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 NOPLD form is to notify the claimant (or heirs/dependents of a claimant) and the Department of Labor and Industry of the insurer's position regarding primary liability on the claim, with specific details of the accepted or denied claim. (It is important to note this form could be completed several different times on the same claim to reflect a change in the insurer's position or a change in the specific details of the claim. These subsequent filings of the form would be considered amended NOPLD forms.) The department uses the information supplied on the form to review for timely and accurate compliance with the statutes and rules, for statistical data and to publish a legislatively mandated annual report about the promptness of insurers first actions on claims.
What, specifically, is this form used for?
To report the acceptance of an injury or death claim with any of the following type of wage-loss benefits commencing:
temporary total disability (TTD) (or full-wage plan)
temporary partial disability (TPD)
permanent total disability (PTD)
fatality with no dependents.
To report the acceptance of an injury with advisement that payment of TPD benefits will commence in the future, upon your receipt of wage-loss information (an amended NOPLD form must be filed when payment is made or upon change to a nonwage-loss payment claim)
To report acceptance of medical liability on a claim, but denial of wage-loss liability
To report a denial of primary liability of an injury or death claim
To amend initial report to:
accept liability on a previously denied claim
deny primary liability on a previously accepted claim (applies only if filed within 60 days pursuant to Minnesota Statutes 176.221 subd.1)
payment of wage-loss benefits on a claim where previously no wage-loss payments had been made
TPD payment now made upon receipt of wage-loss information
To comply with statutes and rules:
Minnesota Statutes 176.221
Minnesota Statutes 176.84
Minnesota Statutes 176.225
Minnesota Statutes 176.231
Minnesota Rules 5220.2540
Minnesota Rules 5220.2570
Minnesota Rules 5220.2770
Minnesota Rules 5220.2790
When is this form completed?
Accepting primary liability: The first payment must be made within 14 days of the first day of claimed lost time or the date on which the employer first received notice of the claimed lost time, whichever is later. This form must be filed whenever the following occurs:
liability is accepted with an initial wage-loss payment;
liability is accepted for wage-loss benefits and the employer has a full-wage plan;
liability is accepted for temporary partial benefits and payment will be made in the future, upon receipt of wage-loss information; or
liability is accepted on a fatality claim.
Denying primary liability (or denying partial liability): This form must be filed with the department within 14 days of the first day of the disability or the date the employer was aware of the disability, whichever is later, when the following occurs:
denial of primary liability is determined;
partial denial of liability for the initial claimed disability is determined.
Where is this form sent?
A copy of this form is sent to:
claimant, heirs or dependents;
attorney for claimant, heirs or dependents (if represented);
the Minnesota Department of Labor and Industry, Safety and Workers' Compensation Division;
the employer; and