Minn. R. agency 167, ch. 7190, CLAIM APPLICATION, pt. 7190.0006

Current through Register Vol. 49, No. 20, November 12, 2024

Part 7190.0006 - APPLICATION FOR COMPENSATION

A claimant must apply for compensation within the time limits established by Minnesota Statutes, section 115B.30, subdivision 3. The application must be on a form supplied by the Pollution Control Agency, containing substantially the following:

A. the name, address, telephone number, social security number, and age of the claimant;

B. the name, address, and telephone number of the claimant's employer if the claimant is seeking compensation for personal injury or claiming hardship;

C. the name, address, telephone number, and relationship to the claimant of any representative;

D. the identity of the harmful substances to which the claimant was exposed;

E. a description of the property damage or personal injury;

F. the date the claimant discovered the property damage or the personal injury;

G. the date the claimant discovered the connection between the injury or property damage and the exposure to harmful substances and an explanation of how the connection was discovered;

H. the name, address, and phone number of any medical practitioner who examined the claimant regarding the personal injury;

I. in the case of death as a personal injury, the cause of death on the death record and the report of an autopsy if performed;

J. the identity of any government agency or official that the claimant contacted concerning the presence of harmful substances;

K. the identity, if the claimant knows, of the source of the harmful substances related to the exposure, including the location of the source and the person responsible for the release;

L. the duration and location of the exposure to the substances;

M. the amount of compensation the claimant seeks from the agency for the property damage or personal injury including losses for medical expenses, lost wages, or income and lost household labor;

N. the amount of reimbursement the claimant has received for losses and identification of the sources of reimbursement;

O. a description of actions the claimant has taken if any to recover compensation from the person responsible for the release of the harmful substance;

P. a statement signed by the claimant, certifying under oath the accuracy and completeness of the information provided;

Q. an authorization signed by the claimant for access to medical and financial records if the compensation requested is for personal injury or hardship; and

R. other relevant information the agency deems essential to a determination on the application.

Minn. R. agency 167, ch. 7190, CLAIM APPLICATION, pt. 7190.0006

11 SR 2077; L 1989 c 325 s 78; L 2001 1Sp9 art 15 s 32; L 2002 c 379 art 2 s 23

Statutory Authority: MS s 115B.28