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.

Links

• Employee's Request for Administrative Conference form
  
  
• Back to forms page