Free untitled - Minnesota

Reset

PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.

Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee
DATE OF INJURY

B D 0 2

DO NOT USE THIS SPACE

WID or SSN

EMPLOYEE

EMPLOYER

EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

INSURER CLAIM NUMBER

THIS IS NOTIFICATION THAT WORKERS' COMPENSATION BENEFITS HAVE BEEN DISCONTINUED UPON THE DEATH (date). OF THE EMPLOYEE ON
INSURER: PLEASE ANSWER THE FOLLOWING QUESTION(S)

1. Was the employee's death related to the work-related injury?

YES

NO

UNKNOWN

Insurer: If yes, please contact the heirs and dependents as soon as possible, and file a new First Report of Injury (with regard to the death) with the Workers' Compensation Division 2. If the employee was receiving periodic permanent partial disability, impairment compensation, or economic recovery compensation at the time of death, will this compensation continued to be paid to the heirs or dependents?
YES NO

If yes, for how long? If no, why not? INSTRUCTIONS TO HEIRS AND DEPENDENTS REGARDING DISCONTINUANCE

If the answer to Question 1 is "yes," the claim representative will be contacting the heirs and dependents within a reasonable period of time concerning any benefits to which they may be entitled. If you are not contacted, you should call the claim representative at the telephone number listed on the back of this form. If the answer to Question 1 is "no" or "unknown," and you believe there is a relationship between the employee's death and the work-related injury, you and other heirs/dependents are entitled to make a claim for benefits. To make a claim, you should notify the above-named employer or the workers' compensation insurer in writing that you believe that the death was related to the injury and are claiming benefits under the Workers' Compensation Law. If you have questions about the benefits that were paid to the employee, the possibility of continuing permanent partial disability, impairment compensation or economic recovery compensation, or the possibility of dependency benefits, you should first contact the claim representative whose telephone number is listed on the back of this form. If you still have questions, contact the Workers' Compensation Division's Benefit Management and Resolution Unit at the office nearest you. Minnesota Department of Labor and Industry 5 North Third Avenue West, Suite 400 Duluth, MN 55802-1614 Telephone: (218) 733-7810 1-800-365-4584 443 Lafayette Road North St. Paul, MN 55155-4301 Telephone: (651) 284-5030 1-800-342-5354 Mailing Address Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221

MN BD02 (5/08)

(over)

THE FOLLOWING BENEFITS HAVE BEEN PAID Temporary Total Disability or Permanent Total Disability

FROM

THROUGH

WEEKS

RATE

*TOTAL

Benefit Addendum Attached Temporary Partial Disability Retraining Benefits Permanent Partial Disability ___________% Injuries on or after 10/01/95 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 M.S. 176.081, subd. 1 & 3 Paid M.S. 176.081, subd. 1 & 3 Still Withheld Heaton Fees Paid Roraff Fees Paid M.S. 176.191 Paid Other Fees Paid Costs & Disbursements Paid INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME Benefit Totals *Lump sum Payment Under Award or Order Attorney Fees Reimbursed to Employee (M.S. 176.081, subd. 7) Interest Paid *TOTAL COMPENSATION PAID *Total Supplementary Benefits Total Medical Expenses Paid to Date

ADDRESS

PHONE NUMBER (include area code)

CITY

STATE

ZIP CODE

DATE SERVED ON EMPLOYEE

DATE SERVED ON ATTORNEY

*Include attorney fees in these totals.

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.
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.

Distribution: Workers' Compensation Division, Employer, Employee, Insurer, Heirs and Dependents