Office of Administrative Hearings Workers222 Compensation Division PO Box 64620 St. Paul, MN 55164-0620 (651) 361-7900 Employee222s Objection To Discontinuance of Temporary Total, Temporary Partial or Permanent Total Disability Benefits PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT Reset ED02 DO NOT USE THIS SPACE WID or SSN DATE(S) OF CLAIMED INJURY EMPLOYER AND INSURER AND EMPLOYEE VS. Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers222 compensation dispute. The data will be used by the office of administrative hearings (OAH) and the department of labor and industry staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department222s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the workers222 compensation court of appeals; the departments of revenue and health; and the workers222 compensation reinsurance association. TO THE OFFICE OF ADMINISTRATIVE HEARINGS 1. The Objection to Discontinuance is filed in response to: An administrative decision issued under Minn. Stat. 247 176.239 by served Name of Judge and filed on or A Notice of Intention to Discontinue Benefits dated (Check only if no administrative decision has been issued on this discontinuance.) or Other 2. The employee alleges that he/she is entitled to the following additional benefits: a. Temporary Total from to b. Temporary Partial from to c. Permanent Total from to 3. Trial Data: a. Requested place of: Pretrial Trial b. Estimated hours to present evidence: c. If an interpreter is requested for a hearing or conference, specify the language/dialect: d. If a reasonable accommodation of disability is requested for a hearing or conference, describe: WHEREFORE, the Employee objects to the discontinuance of compensation benefits and requests that this matter be set for hearing in accordance with Minn. Stat. 247 176.238. EMPLOYEE SIGNATURE ATTORNEY FOR EMPLOYEE SIGNATURE ADDRESS ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE TELEPHONE ATTORNEY REGISTRATION # TELEPHONE MN ED02 (6/18) (over) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MINNESOTA } } ss. AFFIDAVIT OF SERVICE COUNTY OF } I, , being first duly sworn, state that on , I served a true and correct copy of this document, enclosed in a properly addressed envelope, by depositing the same, with postage prepaid, in the United States mail at , Minnesota, addressed as follows: NAMES AND ADDRESSES Subscribed and sworn to before me this day of Signature Notary Public My Commission expires INSTRUCTIONS 1. The hearing will be expedited if the Objection to Discontinuance is within 60 calendar days after a Notice of Intention to Discontinue Benefits has been filed (if no administrative decision has been issued) or within 60 days after a decision concerning the discontinuance has been issued pursuant to Minn. Stat. 247 176.239. 2. Failure to properly and fully fill out this form, with appropriate documentation, in accordance with workers222 compensation rules of practice, is not considered proper filing. The Office of Administrative Hearings may refuse to accept this form if it lacks any of the following: employee222s name, date of injury, WID or social security number, or name of employer/insurer. 3. The claim must be presented in terms of the Minnesota Workers222 Compensation Act. 4. If you have more defendants or more injuries than can be listed, this form may be modified accordingly. 5. A doctor222s report or other information supporting the claim MUST be filed with this form. 6. A copy of this form must be served on the employer and the insurer, their attorney, potential intervenors, and the Special Compensation Fund, if applicable, by first class mail or personally. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800- 342-5354. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS222 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. American LegalNet, Inc. www.FormsWorkFlow.com