Legal Forms >> Minnesota >> Workers' Compensation >> Claims and Reports
Form #:AC03 Formerly form 3202. This form is to be filled out and submitted once per year to request reimbursement for an injury or death that took place on the job. If government disability benefits have changed (other than standard cost-of-living adjustments), evidence of this must be attached. (Downloadable PDF)
Name:Annual Claim for Reimbursement of Supplementary Benefits (Downloadable PDF) Form Number: AC03 State:Minnesota Statute:N/A Form Category:> Claims and Reports' itemprop="category">Claims and Reports
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