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The Notice of Discontinuance of Workers' Compensation Dependency Benefits form is completed by the insurer, self-insured employer or third-party administrator. It is used to notify the dependents of a reduction or discontinuance of dependency benefits, the amount of benefits that have been paid and some basic instruction regarding the discontinuance. The Department of Labor and Industry uses the form to verify calculation of benefits and for statistical data.

Because the laws regarding dependent's benefits differ so much throughout the history of the Minnesota workers' compensation system, it is very important to always check the law in effect on the date of death (date of death is the governing law) to determine whether the following reasons for discontinuing dependency benefits are applicable:

  • to report reducing or stopping benefits when a child no longer fits the criteria of dependent under Minnesota Statutes 176.111, subd. 1(b) or subd. 2;

  • to report reducing or stopping benefits when a spouse reaches the maximum allowable years of compensation;

  • to report reducing or stopping benefits upon death of a dependent;

  • to report reducing or stopping benefits upon re-marriage of a spouse;

  • to report reducing or stopping benefits upon marriage of a dependent;

  • to report reducing or stopping benefits for other reasons (such as payments made upon mistake of fact, etc.); and

  • to comply with statutes and rules --

This form must be filed at the time the dependent's benefits are reduced or stopped. A copy of the form is sent to dependents, the dependent's attorney (if represented), the Minnesota Department of Labor and Industry's Workers' Compensation Division and the employer. It is a good idea to keep a copy for your files as well.