Form Mn Mo0001 (9/15) - Motion/application To Intervene
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State of Minnesota
Mail or fax to:
Office of Administrative Hearings
P.O. Box 64221
Workers’ Compensation Division
St. Paul, MN 55164-0221
Fax: (651) 284-5731
MO0001
(651) 361-7900
DO NOT USE THIS SPACE
WID number
Date(s) of claimed injury
Motion/Application to
Intervene
Employee
vs.
Print in ink or type.
Employer(s)
Enter dates in MM/DD/YYYY format.
and
Insurer(s)
and
1.
The applicant is filing this Motion to Intervene in the following disputes(s):
Claim Petition dated ______________________
Rehabilitation Request dated ______________________
Medical Request dated __________________
Request for Formal Hearing 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 section
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 that 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).
The applicant’s representative _________________________________________ (print name and title), can be contacted at
5.
________________________ (phone number).
6.
This statement applies only to proceedings that may be scheduled at the Office of Administrative Hearings (OAH): The
applicant elects to attend all settlement conferences, pretrial conferences and other prehearing conferences by telephone, and
will be available during the scheduled conferences at the above telephone number. The applicant acknowledges that electing to
attend by telephone any settlement conference, pretrial conference, other prehearing conference, or a hearing at OAH, requires
the applicant to comply with the OAH Standing Order Regarding Intervention, dated August 26, 2015 (available on the OAH
website). The applicant also acknowledges that it has a right to appear in person at any scheduled OAH proceeding.
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 (9/15)
(over)
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