Notice Of Insurers Primary Liability Determination
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Notice of Insurer’s Primary Liability Determination
See instructions on reverse side.
PRINT IN INK or TYPE
N L 0 1
Enter dates in MM/DD/YYYY format.
DO NOT USE THIS SPACE
Amended
WID or SSN
DATE OF INJURY
DATE OF DEATH
(if applicable)
EMPLOYEE (last, first, mi)
EMPLOYER
INSURER/SELF-INSURER/TPA
INSURER CLAIM NUMBER
First date of lost time
Date employer notified of this lost time
Initial date of return to work
Average weekly wage at date of injury
If the initial return to work was followed by a new period of lost time, complete the following information:
First date of new
Date employer
period of lost time: ____________________________________________
notified of this lost time: ________________________________
1. Your claim is ACCEPTED and wage loss benefits will be paid.
Benefit type:
Temporary Total (TTD)
Temporary Partial (TPD)
Permanent Total (PTD)
Dependency (DEP)
Date of payment
Amount of payment
Time period covered with this payment
Compensation rate
Date from
Date through
__
Any ongoing payments will be made on ____________________ (day of week) at________________________(weekly, biweekly, etc.) intervals.
Full wage continuation by the employer under M.S. § 176.221, subd. 9.
TPD payment made according to the wage loss verification received by the insurer on __________________________(date).
Fatality with dependents. Payment is being made according to dependent information, which must be ATTACHED.
Fatality with no dependents. Payment is being made to the estate or the Special Compensation Fund.
2. Your claim is ACCEPTED. However, wage loss benefits will not be paid at this time for the following reason:
A. Injury did not cause lost time from work beyond the three calendar day waiting period. If employee’s work schedule is not
Monday through Friday, explain: _______________________________________________________________________
B. Verification of reduced wages for TPD has not been received from the employee or employer.
C. Other reason (include legal and factual basis):
3. Primary liability is DENIED for the claimed work related
injury and/or
death. (Check one or both)
Reason for denial (include legal and factual basis):
NAME OF THE PERSON MAKING THIS DETERMINATION (print) PHONE NUMBER (area code)
EXTENSION DATE SERVED (must be completed)
MN NL01 (2/10)
Distribution: Workers’ Compensation Division, Employer, Insurer, Employee/Heirs and Dependents
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