Who is responsible for completing this attachment to other forms?
The insurer, self-insured employer or third-party administrator
Why is this form attachment needed?
The purpose of this form is to attach to the back of forms, such as the NOID, the NOBP and the 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 TTD payments together and separate from any TPD payments.)
The department uses the information reported on this form attachment to verify calculation of benefits and for statistical data.
What, specifically, is this form attachment used for?
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);
When is this form attachment completed?
This form attachment should only be completed when you need additional space when filing one of the following forms:
Notice of Intention to Discontinue Benefits (NOID);
Notice of Benefit Payment (NOBP);
Interim Status Report (ISR);
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (NOD Upon Death).
Where is this form attachment sent?
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, Safety and Workers' Compensation Division;
copy to your files.