Notice Of Benefit Reinstatement {NC01} | Pdf Fpdf Doc Docx | Minnesota

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Notice Of Benefit Reinstatement {NC01} | Pdf Fpdf Doc Docx | Minnesota

Notice Of Benefit Reinstatement {NC01}

This is a Minnesota form that can be used for Workers Comp.

Alternate TextLast updated: 5/26/2016

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Mail or fax to: Department of Labor and Industry Workers' Compensation Division P.O. Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 or 1-800-342-5354 Fax: (651) 284-5731 Notice of Benefit Reinstatement Print in ink or type Enter dates in MM/DD/YYYY format NC0 1 Do not use this space WID number or SSN Employee (last, first, MI) Employer Insurer/self-insurer/TPA Insurer claim number Date of injury (DOI) Date of death (if applicable) This is notification that workers' compensation benefits have been reinstated or changed. Date of new payment Amount of payment Type of benefit TTD PTD TPD DEP Time period covered with this payment Date from Date through Compensation rate Insurer: Check the appropriate box(es) and enter date(s). 1. Payment resumed voluntarily. First date of new period of time lost Date of notice to employer of new period of time lost 2. Payment resumed pursuant to order served and filed on M.S. § 176.239 decision OR Other decision (OAH, WCCA or Supreme Court) 3. TPD changed to TTD effective 4. Full wage continuation changed to TTD effective Provide the following pre-injury wage information only if it differs from prior submissions. Average weekly wage at DOI Weekly value of: Meals Lodging Second income Explain below the reason for the change and attach a 26-week wage statement. Claim representative name Phone number (include area code) Date American LegalNet, Inc. www.FormsWorkFlow.com MN NC01 (09/15) Send to: Workers' Compensation Division, insurer

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