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Notice of Benefit Reinstatement
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.

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DO NOT USE THIS SPACE DATE OF INJURY DATE OF DEATH (if applicable)

WID or SSN

EMPLOYEE

EMPLOYER

INSURER/SELF-INSURER-TPA

INSURER CLAIM NUMBER

THIS IS NOTIFICATION THAT WORKERS' COMPENSATION BENEFITS HAVE BEEN REINSTATED. 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 appropriate box and enter data information: 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 Please provide the following pre-injury wage information ONLY if it differs from prior submissions: Average Weekly Wage Weekly value of: Meals Lodging 2nd income

Straight time: Rate per hour Hours per day Days per week 26 week earnings Total days worked in last 26 weeks Total weeks worked in last 26 weeks

IF OVERTIME IS PAID OR IF EMPLOYEE IS IRREGULARLY SCHEDULED, ATTACH A 26 WEEK WAGE STATEMENT.

CLAIM REPRESENTATIVE NAME

PHONE # (include area code)

DATE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

MN NC01 (5/08)

Distribution: Workers' Compensation Division, Insurer