MN BD02 (5/18) (over) Mail or fax to: Department of Labor and Industry P . O . Box 64221 St. Paul, MN 55164 - 0221 (651) 284 - 5032 or 1 - 800 - 342 - 5354 Fax: (651) 284 - 5731 Notice of Compensation Benefits Upon Death of Employee Print in ink or type Enter dates in MM/DD/YYYY format DO NOT USE THIS SPACE WID number or SSN Date of injury (DOI) Date of death Employee (last, first, middle initial ) Employer Employee address City State ZIP code Notes Insurer claim number Reasonable medical expense related to the injury will still be paid. Insurer must complete the following . Due to the employee s death , - loss benefits were discontinued on (date). 1. Was the employ injury? Yes N o U nknown If yes, the insurer mu st contact the heirs or dependents as soon as possible a nd file a First Report of Injury ( related to . 2. Will any permanent partial disability benefits the employee was receiving at the time of death continue to be paid to the heirs or dependents? Yes , for how long? No , why not? Information for heirs and dependents regarding discontinuance You may make a claim for benefits by notifying the employer or the claim representative in writing that you believe the death was related to the injury and are claiming benefits. If you have questions about the benefits paid or owed to the deceased employee, continuing permanent partial disability benefits or dependency benefits, call the insurer claim representative at the telephone number listed at the end of this form. 525 Lake Ave. S. , Suite 330 443 Lafayette R oad N. Duluth, MN 55802 St. Paul, MN 55155 (218) 733 - 7810 or 1 - 800 - 342 - 5354 (651) 284 - 5032 or 1 - 800 - 342 - 5354 American LegalNet, Inc. www.FormsWorkFlow.com Send to: Wion, employer, employee, insurer, heirs and dependents, Average weekly wage at DOI $ Include contingent attorney fees in benefit totals The following benefits have been paid From Through Weeks Rate Total Temporary total d isability or Permanent total d isability Benefit addendum a ttached Temporary partial d isability Retraining b enefits Permanent partial d isability % Injuries on or after 10/01/95 Impairment c om pensation (injuries 01/01/1984 through 09/30/1995) Economic recovery c omp ensati on (injuries 01/01/1984 through 9/30/1995) Part of body (injuries before 01/01/1984) Attorney fees/ expenses Benefit totals M.S. 247 176.081, subd. 1 , contingent fees paid Lump - sum payment under award or order (include contingent attorney fees) M.S. 247 176.081, subd. 1, contingent fees still withheld Attorney fees reimbursed to employee (M.S. 247 176.081, subd. 7) Heaton fees paid Interest paid Roraff fees p aid Total compensation paid (include contingent attorney fees) M.S. 247 176.191 fees paid Total supplementary benefits (include contingent attorney fees) Other fees paid Total medical expenses paid to date Costs and disbursements paid Insurer/self - insurer/TPA Claim representative name Address Phone number (include area code) Extension City State ZIP code Date sent to employee known address Date served on employee attorney ( if any) This document can be given to you in Braille, large print or audio. To request, call (651) 284-5032 or 1-800-342-5354. 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 Minnesota Statutes 247 609.52, subdivision 3. American LegalNet, Inc. www.FormsWorkFlow.com