Minnesota Department of Labor and Industry Orange bar
Minnesota Department of Labor and Industry Powered by google

Workers' compensation -- Forms



Notice of Benefit Payment (NOBP)

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 NOBP form is two-fold:

    • 1) to notify the claimant about payment(s) of PPD benefits (or monitoring period benefits) and how those PPD benefits are paid; and

    • 2) to notify the claimant of a final benefit payment according to an award, decision or order.

  • In addition, this form supplies the claimant with a summary total of all benefits that have been paid or withheld on the claim. The Department of Labor and Industry uses the form to review for compliance with the statutes and rules, to verify calculation of benefits and for statistical data.

What, specifically, is this form used for?

  • To report a commencement of periodic PPD benefit payments

  • To report a completion of periodic PPD benefit payments

  • To report a lump-sum payment of PPD benefits

  • To report final payment according to an award (stipulation or mediation)

  • To report final payment according to an administrative decision (discontinuance conference)

  • To report final payment according to a judge's decision and order

  • To comply with statutes and rules:

    • Minnesota Statutes 176.021

    • Minnesota Statutes 176.101

    • Minnesota Statutes 176.221

    • Minnesota Rules 5220.2550

    • Minnesota Rules 5220.2630

When is this form completed?

  • This form must be filed at the time the PPD or final payment occurs.

Where is this form sent?

  • A copy of this form is sent to:

    • the claimant, heirs or dependents;

    • the claimant's, heirs' or dependents' attorney (if represented);

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

    • the employer;

    • your file.

Links

DLI home page | Directions and maps | News and media | Website disclaimer