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The Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee form is completed by the insurer, self-insured employer or third-party administrator as soon as they learn of the death of a claimant who was receiving benefits. It notifies the heirs and dependents of the discontinuance of benefits, the amount of benefits that were paid and some basic instructions. It also notifies them of the insurer's decision about whether the death is considered related to the work injury and, for certain dates of injury, whether any remaining permanent partial disability (PPD) benefit payments will be made to the heirs/dependents.

The Department of Labor and Industry uses the form as a trigger to send a statutorily required letter to the heirs and dependents about their rights, to verify calculation of benefits and for statistical data.

The discontinuance of any of the following benefits due to the death of the claimant are reported on this form:

  • temporary total disability (TTD);

  • permanent total disability (PTD);

  • temporary partial disability (TPD);

  • retraining; and

  • permanent partial disability (PPD) for dates of injuries between Dec. 31, 1983, and Oct. 1, 1995.

The form complies with theses statutes and rules:

A copy of this form is sent to:

  • heirs and dependents;

  • the claimant's attorney (if represented);

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

  • the employer.

You may want to keep a copy for your files as well.