
Notice Of Benefit Payment {NB01}
This is a Minnesota form that can be used for Workers Comp.
Last updated: 2/19/2018
Description
MN NB01 (5/1) (over) Mail or fax to: Department of Labor and Industry P . O . Box 64221 St. Paul, MN 55164 - 0221 (651) 284 - 5032 or 1 - 800 - 342 - 5354 Fax: (651) 284 - 5731 Notice of Benefit Payment Print i n i nk o r t ype Enter d ates in MM/DD/YYYY f ormat Do n ot u se t his s pace WID number or SSN Date of i njury (DOI) Employee ( last, first, middle initial ) Employer Employee address City State ZIP c ode Insurer claim number The following permanent partial disability benefit will be paid to you : % of whole body according to M ermanent Partial Disability S chedule rule number(s): . The rating is based on the attached medical report of Dr. dated , received by the insurer on (date). This payment is based on the preliminary rating. If your final disability rating is higher, additional payments may be made. For injuries on or after 10/01/1995 : The initial payment of weekly benefits was or will be made on (date) . Benefits will be paid at a weekly rate of $ through (date) for a total of $ . A lump - sum payment of $ , instead of weekl y payments, was or will be made on (date) as requested by the employee on ( date). For injuries from 01/01/1984 through 09/30/1995 payment of : $ for impairment compensation was or will be paid in a lump sum on (date). Periodic impairment compensation or Periodic economic recovery compensation will be paid at a weekly rat e of $ through (date) for a total of $ . Your final payment of $ for benefits was or will be paid on (date) according to: A. An award on agreement of the parties served and filed on (date) . B. A prior Notice of Benefit Payment form for periodic payment of permanent partial disability dated . C. An administrative decision under M innesota S tatutes 247 176.239 served and filed on (date). D. served and filed on (date). A - up to a Notice of Intention to Discontinue Benefits form served on the employee on ( date ) . Notes American LegalNet, Inc. www.FormsWorkFlow.com Send to: INSTRUCTIONS TO EMPLOYEE Review this form to make sure your benefits have been properly paid. You do not need to take any action if the benefits listed are correct. 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 either Division office: 525 Lake Ave. S., Suite 330 443 Lafayette Road N. Duluth, MN 55802 St. Paul, MN 55155 (218) 733-7810 or 1-800-342-5354 (651) 284-5030 or 1-800-342-5354 Average weekly wage at DOI $ Include contingent attorney fees in benefit totals 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 through 09/30/1995) Economic recovery compensation (injuries 01/01/1984 th rough 09/30/1995) Part of body (injuries before 01/01/1984) Attorney fees/expenses Benefit totals M.S. 247 176.081, subd. 1, contingent fees paid Lump - sum payment under award or order (include contingent attorney fees) M.S. 247 176.081, subd. 1, contingent fees still withheld Attorney fees reimbursed to employee (M.S. 247 176.081, subd. 7) Heaton fees paid Interest paid Roraff fees paid Total compensation paid (include contingent attorney fees) M.S. 247 176.191 fees paid Total supplementary benefits (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 City State ZIP code Date served on employee Date served on attorney This document can be given to you in Braille, large print or audio. To request, call (651) 284-5032 or 1-800-342-5354. gly misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to Minnesota Statutes 247 609.52, subdivision 3. Notes American LegalNet, Inc. www.FormsWorkFlow.com
Related forms
-
Annual Claim For Reimbursement From Secondary Injury Fund
Minnesota/Workers Comp/ -
Application For Approval And Registration - Rehabilitation Consultant Intern
Minnesota/Workers Comp/ -
Application For Registration Or Renewal As Organization Approved For Employment Of Qualified Rehabilitation Consultant Or Independent
Minnesota/Workers Comp/ -
Application For Registration Or Renewal Of Registration As Registered Rehabilitation Vendor
Minnesota/Workers Comp/ -
Application For Renewal Of Qualified Rehabilitation Consultant-Consultant Intern Registration
Minnesota/Workers Comp/ -
Authorization For File Review Or Release Of Copies Of Workers Compensation Claim File
Minnesota/Workers Comp/ -
Benefit Addendum
Minnesota/Workers Comp/ -
Disability Status Report
Minnesota/Workers Comp/ -
Employees Request For Administrative Conference
Minnesota/Workers Comp/ -
First Report Of Injury
Minnesota/Workers Comp/ -
Health Care Provider Report
Minnesota/Workers Comp/ -
Interim Status Report
Minnesota/Workers Comp/ -
Medical Request
Minnesota/Workers Comp/ -
Medical Response
Minnesota/Workers Comp/ -
Notice Of Benefit Payment
Minnesota/Workers Comp/ -
Notice Of Benefit Reinstatement
Minnesota/Workers Comp/ -
Notice Of Discontinuance Of Workers Compensation Benefits Upon Death Of Employee
Minnesota/Workers Comp/ -
Notice Of Discontinuance Of Workers Compensation Dependency Benefits
Minnesota/Workers Comp/ -
Notice Of File Closing
Minnesota/Workers Comp/ -
Notice Of Intention To Claim Reimbursement From Second Injury Fund
Minnesota/Workers Comp/ -
Notice Of Intention To Discontinue Workers Compensation Benefits
Minnesota/Workers Comp/ -
Objection To Penalty Assessment
Minnesota/Workers Comp/ -
On The Job Training Plan
Minnesota/Workers Comp/ -
Permanent Total Disability Agreement
Minnesota/Workers Comp/ -
Plan Progress Report
Minnesota/Workers Comp/ -
R-2 Rehabilitation Plan
Minnesota/Workers Comp/ -
R-3 Rehabilitation Plan Amendment
Minnesota/Workers Comp/ -
R-8 Notice Of Rehabilitation Plan Closure
Minnesota/Workers Comp/ -
Rehabilitation Consultation Report
Minnesota/Workers Comp/ -
Rehabilitation Request
Minnesota/Workers Comp/ -
Rehabilitation Response
Minnesota/Workers Comp/ -
Rehabilitation Rights And Responsibilities Of Injured Worker
Minnesota/Workers Comp/ -
Report Of Work Ability
Minnesota/Workers Comp/ -
Request For Extension
Minnesota/Workers Comp/ -
Retraining Plan
Minnesota/Workers Comp/ -
Notice Of Insurers Primary Liability Determination
Minnesota/Workers Comp/ -
Affidavit Of Significant Financial Hardship
Minnesota/Workers Comp/ -
Claim Petition For Dependency Benefits Or Payment To Estate
Minnesota/Workers Comp/ -
Employee Or Insurers Objection To Requested Attorney Fees And Or Costs
Minnesota/Workers Comp/ -
Employees Claim Petition
Minnesota/Workers Comp/ -
Employees Objection To Discontinuance
Minnesota/Workers Comp/ -
Excess Fee Exhibit
Minnesota/Workers Comp/ -
Notice Of Appeal To Workers Compensation Court Of Appeals
Minnesota/Workers Comp/ -
Notice Of Appearance Of Attorney For Employee
Minnesota/Workers Comp/ -
Notice Of Penalty Payment
Minnesota/Workers Comp/ -
Petition For Taxation Of Actual And Necessary Disbursements
Minnesota/Workers Comp/ -
Request For Certification Of Dispute
Minnesota/Workers Comp/ -
Request For Formal Hearing
Minnesota/Workers Comp/ -
Statement Of Attorney Fees And Costs
Minnesota/Workers Comp/ -
Motion To Intervene
Minnesota/Workers Comp/ -
Certificate Of Compliance
Minnesota/Workers Comp/ -
Election To Exclude Certain Relatives Of Executive Officers Of A Closely Held Corporation
Minnesota/Workers Comp/ -
Election To Exclude Certain Relatives Of Managers Of Limited Liability Company
Minnesota/Workers Comp/ -
Stipulation Of Intervention (Attachment To MO0001)
Minnesota/Workers Comp/ -
Qualified Rehabilitation Consultant Internship Completion Checklists (QRC)
Minnesota/Workers Comp/ -
Annual Claim For Reimbursement Of Supplementary Benefits
Minnesota/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!