Work comp: Form -- Benefit Addendum

The Benefit Addendum form is completed by the insurer, self-insured employer or third-party administrator. It is attached to the back of forms, such as the Notice of Intention to Discontinue Workers' Compensation Benefits (NOID), the Notice of Benefit Payment (NOBP) and the Interim Status Report (ISR), when there is a need for additional space in reporting the specific benefits that have been paid on the claim.

Benefits should be grouped by type and not reported intermittently on the form. For example, group all temporary total disability (TTD) payments together and separate from any total partial disability (TPD) payments. The Department of Labor and Industry uses the information to verify calculation of benefits and for statistical data.

The form is used to report detailed payments of one or more of the following benefit types:

• temporary total disability (TTD);

• temporary partial disability (TPD);

• permanent total disability (PTD);

• retraining;

• dependency (DEP); and

• supplementary (SB).

This form attachment should only be completed when you need additional space filing one of the following forms:

• Notice of Intention to Discontinue Workers' Compensation Benefits (NOID);

• Notice of Benefit Payment (NOBP);

• Interim Status Report (ISR); or

• Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (NOD Upon Death).

Although use of this form attachment is not required by statute or rule, the information reported about the specific benefits paid on the claim is required. So, when choosing to use this form attachment when reporting benefits paid, send the form and this attachment to the:

• claimant, heirs or dependents;

• attorney for claimant, heirs or dependents ( if represented);

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

• employer.

You may also want to keep a copy to your files.