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:
the name, address, and telephone number of the claimant's employer if the claimant is seeking compensation for personal injury or claiming hardship;
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;
the name, address, and phone number of any medical practitioner who examined the claimant regarding the personal injury;
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;
the identity of any government agency or official that the claimant contacted concerning the presence of harmful substances;
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;
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;
the amount of reimbursement the claimant has received for losses and identification of the sources of reimbursement;
a description of actions the claimant has taken if any to recover compensation from the person responsible for the release of the harmful substance;
a statement signed by the claimant, certifying under oath the accuracy and completeness of the information provided;
an authorization signed by the claimant for access to medical and financial records if the compensation requested is for personal injury or hardship; and
MS s 115B.28
11 SR 2077; L 1989 c 325 s 78; L 2001 1Sp9 art 15 s 32; L 2002 c 379 art 2 s 23
August 18, 2005
Official Publication of the State of Minnesota
Revisor of Statutes