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Workers' compensation -- Forms



Employee's Request for Administrative Conference (attachment to the NOID form)

Who is responsible for completing this attachment to the NOID form?

  • It is the insurer's, self-insured employer's or third-party administrator's responsibility to attach this blank form to the NOID form. It is the claimant's responsibility to complete the form.

Why is this attachment to the NOID form needed?

  • The purpose of this attachment to the NOID form is to provide the claimant with a format in which to request an administrative conference if there is any disagreement with the proposed discontinuance of benefits.

What, specifically, is this attachment to the NOID form used for?

  • The claimant may request an administrative conference when one of the following benefits are reduced or suspended:

    • temporary total disability (TTD)

    • temporary partial disability (TPD)

    • permanent total disability (PTD)

  • To comply with statutes and rules:

    • Minnesota Statutes 176.238

    • Minnesota Statutes 176.239

    • Minnesota Rules 5220.2630 subp. 4A

    • Minnesota Rules 5220.2643

When is this form attachment sent?

  • This form must be attached to the NOID form every time a NOID form is sent to the claimant.

Where is the form attachment sent?

  • The form is sent to the claimant.

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