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Policy including effective dates or self-insured certificate 49. Insurer FEIN 53. CA FEIN Insurer TPA 50. The Minnesota implementation guide can be found on the Department s website at www. dli. mn.gov/WC/Edi. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR For first reports of injury filed on or after Jan. 1 2014 Pursuant to Minnesota Statutes section 176. Date employer notified of injury No lost time on DOI 30. Return to work date 31. RTW same employer 33. INSURER name 51. CLAIMS ADMIN...

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WC7595XDOC refers to a specific document or form that needs to be filed for a particular purpose.

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