Minnesota Notice of Discontinuance of Workers' Compensation Benefits Upon Death of EmployeeMinnesota Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee
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Notice of Discontinuance of Workers’
Compensation Benefits Upon Death of
Employee

WID or SSN

DATE OF INJURY

EMPLOYEE (last, first, mi)

EMPLOYER

B D 0 2

DO NOT USE THIS SPACE

EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

INSURER CLAIM NUMBER

THIS IS NOTIFICATION THAT WORKERS’ COMPENSATION BENEFITS HAVE BEEN DISCONTINUED UPON THE DEATH
(date).
OF THE EMPLOYEE ON
INSURER: PLEASE ANSWER THE FOLLOWING QUESTION(S)

1. Was the employee’s death related to the work-related injury?

YES

NO

UNKNOWN

Insurer: If yes, please contact the heirs and dependents as soon as possible, and file a new First Report of Injury (with
regard to the death) with the Workers’ Compensation Division
2. If the employee was receiving periodic permanent partial disability, impairment compensation, or economic recovery
compensation at the time of death, will this compensation continued to be paid to the heirs or dependents?
YES

If yes, for how long?

NO