Mail or fax to:
Notice of Intention to Discontinue
Department of Labor and Industry
Workers’ Compensation Benefits
Workers’ Compensation Division
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)
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
You returned to work at reduced hours or wage on
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
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)