Report of employer conducting business without workers' compensation coverage

This form may be used to report an uninsured employer to the Special Compensation Fund unit at the Minnesota Department of Labor and Industry.

Fields marked by * are required and cannot be left blank. If you cannot provide an answer to a required field, enter "unknown". If you have any questions, call (651) 284-5950.

Establishment/Business name: *

	Business address			Owner
Address1:*		required	First name:*		required
Address2:			Last name:*		required
City:*		required	MI:
State:*		required	Age:
Zip code:			Phone:
Phone:*		required	Address1:
Fax:			Address2:
			City:
			State:
			Zip code:

How long has this employer been uninsured?

Other details:* (i.e. Job site, subcontractor (if any), workplace injuries, type of business) 250 character limit
remaining characters

Employee(s) (enter up to four employees)


First name:
Last name:
MI:
Dates employed:
more...

Click the more button to add additional employees.

About you (optional)

Notice: The information you provided above will be used to investigate whether there has been a violation of workers' compensation insurance law. We are requesting your name, telephone number, and e-mail address so that we can contact you if we need more information. You do not have to give us any information about yourself. However, if you do not provide your contact information, we may not be able to get the details we need to fully investigate this matter.

Your identity is not public and will only be given to people authorized by law to receive the information, such as:

Department of Labor and Industry staff who need the information for their work;
the Attorney General’s Office;
the Office of the Legislative Auditor;
the Office of Administrative Hearings or the courts; or
a person with a court order to obtain the information.

First name:
Last name:
Phone:
E-mail:
"By submitting this information, you agree you have read and understand the statement above."