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Workers' compensation -- Forms



Notice of Benefit Reinstatement (NOBR)

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 NOBR form is to report a resumption of wage-loss payments with the department after they have been previously discontinued by a NOID form (or an order by the division). It is also used to report several different benefit-type changes on the claim. The department uses this form to review for compliance with the statutes and rules, and for statistical data.

What, specifically, is this form used for?

  • To report a voluntary (or by order) reinstatement of one of the following types of benefits:

    • temporary total disability (TTD)

    • temporary partial disability (TPD)

    • permanent total disability (PTD)

    • dependency (DEP)

  • To report a change from TPD benefits to TTD benefits

  • To report a change from full wage payment (paid by employer) to TTD benefits

  • To comply with statutes and rules:

    • Minnesota Rules 5220.2540, subp. 3B

    • Minnesota Statutes 176.231, subd. 5

    • Minnesota Statutes 176.231 subd. 10

When is this form completed?

  • This form must be filed at the time the benefits are reinstated or changed.

Where is this form sent?

  • A copy of this form is sent to:

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

    • the claimant -- although service of this form on the claimant is not required by statute or rule, it is recommended as an appropriate notification to the claimant about the change or reinstatement of their benefits;

    • your file.

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