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?
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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?
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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?
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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?
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The form is sent to the claimant.
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