Minnesota Administrative Rules

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.

Statutory Authority:

MS s 115B.28

History:

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

Published Electronically:

August 18, 2005