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The insurer, self-insured employer or third-party administrator must attach this blank form to the Notice of Intention to Discontinue Workers' Compensation Benefits (NOID) form given to the employee.

This form allows the claimant to request an administrative conference if they disagree with the proposed discontinuance of the following benefits:

  • temporary total disability (TTD);

  • temporary partial disability (TPD); or

  • permanent total disability (PTD).

Applicable statutes and rules are: