索赔表单

汽车, 责任, and property claim forms

Members can submit auto, 责任, and property claims using any type of format that is most convenient. Here are some forms developed by LMCIT. Submit these types of claims as soon as you can.

• 汽车mobile claim form (doc)
• Liability claim form (doc)
• 财产 claim form (doc)

Workers’ compensation claim forms

Here are the requirements for filing a workers’ compensation claim, according to Minnesota’s Workers’ Compensation Statute:

• Claim must be submitted by the 雇主 (not employee) on a First Report of Injury (FROI) form.
  • A link to that form is below. Only 雇主s that are LMCIT members should use this form and submit it to LMCIT.
  • Once the 雇主 has completed the form, email it to LMCIT at [email protected]; fax it to LMCIT at (651) 281-1297; or mail it to LMCIT at 145 University Ave W, St. Paul MN 55103-2044. Do not submit this form to the Minnesota Department of Labor and Industry.

• Claim must be submitted within 10 days of first knowledge of an employee’s injuries (given a death or serious injury, claim must be reported by phone within 48 hours and a FROI must be submitted within seven days of injury). Employers must provide employees with a copy of the Minnesota Workers’ Compensation System Employee Information Sheet at the time the employee is given a copy of the FROI.

• • First Report of Injury (pdf): Use this form to report injuries to employees or emergency response volunteers (including paid on-call volunteers)
  • Volunteer Accident Form (doc): Use this form to report injuries to all other volunteers who do general volunteering (such as those helping with park and rec programs, homeless shelters, and special events)
  • Workers’ Compensation System Employee Information Sheet (pdf)