Skip to main content

Benefit payment forms

Note:  The law does not require a claim to be reported to the Department of Labor and Industry (DLI) unless it involves any claimed disability beyond the waiting period and/or possible permanent partial disability (PPD). Requirements for filing subsequent documents apply to this type of claim only if the First Report of Injury (FROI) form has already been (perhaps mistakenly) sent to DLI.

First Report of Injury

The First Report of Injury (FROI) form is the reporting document for all work-related injury claims. It provides basic information necessary to start the claim. The electronic data interchange (EDI) report must be sent by the insurer for all claims that involve disability beyond the three-day waiting period or that result in permanent partial disability.

Notice of Insurer's Primary Liability Determination

The Notice of Insurer's Primary Liability Determination (NOPLD) form is filed when there is claimed disability beyond the three-day waiting period -- there are no exceptions. It is used to report:

  • the first payment of wage-loss benefits;

  • acceptance of liability, but denial of initial wage-loss benefits; and

  • a denial of primary liability.

The NOPLD form can be required more than once for some claims, such as when the insurer:

  • initially denies primary liability, but later accepts liability;

  • initially accepts a claim and pays wage-loss benefits, but later denies primary liability within 60 days pursuant to Minnesota Statutes 176.221, subd. 1; or

  • accepts a claim on which there are no wage-loss benefits initially paid, but later pays wage-loss benefits voluntarily.

This form is not to be used to report a resumption of wage-loss payments after they have been previously discontinued. The Notice of Benefit Reinstatement form is used for this purpose.

Note:  For claims that are denied or found to have no compensable disability beyond the waiting period, the above two forms may be the only ones required.

Notice of Intention to Discontinue Workers' Compensation Benefits

The Notice of Intention to Discontinue Workers' Compensation Benefits (NOID) form is used to reduce or discontinue temporary total disability (TTD), temporary partial disability (TPD) or permanent total disability (PTD) benefits:

  • when the employee returns to work at full wage;

  • when the employee returns to work at reduced wage; or

  • for reasons other than a return to work.

Notice of Benefit Reinstatement

The Notice of Benefit Reinstatement (NOBR) form for is used to report:

  • a resumption of wage-loss benefits, either voluntarily or pursuant to an order, after an NOID form has been filed;

  • a change in wage-loss benefits being paid from TPD to TTD; or

  • a change from full wage continuation by the employer to insurer-paid benefits.

This form is not to be used to report the initial payment of wage-loss benefits. The NOPLD form (above) is used for that purpose.

Notice of Benefit Payment

The Notice of Benefit Payment (NOBP) form is a multi-purpose form used when:

  • paying PPD in a lump sum;

  • making the first payment of periodic PPD benefits;

  • paying under an award, order or administrative decision; and

  • making the final payment of periodic PPD.

Interim Status Report 

The Interim Status Report (ISR) form is filed annually for all claims with ongoing payments of indemnity benefits and/or supplementary benefits.

Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee

The Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (NOD Upon Death) form is used to discontinue TTD, TPD or PTD because the employee died. It is always required in this situation, no exceptions.

Health Care Provider Report

The Health Care Provider Report form or a narrative report should be filed:

  • with any denial of benefits to justify the reason for denial;

  • when a doctor assesses PPD and/or maximum medical improvement; or

  • with the NOID form (above) when the reason for discontinuance is based on a medical opinion (for example, full release to return to work, no restrictions).

Disability Status Report

The Disability Status Report (DSR) form must be filed when any of the following occur:

  • within 14 calendar-days of knowledge the employee's TTD is likely to exceed 13 cumulative weeks;

  • within 90 calendar-days of the date of injury when the employee has not returned to work following a work injury; or

  • within 14 calendar-days after receiving a request for a rehabilitation consultation, whichever is earlier.

If the insurer is requesting a waiver, documentation that the employee will return to suitable, gainful employment must be attached. In addition, a DSR form must be filed within 14 calendar-days of expiration of an approved waiver of rehabilitation services.

Notice of File Closing

The Notice of File Closing form is an optional form used to notify the department the insurer is closing a file.