Minnesota Department of Labor and Industry

Report of employer conducting business without workers' compensation coverage

This form may be used to report an uninsured employer to the Claims Services and Investigations' Investigative Services Section of the Minnesota Department of Labor and Industry.

Fields marked by required 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) 284-5109.

 
Business
Business namerequired
Business address
Addressrequired

Cityrequired
 Staterequired
 ZIP code
Business phone
 Cell phone
Owner
First namerequired
Last namerequired
Middle name
Age
Home phone
Home address

City
 State
 ZIP code
How long has this employer been uninsured?
Other details
required indicates required field. If you cannot provide an answer to a required field, enter "unknown".  



Employee(s) (enter up to four employees)
First name
 Last name
 Middle name
Home phone
Home address

City
 		State
 		ZIP code
Dates employed
 Rate of pay
First name
 Last name
 Middle name
Home phone
Home address

City
 		State
 		ZIP code
Dates employed
 Rate of pay
First name
 Last name
 Middle name
Home phone
Home address

City
 		State
 		ZIP code
Dates employed
 Rate of pay
First name
 Last name
 Middle name
Home phone
Home address

City
 		State
 		ZIP code
Dates employed
 Rate of pay
required indicates required field. If you cannot provide an answer to a required field, enter "unknown".

About you (optional)
First name
 Last name
Phone
E-mail address

Click the button below to submit this report.