WORKERS’ COMPENSATION INTERVENOR CONTACT INFORMATION
The information on this form will be used to create a master list of contact information for entities to be given notice of the right to intervene in a workers’ compensation dispute to request payment by the workers’ compensation insurer. The information you provide below will be placed on the Office of Administrative Hearing’s web site at http://www.oah.state.mn.us/wcforms/forms.html.
You are not required to provide this information. However, by providing correct contact information you will help parties to workers’ compensation claims in which you have an interest provide your organization with direct, accurate and timely notice of the right to intervene. The agencies will periodically provide you with an opportunity to update the information. However, please send updated information to OAH at any time if this information changes.
Name of potential intervenor’s organization or company: ______________________________________________________
Mailing address:
______________________________________________________
______________________________________________________
______________________________________________________
Information regarding primary contact person with authority to settle your claims:
Name:_____________________________________________
Phone number:______________________________________
E-mail address: _____________________________________
Fax number:________________________________________
Information regarding alternate contact person with authority to settle claims:
Name:_____________________________________________
Phone number:______________________________________
E-mail address:______________________________________
Fax number:_________________________________________
Website address (if you wish to provide a link to additional information regarding your workers’ compensation cases):________________________________________
Please send this form to: Kim Pogue
Office of Administrative Hearings
(651) 361-7891, kim.pogue@state.mn.us