Notice Of Intention To Discontinue Workers Compensation Benefits Page 2
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1
2Instead of requesting a conference, you or your attorney may request a formal hearing by filing an Objection to Discontinuance
form with the Workers’ Compensation Division. A formal hearing process takes longer than the conference process. You may
want to talk with an attorney.
If you have questions about your benefits, contact the claim representative whose telephone number is at the bottom of the
page. If you still have questions after talking to the claim representative, contact the Workers’ Compensation Division office:
525 Lake Ave. S., Suite 330
443 Lafayette Road N.
Duluth, MN 55802
St. Paul, MN 55155
(218) 733-7810
(651) 284-5030
1-800-342-5354
1-800-342-5354
Include contingent attorney fees in benefit totals
Average weekly wage at DOI $
____________________
The following benefits have been paid
From
Through
Weeks
Rate
Total
Temporary total disability or
Permanent total disability
Notes
Benefit addendum attached
Temporary partial disability
Retraining benefits
Permanent partial disability ___________%
Injuries on or after 10/01/1995
Impairment compensation (injuries 01/01/1984 through 09/30/1995)
Economic recovery compensation (injuries 01/01/1984 through 09/30/1995)
Part of body_______________________ (injuries before 01/01/1984)
Attorney fees/expenses
Benefit totals
M.S. § 176.081, subd. 1, contingent
Lump-sum payment under award or order
fees paid
(include contingent attorney fees)
M.S. § 176.081, subd. 1, contingent
Attorney fees reimbursed to
fees still withheld
employee (M.S. § 176.081, subd. 7)
Heaton fees paid
Interest paid
Total compensation paid
Roraff fees paid
(include contingent attorney fees)
Total supplementary benefits
M.S. § 176.191 fees paid
(include contingent attorney fees)
Other fees paid
Total medical expenses paid to date
Costs and disbursements paid
Insurer/self-insurer/TPA
Claim representative name
Address
Phone number (include area code)
Extension
Date served on employee’s attorney
City
State
ZIP code
Date served on employee
This document can be given to you in Braille, large print or audio. To request, call (651) 284-5032 or 1-800-342-5354.
Any person who, with intent to defraud, receives workers’ compensation benefits to which the person is not entitled by
knowingly misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant
to Minnesota Statutes § 609.52, subdivision 3.
Send to: Workers’ Compensation Division, employee and the employee’s attorney (if any).
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