Your average hourly wage is extreme (less than $5 or
greater than $80). If correct, please check the box below. If
not, make corrections on the MCPAP Data Screen.
Note: Executive officer's, partners, or sole proprietors wages should be limited
Extreme rate is fine
This application may be rejected if it does not include all WC code numbers, all
Minnesota wage data and all hours worked or if data is not submitted for all commonly
owned businesses. Please retain a copy of this form for auditing purposes.
Applications with an electronic submission date later than April 1,
will be subject to a two-point (.02) late penalty adjustment in the