Fill and Sign the Notice of Benefit Reinstatement Form

MN NC01 (09/1 5) Send to : Workers’ Compensation Division, insurer Mail or fax to: Department of Labor and Industry Workers’ Compensation Division P .O. Box 64221 St. Paul, MN 55164 - 0221 (651) 284 - 5032 or 1 - 800 - 342 - 5354 Fax: (651) 284 - 5731 Notice of Benefit Reinstatement Print i n i nk o r t ype Enter d ates in MM/DD/YYYY format Do not use this space WID number or SSN Date of i njury (DOI) Date of d eath (if applicable) Employee ( l ast, f irst, MI ) Employer Insurer/ s elf - i nsurer/T PA Insurer c laim n umber This is notification that workers’ compensation benefits have been reinstated or changed . Date of new payment Amount of payment Type of benefit Time period covered with this payment Compensation rate TTD TPD PTD DEP Date from - Date through Insurer: Check the appropriate box (es) and enter dat e (s) . 1. Payment resumed voluntarily. First date of new period of time lost Date of notice to employer of new period of time lost 2. Payment resumed pursuant to order served and filed on M.S. § 176.239 decision OR Other decision (OAH, WCCA or Supreme Court) 3. TPD changed to TTD effective 4. Full wage continuation changed to TTD effective Provide the following pre - injury wage information only if it differs from prior submissions . Average weekly wage at DOI Weekly value of : Meals Lodging Seco nd income E xplain below the reason for the change and attach a 26 - week wage statement . Claim representative n ame Phone n umber ( i nclude a rea c ode) Date NC01