disability on March 10,
2005. The FROI needs to be filed with the department and timely payment or
denial must occur as the disability extends beyond the waiting period, March
1st through March 3rd. Compensation might be due for March 7th through
March 9th.
disability is March 3, 2005. The employee again has disability beginning
March 10, 2005, and another return to work date without disability on March
15, 2005. The FROI needs to be filed with the department and timely payment
or denial must occur as the disability extends beyond the waiting period, March
1st through March 3rd. Both periods of disability (March 1st and March 2nd
and March 10th through March 14th) might be due, as there is disability on or
after the 10th calendar day from March 1st (March 10th).
For the following example, the employee only works Saturdays and Sundays.
• First day of disability is Saturday, March 5, 2005, and return to work date
without disability is Saturday, March 12, 2005. The waiting period is March 5th
through March 7th. The FROI needs to be filed with the department and timely
action must occur even though compensation is probably not due as March 8th
through March 11th are non-work days.

Waiting Period – Exercise 1A

1. An employee who works Monday through Friday was injured on February 7,
2005. The employee lost one hour from work on the date of injury and
remained off work through February 15, 2005. The employee returned to work
on February 16, 2005. What are the dates of the waiting period?
2. An employee who works Monday through Friday was injured on March 4,

2005. The first day of disability was March 7, 2005, and the employee
returned to work without disability on March 10, 2005. What are the dates of
the waiting period? Are you required to report this claim to the department?
3. An employee who works Monday through Friday was injured on April 8, 2005,
and lost one hour of work on that date. The employer paid the employee full
wages for the date of the injury. The employee returned to work without
disability on April 14, 2005. For which dates do you possibly owe
compensation?
4. An employee who works Monday through Thursday was injured on May 5,

2005. The first day of disability wasn’t until May 16, 2005. The employee
returned to work without disability on May 23, 2005. Disability began again on
May 26, 2005, with a return to work without disability on May 30, 2005. All
dates of disability were authorized by the treating doctor. What are the dates
of the waiting period? Should the waiting period be paid?
5. An employee who works Monday through Friday was injured on April 15, 2005,
and lost three hours of work on the date of injury. The employer paid full
wages for the date of the injury. The employee returned to work without
disability on April 25, 2005. All disability was authorized by the treating doctor.
What are the dates of the waiting period? Should the waiting period be paid?

Liability Determinations
The NOPLD form is used to notify the employee (or heirs/dependents of an
employee), the employer, and the department of the insurer’s position regarding
primary liability on the claim, including specific details of the accepted or denied
claim. It is important to remember that this form could be completed several
different times on the same claim to reflect changes in the insurer’s position or
changes in the specific details of the claim. These subsequent filings of the form
would be considered amended NOPLD forms. In addition, this form outlines the
employee’s rights and responsibilities.
The NOPLD form is used to convey to all parties on all claims (with claimed
disability that exceeds the waiting period) what action the insurer is initially taking
on the claim. In most situations it is filed only once on a claim. However in certain
circumstances it can be filed multiple times. The following are some of the
examples where this might occur:
• When the insurer initially denies primary liability, but later accepts liability.
• When the insurer initially accepts a claim and pays wage loss benefits, but
later denies primary liability within 60 days per Minnesota Statutes §176.221,
Subd. 1.
• When the insurer accepts a claim on which there are no wage loss benefits
initially paid, but later pays wage loss benefits voluntarily.
Investigation Tips
An investigation or a good faith effort to attempt an investigation of the claim must
be done on each claim before an informed decision can be made regarding
acceptance or denial of liability. What is considered an adequate investigation can
vary depending upon the type of injury, whether it was witnessed, and if the injury
was caused, accelerated, or aggravated by the work activities. At times it is not
necessary to talk to the employee prior to making a determination. Other times it
might not be necessary to reach the employee’s supervisor prior to making a
determination.
Acceptance of Liability
(with payment of wage loss benefits)
After completing an investigation, if the injury and the claimed wage loss benefits
are determined to be compensable, the insurer checks Box 1 on the NOPLD form.
The payment must be made within 14 days of the first day of disability or the date
the employer was aware of disability, whichever is later, to be considered timely.
Complete all boxes that are applicable to the injury. If payments are continuing,
indicate the day of the week that further checks will be issued and how often. Be
sure to include the dates the payment covers, not just the amount of time covered.
For example, state the period is May 2, 2005, through May 8, 2005, not one week.

Partial Acceptance of Liability

(without payment of wage loss benefits)
For injuries where there is no claimed disability beyond the waiting period, the
FROI and NOPLD are not required to be filed with the department. An exception to
this occurs when the FROI showing possible disability beyond the waiting period
has already been filed with the department. In these situations, Box 2A should be
used on the NOPLD form to explain that liability for the injury is accepted but that
the disability did not exceed the waiting period.
For injuries where there is claimed disability beyond the waiting period, if the
insurer has determined that an injury is compensable but they are denying
responsibility for the wage loss benefits, an NOPLD must be filed with the
department. This is frequently called a partial denial of liability and the insurer
checks Box 2C on the NOPLD form. The NOPLD must be served within 14 days of
the first day of disability or the date the employer was aware of disability, whichever
is later, to be considered timely. The reason given for denying payment of the
wage loss must be specific and not frivolous. Again, remember that this is a denial
of liability and it must be in compliance with all applicable statutes, rules, and case
law.
Denial of Primary Liability

A primary denial of liability is a determination that the injury is not compensable
under Minnesota workers’ compensation statutes and rules. It informs the
employee and the department that the insurer is not voluntarily paying any benefits
because they do not believe the circumstances surrounding the injury indicate the
claim is compensable.
Before a determination is made, the insurer must complete or at least attempt to

complete an investigation of the claim. There can be many questions that need to
be considered, two of which are:
• Did something happen at work and/or is it work related?
• Is it covered under Minnesota workers’ compensation statutes and rules?
If the insurer is denying primary liability, an NOPLD form must be filed with the
department, for any claim where the employee has claimed disability that exceeds
the waiting period. The insurer checks Box 3 on the NOPLD form. The NOPLD
must be served within 14 days of the first day of disability or the date the employer
was aware of disability, whichever is later, to be considered timely.
Denials must meet the criteria in the statutes and rules in order to avoid being
considered non-specific or frivolous. The insurer must attach supporting
documentation, as necessary. If the denial is based on medical information, the
insurer must attach a copy of the medical report. If the medical information was
obtained over the telephone, in addition to stating the substance of the
conversation, the name of the health care provider, along with the date the
telephone information was obtained, should be stated on the form.
In order for a denial to be considered specific, the reasons for the denial must be
clear and state a specific reason in language easily readable to a person of
average intelligence and education. Remember both the employee and the
department must be able to easily understand why the claim was denied.
In order for a denial not to be considered frivolous, the reason for denial must state
a legal basis and provide an accurate statement of facts concerning the claimed
injury. It must also show that an investigation has been completed or that a good
faith effort to investigate has been attempted.
Presently, the department reviews denials for:
• proper wording
• inclusion of reported facts surrounding the injury
• extent of the investigation performed by the insurer
• a legal basis for the denial as stated by the insurer
• inclusion of supporting documentation, as necessary
Failure to give a specific and non-frivolous reason for the denial or failure to
investigate or attempt to investigate a claim can be grounds for assessment of
frivolous1 and/or non-specific denial2 penalties. Minnesota statutes and rules
outline some basic information regarding what are considered frivolous and non-
specific denials.
Statutory Language and Rule Cites

For additional information regarding liability determinations see Minnesota Statutes
§176.194, Subd. 3(4) and Subd. 4, 176.221, Subd. 3a, and 176.225, Subd. 1. Also
see Minnesota Rules Parts 5220.2570, Subp. 10B, 5220.2540, Subp. 4,
5220.2760, Subp. 1C, and 5220.2770, Subp. 2E.
1
Frivolous Denials
Minnesota Rules Part 5220.2570, Subp. 10B defines a frivolous denial as one which:
(1) does not state facts indicating that an investigation has been completed or that a good
faith effort to investigate has been attempted; or
(2) states a basis which is a clearly inaccurate statement of fact or the applicable law.
2
Non-specific denials
Minnesota Rules Part 5220.2570, Subp. 2E gives information regarding what is not considered a
specific denial. In part the rule states:
... A denial which states only that the injury did not arise out of and in the course and scope
of employment or that the injury was denied for lack of a medical report, for example, is not
specific within the meaning of this item; ...

Liability Determination – Exercise 1B
Part 1
See the FROI for Susan Jones. The employee normally works Monday through
Friday. You have been unable to reach the employee. Upon contacting the
employer, you are told that the injury was witnessed and the supervisor took the
employee to a local hospital for immediate medical attention. The employer also
states that the employee has not returned to work yet and according to medical
information, should stay off work at least until the follow-up appointment on
February 11th.
1. Should liability be accepted or denied? Why?
2. What forms need to be filed?
3. What boxes need to be checked on the NOPLD?

Part 2
See the FROI for Sam Smith. This claim has been assigned to you.
1. What steps do you need to take to determine if the claim is compensable?
2. What questions should you ask of the employer/employee?
3. If the treating doctor said she had been treating the employee since he hurt his
back three weeks ago lifting a refrigerator at home, would this affect your
investigation and determination of liability?
4. Based on your determination, what box needs to be checked on the NOPLD?

Part 3
See the FROI for Andrew Anderson. You have tried on three occasions to reach
the employee and left messages twice. The employee hasn’t called you back. The
employer tells you the employee was returning from a work-related training seminar
when the vehicle accident occurred. The employee was taken from the scene of
the accident by ambulance. You contact the treating doctor listed on the FROI.
The doctor tells you the records have not been transcribed yet.
1. Should primary liability be accepted to denied? Why?
2. What boxes should be checked on the NOPLD?
3. After paying benefits for four weeks, the employee tells you he stopped at his
parent’s house on his way back from training. The police report verifies that
the accident occurred two blocks from his parent’s home. What should you do?

Minnesota Department of Labor and Industry
Workers’ Compensation Division First Report of Injury
443 Lafayette Road North See Instructions on Reverse Side
St. Paul, MN 55155-4305 PRINT or TYPE your responses.
(651) 284-5030 F R 0 1
Enter dates in MM/DD/YYYY format.
1. EMPLOYEE SOCIAL SECURITY # 2. OSHA Case # DO NOT USE THIS SPACE
555-55-5555 01
3. DATE OF CLAIMED INJURY 4. Time of ✔ am 5. Time employee ✔ am
injury began work on date
02/03/2005 8:30 pm of injury 7 :30 pm
6. EMPLOYEE Name (last, first, middle) 7. Gender 8. Marital ✔ Married
JONES, SUSAN M M ✔ F
Status Unmarried
9. Home Address 10. Home phone # 11. Date of birth
1600 MAIN ST (651) 666-6666 02/12/1969

City State Zip Code 12. Occupation 13. Regular department 14. Date hired
HOMETOWN MN 55155 MACHINE OPERATO MOLDING 07/01/1992

15. Average weekly wage 16. Rate per hour 17. Hours per day 18. Days per week 19. Employment ✔ Full time Part time
Status
$400.00 $10.00 8.00 5 Seasonal Volunteer
20. Weekly value of: Meals Lodging

nd
2 Income 21. Apprentice Yes ✔ No
22. Tell us how the injury occurred and what the employee was doing before the incident (give details). 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.”
Caught left hand in molding machine
23. What was the injury or illness (include the part(s) of body)? Examples: chemical 24. What tools, equipment, machines, objects, or substances were involved?
burn left hand, broken left leg, carpal tunnel syndrome in left wrist. Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
Amputation of left index finger Molding machine
25. Did injury occur on employer’s premises? 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOI)
✔ Yes No 02/03/2005 ✔ Yes No No lost time on DOI
If no, indicate name and address of place of occurrence
28. Date employer notified of injury 29. Date employer notified of lost time
02/03/2005 02/03/2005
30. Return to work date 31. Date of death
32. TREATING PHYSICIAN (name, address, and phone) 33. HOSPITAL/CLINIC (name and address) (if any) 34. Emergency Room Visit
REGIONS HOSPITAL ER ✔ Yes No
ST PAUL, MN 35. Overnight in-patient
Yes No
36. EMPLOYER Legal name 37. EMPLOYER DBA name (if different)
ABC MACHINE
38. Mailing address 39. Employer FEIN 40. Unemployment ID#
2000 RIVER ST
City State Zip Code 41. Employer’s contact name and phone #
HOMETOWN MN 55155 JOHN JOHNSON, SAFETY OFFICE (651) 444-4444

42. Physical address (if different) 43. Witness (name and phone)
MIKE SMITH (651) 333-3333

City State Zip Code 44. NAICS code 45. Date form completed
02/03/2005
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one) Insurer
YOUR INSURANCE COMPANY TPA
47. Insured legal name 52. CA address
48. Policy # or self-insured certificate # City State Zip Code
49. Insurer FEIN 50. Date insurer received notice 53. CA FEIN 54. Claim #
02/08/2005 123123
MN FR01 (02/06) Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)
GENERAL INSTRUCTIONS TO THE EMPLOYER
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 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. Self-insured
employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly
to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if 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 within seven days of the occurrence.
Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits.
Failure to complete the form may result in delayed processing and possible penalties. 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’s web site at www.doli.state.mn.us. Employees are not responsible for
completing this form.
SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT
SPECIFIC INSTRUCTIONS FOR 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 15-20: 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.
• 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 notify your insurer if the employee misses time due to this injury after that date.
• Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstgov.gov and click on
Employer ID Number under Business.
• 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.
INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER
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 (per 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 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 Federal Employment ID number (FEIN) number.
• 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.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030
or 1-800-342-5354 (DIAL-DLI)/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.
(651) 284-5030 F R 0 1
666-66-6666
3. DATE OF CLAIMED INJURY 4. Time of am 5. Time employee am
03/02/2005 pm of injury pm
SMITH, SAMUEL S ✔ M F
Status Unmarried
320 1ST AVE S (651) 777-7777 08/08/1955

HOMETOWN MN 55155 LABORER BOX DEPT 06/22/1975

Status
$600.00 $15.00 10.00 4 Seasonal Volunteer

nd
Normal job duties, complained last week or so
Lower back pain
✔ Yes No 03/03/2005 Yes No ✔ No lost time on DOI
03/03/2005 03/03/2005
DR JOHNSON HEALTHPARTNERS Yes ✔ No
HOMETOWN, MN 35. Overnight in-patient
Yes No
DO BOX US IN
555 SOMEWHERE
ST PAUL MN 55155 I M SAFETY, CONTROLLER (651) 888-8888

NONE
03/10/2005
03/15/2005
301.
(651) 284-5030 F R 0 1
444-44-4444
3. DATE OF CLAIMED INJURY 4. Time of am 5. Time employee am
04/26/2005 3:00 ✔ pm of injury pm
ANDERSON, ANDREW A ✔ M F
Status Unmarried
1 MAIN ST (612) 999-9999 04/15/1950

MINNEAPOLIS MN AUDITOR 01/01/1988

Status
$2,000.00 5 Seasonal Volunteer

nd
Vehicle accident
Fractured left leg, neck pain, bruises
Yes ✔ No 04/26/2005 Yes ✔ No No lost time on DOI
HWY 394 & HWY 100
04/27/2005 04/27/2005
METHODIST HOSPITAL ✔ Yes No
ST LOUIS PARK, MN 35. Overnight in-patient
Yes ✔ No
XYZ ENTERPRISES
1234 ANY PL
ST PAUL MN NEIL NUMBERS, OWNER (651) 999-9999

UNKNOWN
05/02/2005
05/05/2005
301.

Department of Labor: WC Batg 1

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Section 1

Workers’ Compensation Overview

A work-related injury can be any condition that is caused, aggravated, or

For example, an employee is injured on August 30 with earnings of $400.00 per

Basic Adjusters’ Training Guide July 2007

First Report of Injury (FROI)

Other Time Requirements

July 2007 Basic Adjusters’ Training Guide

If a compensation judge or the commissioner determines the compensation paid by

Maximum Medical Improvement (MMI)

MMI determinations are important because the employee’s entitlement to future

Below is the statutory language which defines the waiting period.

176.121 Commencement of Compensation.

Basic Adjusters’ Training Guide July 2007

commencement of the disability. Disability is deemed to commence on the first

Waiting Period Application

• Any disability (claimed lost time or wages), including a fraction of a day of

Waiting Period Examples:

July 2007 Basic Adjusters’ Training Guide

Basic Adjusters’ Training Guide July 2007

Waiting Period – Exercise 1A

2. An employee who works Monday through Friday was injured on March 4,

4. An employee who works Monday through Thursday was injured on May 5,

July 2007 Basic Adjusters’ Training Guide

Basic Adjusters’ Training Guide July 2007

Partial Acceptance of Liability

Denial of Primary Liability

Before a determination is made, the insurer must complete or at least attempt to

• Did something happen at work and/or is it work related?

• Is it covered under Minnesota workers’ compensation statutes and rules?

Presently, the department reviews denials for:

• inclusion of reported facts surrounding the injury

• extent of the investigation performed by the insurer

• a legal basis for the denial as stated by the insurer

• inclusion of supporting documentation, as necessary

Statutory Language and Rule Cites

Basic Adjusters’ Training Guide July 2007

Liability Determination – Exercise 1B

1. Should liability be accepted or denied? Why?

2. What forms need to be filed?

3. What boxes need to be checked on the NOPLD?

July 2007 Basic Adjusters’ Training Guide

1. What steps do you need to take to determine if the claim is compensable?

2. What questions should you ask of the employer/employee?

4. Based on your determination, what box needs to be checked on the NOPLD?

Basic Adjusters’ Training Guide July 2007

1. Should primary liability be accepted to denied? Why?

2. What boxes should be checked on the NOPLD?

July 2007 Basic Adjusters’ Training Guide

1600 MAIN ST (651) 666-6666 02/12/1969

HOMETOWN MN 55155 MACHINE OPERATO MOLDING 07/01/1992

20. Weekly value of: Meals Lodging

Caught left hand in molding machine

Amputation of left index finger Molding machine

HOMETOWN MN 55155 JOHN JOHNSON, SAFETY OFFICE (651) 444-4444

MIKE SMITH (651) 333-3333

48. Policy # or self-insured certificate # City State Zip Code

SEND REPORT TO INSURER IMMEDIATELY – DO NOT WAIT FOR DOCTOR’S REPORT

SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM

INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER

320 1ST AVE S (651) 777-7777 08/08/1955

HOMETOWN MN 55155 LABORER BOX DEPT 06/22/1975