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Workers' compensation -- Forms



Notice of Discontinuance of Workers' Compensation Dependency Benefits (NOD of Dep)

Who is responsible for completing the form?

  • The insurer, self-insured employer or third-party administrator is responsible for completing this form.

Why is this form needed?

  • The purpose of the NOD of Dep form is to notify the dependents of a reduction or discontinuance of dependency benefits, the amount of benefits that have been paid and some basic instruction regarding the discontinuance. The department uses the form to verify calculation of benefits and for statistical data.

What, specifically, is this form used for?

  • Because the laws regarding dependent's benefits differ so much throughout the history of the Minnesota workers' compensation system, it is very important to always check the law in effect on the date of death (date of death is the governing law) to determine whether the following reasons for discontinuing dependency benefits are applicable:

    • to report reducing or stopping benefits when a child no longer fits the criteria of dependent under Minnesota Statutes 176.111, subd. 1(b) or subd. 2;

    • to report reducing or stopping benefits when a spouse reaches the maximum allowable years of compensation;

    • to report reducing or stopping benefits upon death of a dependent;

    • to report reducing or stopping benefits upon re-marriage of a spouse;

    • to report reducing or stopping benefits upon marriage of a dependent;

    • to report reducing or stopping benefits for other reasons (such as payments made upon mistake of fact, etc.);

    • to comply with statutes and rules:

      • Minnesota Statutes 176.231, subd. 5

      • Minnesota Statutes 176.231, subd. 10

      • Minnesota Rules 5220.2630 ("general" discontinuance instructions)

When is this form completed?

  • This form must be filed at the time you reduce or stop the dependent's benefits.

Where is this form sent?

  • A copy of this form is sent to:

    • dependents;

    • the dependent's attorney (if represented);

    • the Minnesota Department of Labor and Industry, Safety and Workers' Compensation Division;

    • the employer; and

    • your file.

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