Fillable Notice Of Insurers Primary Liability Determination (Page 2 of 2) in pdf

INSTRUCTIONS TO EMPLOYEE/HEIRS AND DEPENDENTS

PLEASE KEEP A COPY OF THIS NOTICE FOR YOUR RECORDS

General Information

This liability determination is the opinion of the insurer. If the claim has been denied, this opinion may not be final. If you have

questions about any of the information on this form, you should first contact the person making this determination (see name and

phone number on the front side of this form). If you still have questions, contact the Department of Labor and Industry (DLI),

Workers’ Compensation Division’s Benefit Management and Resolution Unit at the office nearest you (listed below). For the

hearing impaired, please call our Telecommunication Device for the Deaf (TDD) at (651) 297-4198. If there are problems with

your claim, there are several options available to resolve them informally.

Minnesota Department of Labor and Industry

525 Lake Avenue South, Suite 330

443 Lafayette Road North

Mailing Address

Duluth, MN 55802-2368

St. Paul, MN 55155-4301

Workers’ Compensation Division

Telephone: (218) 733-7810

Telephone: (651) 284-5030

PO Box 64221

1-800-342-5354

St. Paul, MN 55164-0221

Time Limitations

If the injury claim has been denied, you may lose your right to benefits if you do not commence legal proceedings within three

years after your employer/insurer filed a written report of your claimed injury with DLI, not to exceed six years after the date of

the claimed injury. If you have an occupational disease, you have three years to begin legal proceedings from the date you

learned that the cause of the disease might be work related and the disease first caused disability.

If the death claim has been denied, you may lose your right to benefits if you do not commence legal proceedings within three

years after the employer/insurer filed the written notice of death with DLI, except that:

For claims where the employer/insurer did not pay benefits for the injury, commencement of legal proceedings

cannot exceed six years from the date of injury resulting in the death.

For claims where the employer/insurer did pay benefits for the injury, commencement of legal proceedings cannot

exceed six years from the date of death.

In very rare circumstances, there may be exceptions to the time limits noted above.

Vocational Rehabilitation

If the insurer is denying primary liability for your claim and you disagree, cannot return to your former employment, and would

like vocational rehabilitation assistance, contact DLI, Vocational Rehabilitation Unit at (651) 284-5038.

Instructions to Insurer/Claims Administrator

1. If the claim is a fatality with dependents and payment is being made, attach dependent information.

2. The reason for a denial must be clear and specific, and state a legal and factual basis in language which is easily

understood. If the reason for a denial is based on medical information, attach medical reports or summary of any health care

provider contacts that support your reason for denial.

3. This form may be filed more than once if your liability determination changes. (Examples: when you initially deny primary

liability, but later accept liability; when you initially accept a claim and pay wage loss benefits, but later deny primary liability

within 60 days pursuant to M.S. § 176.221, subd 1; when you accept liability, but are unable to pay TPD benefits until

verification of wage loss is received, but later issue the first TPD check.)

4. If you file this form more than once, check the Amended box in the upper left-hand corner for each subsequent filing.

5. Do not use this form to reinstate benefits. Use the Notice of Benefit Reinstatement (NOBR) form.

6. If you indicate that the employer paid “full wage,” you must also file a Notice of Intention to Discontinue (NOID) at the

appropriate time showing the date of return to work or other reason for discontinuance and the payment data on the back of

the form as required by M.S. § 176.221, subd. 9.

7. The date served must be completed each time you file this form.

8. The boxes (in the upper left-hand corner on the front of the form) containing claim identifying information must be fully

completed each time you file the form. The boxes containing the dates of lost time, notice, and initial return to work, and the

average weekly wage must also be completed, if applicable, each time you file the form, regardless of your liability

determination.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-

800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.

ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS

NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF

THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Notice Of Insurers Primary Liability Determination Page 2

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