Notice Of Benefit Payment {NB01}

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