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 Upon Death form is to notify the heirs and dependents of a claimant who dies while receiving benefits of the discontinuance of those benefits, the amount of benefits that were paid and some basic instructions regarding the discontinuance. It also notifies them of the insurer's decision about whether the death is considered related to the work injury and, for certain dates of injury, whether any remaining PPD payments will be made to the heirs/dependents. The department uses the form as a trigger to send a statutorily required letter to the heirs and dependents about their rights under the Minnesota workers' compensation system. The department also uses the form to verify calculation of benefits and for statistical data.
What, specifically, is this form used for?
To report a discontinuance of any of the following benefits due to the death of the claimant:
temporary total disability (TTD);
permanent total disability (PTD);
temporary partial disability (TPD);
permanent partial disability (PPD) for dates of injuries between Dec. 31, 1983, and Oct. 1, 1995.
To notify the department of the date of death.
To comply with statutes and rules:
Minnesota Statutes 176.231, subd. 5
Minnesota Statutes 176.231, subd. 10
Minnesota Rules 5220.2630 ("general" discontinuance instruction)
When is this form completed?
This form must be filed as soon as you learn of the death of a claimant (who was receiving benefits).
Where is this form sent?
A copy of this form is sent to:
heirs and dependents;
the claimant's attorney (if represented);
the Minnesota Department of Labor and Industry, Safety and Workers' Compensation Division;
the employer; and