Notice of Discontinuance of Workers' Compensation Dependency Benefits PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format. DB02 DO NOT USE THIS SPACE DATE OF INJURY WID or SSN EMPLOYEE (last, first, mi) EMPLOYER INSURER CLAIM NUMBER DEPENDENT NAME(S) DEPENDENT ADDRESS CITY STATE ZIP CODE THIS IS YOUR NOTICE THAT DEPENDENCY BENEFITS ARE BEING DISCONTINUED ON FOR THE FOLLOWING REASON(S): (DATE) INSTRUCTIONS TO HEIRS AND DEPENDENTS REGARDING DISCONTINUANCE You are responsible for reviewing this form to make sure that you have been properly paid the benefits due you. YOU DO NOT NEED TO TAKE ANY ACTION if you believe that you have received all benefits due. If you have questions about the discontinuance of these benefits, you should first contact the claim representative whose telephone number is listed on the back of this form. If you still have questions, contact the Workers' Compensation Division's Benefit Management and Resolution Unit at the office nearest you. Minnesota Department of Labor and Industry 525 Lake Avenue South, Suite 330 Duluth, MN 55802-2368 Telephone: (218) 733-7810 1-800-342-5354 443 Lafayette Road North St. Paul, MN 55155-4301 Telephone: (651) 284-5030 1-800-342-5354 Mailing Address Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 American LegalNet, Inc. www.FormsWorkFlow.com MN DB02 (2/10) (over) THE FOLLOWING BENEFITS HAVE BEEN PAID Dependency Benefits (please attach a copy of worksheet) Interest Paid Attorney Fees Paid Attorney Fees Still Withheld Total Burial Expenses Paid FROM THROUGH WEEKS RATE TOTAL Dependency Benefits Lump Sum (other than award for death prior to 10/01/1983) Lump Sum Paid Per Award Total Dependency Benefits Paid Additional Payment to SCF (if applicable) Additional Payment to Estate or Dependents (If applicable) INSURER/SELF-INSURER/TPA CLAIM REPRESENTATIVE NAME ADDRESS PHONE NUMBER (include area code) EXTENSION CITY STATE ZIP CODE DATE SERVED ON DEPENDENT(S) 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. Distribution: Workers' Compensation Division, Employer, Insurer, Dependents (one to each household) American LegalNet, Inc. www.FormsWorkFlow.com