Minnesota Statutes Labor, Industry (Ch. 175-189) § 176.145. Service of notice, form

The notice referred to in section 176.141 may be served personally upon the employer, or upon any agent of the employer upon whom a summons may be served in a civil action, or by sending it by certified mail to the employer at the last known residence or business place thereof within the state, and may be substantially in the following form:


You are hereby notified that an injury was received by (Name) ․․․․․․․․․․․․․․․․․․․․, who was in your employment at (place) ․․․․․․․․․․․․, while engaged as (kind of work) ․․․․․․․․․․․․, on or about the ․․․․․․ day of ․․․․․․․․․․․․, ․․․․, and who is now located at (give town, street, and number) ․․․․․․․․․․․․;  that, so far as now known, the nature of the injury was ․․․․․․․․․․․․, and that compensation may be claimed therefor.

Dated ․․․․․․․․․․․․․․․․․․, ․․․․ (signed) ․․․․․․․․․․․․․․․․․․․․

(giving address)”

No variation from this form shall be material if the notice is sufficient to advise the employer that a certain employee, by name, received a specified injury in the course of employment on or about a specified time, at or near a certain place specified.

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