Fillable Notice Of Intention To Discontinue Workers Compensation Benefits printable pdf download

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Mail or fax to:

Notice of Intention to Discontinue

Department of Labor and Industry

Workers’ Compensation Benefits

Workers’ Compensation Division

ND0 1

P.O. Box 64221

St. Paul, MN 55164-0221

Print in ink or type

DO NOT USE THIS SPACE

(651) 284-5032 or 1-800-342-5354

Enter dates in MM/DD/YYYY format

Fax: (651) 284-5731

WID number or SSN

Date of injury

Employee (last, first, middle initial)

Employer

Employee address

Notes

City

State

ZIP code

Insurer claim number

Your benefits for (check one)

temporary total disability

temporary partial disability

permanent total disability

are being discontinued or reduced for the following reason(s):

You returned to work at full wage on

(date).

____________________________

You returned to work at reduced hours or wage on

(date).

____________________________

Temporary partial disability benefits

will be paid or

will not be paid. Temporary partial disability benefits are usually

two-thirds of the difference between your average weekly wage at the time of the injury and your current weekly wage.

For reasons other than return to work as stated below. (Relevant medical reports or other documents must be attached.) Payment

will be made through

(date).

____________________________

Reasonable medical expenses and any permanent partial disability due will still be paid unless your claim has been denied.

INSTRUCTIONS TO EMPLOYEE – THIS REQUIRES YOUR IMMEDIATE ATTENTION

Review this form to make sure your benefits have been properly paid.

You do not need to take any action if you agree the discontinuance or the reduction of benefits is proper.

If box 1 or 2 above is checked, you may request a conference if you think your benefits should be reinstated due to occurrences during

the initial 14 calendar days after your return to work. Your request must be received by the Workers’ Compensation Division within 30

calendar days after the date you returned to work.

If box 3 above is checked, you may request a conference if you think the reason for stopping your benefits is incorrect or you disagree

with the proposed discontinuance. Your request must be received within 12 calendar days after this Notice of Intention to Discontinue

Workers’ Compensation Benefits form is received by the Workers’ Compensation Division.

If the insurer is denying liability for your claim and you disagree with the denial, cannot return to your former employment and would like

vocational rehabilitation assistance, call the Department of Labor and Industry, Vocational Rehabilitation unit, at

(651) 284-5038 for information.

To request a conference, you must mail or deliver the attached form to the Workers’ Compensation Division so it is received within

these time limits. You may also request a conference by calling (651) 361-7901 (Office of Administrative Hearings) or 1-800-342-5354

(Department of Labor and Industry).

The conference will be scheduled within 10 calendar days after your request is received. You, your employer and the insurer will be

invited to attend. You are not required to have an attorney for this conference. If you have an attorney, the attorney will also be invited.

Bring any reports and return-to-work restrictions that show why your benefits should not be discontinued.

MN ND01 (1/17)

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Notice Of Intention To Discontinue Workers Compensation Benefits

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