Report of employer conducting business without workers' compensation coverage
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)284-5911.
How long has this employer been uninsured?
Other details:* (i.e.
Job site, subcontractor(if any), workplace injuries, type of business)
250 character limit
Click the more
button to add additional employees.
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.
"By submitting this information, you agree you have read and understand the statement above."