Non-Resident To Serve As Local Counsel Assessment

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Minnesota Department of Labor and Industry
PO Box 64221
St. Paul, MN 55164-0221
C E 0 0 0 3
(651) 284-5030
WID or SSN
DATE OF INJURY
EMPLOYEE NAME
PENALTY NUMBER
INSURER’S CLAIM NUMBER
DEPARTMENT OF LABOR AND INDUSTRY
WORKERS’ COMPENSATION DIVISION
VS.
EMPLOYER
OBJECTION TO PENALTY
ASSESSMENT
AND
INSURER
Minnesota Rules Part 5220.2870 PENALTY OBJECTION AND HEARING states: “A party to whom notice of assessment has
been issued may object to the penalty assessment by filing a written objection with the division on the form prescribed by the
commissioner. The objection must also be served on the employee if the penalty is payable to the employee. The objection
must be filed and served within 30 days after the date the notice of assessment was served on that party by the division.
(emphasis added) The written objection must contain a detailed statement explaining the legal or factual basis for the objection
and including any documentation supporting the objection. Upon receipt of a timely objection, unresolved issues shall be
referred for a hearing to determine the amount and conditions of any penalty. Objections which are not served and filed within
the 30-day objection period must be dismissed by a compensation judge.”
The above-named Employer/Insurer objects to the following portion of the Notice of Assessment of Penalty filed in this matter
and requests that this matter be set for hearing.
1) Additional award to the Employee (M.S. § 176.225)
2) Payment to the Assigned Risk Safety Account (M.S. § 176.221, subd. 3 or 3a)
3) Penalty for failure to file required report (M.S. § 176.231, subd. 10)
4) Other, please explain:
Detailed statement/documentation to support your objection (M.R. 5220.2870):
(Attached additional sheets as necessary.)
Objection to Penalty Assessment filed by:
Filing party is
NAME
Employer
COMPANY NAME
Insurer
ADDRESS
Attorney
CITY
STATE
ZIP
Other_____________________________
TELEPHONE
MN CE0003 (5/08)

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