Minnesota > Workers Comp
Notice Of Intention To Discontinue Workers Compensation Benefits ND01 - Minnesota
| Notice Of Intention To Discontinue Workers Compensation Benefits Form. This is a Minnesota form and can be used in Workers Comp . |
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Notice of Intention to Discontinue Workers Compensation Benefits Please PRINT or TYPE your responses. N D 0 1Enter dates in MM/DD/YYYY format. SOCIAL SECURITY NUMBER DATE OF INJURY DO NOT USE THIS SPACEEMPLOYEE EMPLOYER EMPLOYEE ADDRESS CITY STATE ZIP CODE INSURER CLAIM NUMBER Your benefits for (check one) TEMPORARY TOTAL TEMPORARY PARTIAL PERMANENT TOTAL disability are being discontinued for one of the following reasons: 1. You have returned to work on (date) at full wage. at reduced hours or wages. 2. You have returned to work on (date) Temporary partial will will not be paid. Temporary partial is usually based on the difference between your wage of at the time of the injury and your current weekly wage. $ (date).3 . Reasons other than return to work. Payment will be made through Give reasons and facts below: (Appropriate medical reports must be attached.) 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 You are responsible for reviewing this form to make sure that you have been properly paid the benefits due you. YOU DO NOT NEED TO TAKE ANY ACTION IF YOU BELIEVE TH AT YOU HAVE RECEIVED ALL BENEFITS DUE OR THAT THE REDUCTION OF BENEFITS IS PROPER. If Box 1 or 2 is checked above and you believe that your benefits should be reinstated due to an occurrence during theinitial 14 calendar days after your retu rn to work, you may request a conference . Your request must be received by theWorkers Compensation Division within 30 calendar days after the date that you returned to work. If Box 3 is checked above and you think the reason for stopping your benefits is incorrect, or you disagree with the proposed discontinuance, you may request a conference. Your re quest must be received within 12 calendar days after thisnotice is received by the Workers Compensation Division. TO REQUEST A CONFERENCE, YOU MUST MAIL OR DELIVE R THE ATTACHED FORM TO THE WORKERS COMPENSATION DIVISION SO THAT IT IS RECEIVED WITHIN THE ABOVE TIME LIMITS. TELEPHONE REQUESTS WILL ALSO BE ACCEPTED AT (612) 349-2513 OR 1-800-342-5354. The conference will be scheduled within 10 calendar days of the date your request is received by the Division. You, youremployer, and the insurer will be invited to attend. You are not required to bring an attorney, but may bring one if you wish. You should bring to the conference any current reports and return-to-work restrictions, if available. You may instead file an Objection to Discontinuance with the Di vision. This is a formal procedure before a compensation judgewhich takes longer than the administrative conference process a nd usually requires an attorney. If you do this, your benefitswill stop on the date stated in this notice and will not be paid during the time you wait for the hearing. MN ND01 (6/03) -over- <<<<<<<<<********>>>>>>>>>>>>> 2If the insurer is denying primary liability for your claim and you disagree with the denial, cannot return to your former employment and would like vocational reha bilitation assistance, contact the Depart ment of Labor and Industry, Vocational Rehabilitation Unit at (651) 284-5114. If you have questions about your benefits, you should first contact the claim representative whose telephone number is at the bottom of the page. Be sure to provide that person with any addi tional information you have to support your claim. If you stillhave questions, contact the Workers Compensation Divisions Customer Assistance Unit at the office nearest you. Minnesota Department of Labor and Industry 5 North Third Avenue West, Suite 400 443 Lafayette Road North Duluth, MN 55802-1614 St. Paul, MN 55155-4301 Telephone: (218) 733-7810 Telephone: (651) 284-5030 1-800-365-4584 1-800-342-5354 This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5 030or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. 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 SECTION 609.52, SUBDIVISION 3. THE FOLLOWING BENEFITS HAVE BEEN PAID FROM THROUGH WEEKS RATE *TOTAL Temporary Total Disability or Permanent Total Disability Benefit Addendum Attached Temporary Partial Disability Retraining Benefits Permanent Partial Disability % Injuries on or after 10/01/1995 Impairment Compensation (injuries 01/01/1984 - 09/30/1995) Economic Recovery Compensation (injuries 01/01/1984 - 09/30/1995) [part of body] (injuries before 01/01/1984) Attorney Fees/Expenses Benefit Totals *Lump Sum Payment Under M.S. 176.081, subd. 1 & 3 Paid Award or Order M.S. 176.081, subd. 1 & 3 Attorney Fees Reimbursed to Still Withheld Employee (M.S. 176.081, subd. 7) Heaton Fees Paid Interest Paid Roraff Fees Paid *TOTAL COMPENSATION PAID M.S. 176.191 Paid *Total Supplementary Benefits Other Fees Paid Total Medical Expenses Paid to Date Costs & Disbursements Paid INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME AREA CODE ADDRESS PHONE NUMBER CITY STATE ZIP CODE DATE SERVED ON EMPLOYEE DATE SERVED ON ATTORNEY * Include attorney fees in these totals. Distribution: Workers Compensation Division, Employer, Employee, Insurer
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