Employee’s Objection To
Office of Administrative Hearings
Workers’ Compensation Division
Discontinuance
PO Box 64620
ED0 2
of Temporary Total, Temporary Partial
St. Paul, MN 55164-0620
(651) 361-7900
or Permanent Total Disability Benefits
DO NOT USE THIS SPACE
Reset
PRINT IN INK or TYPE
ENTER DATES in MM/DD/YYYY FORMAT
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 workers’ 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 department’s
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 workers’ compensation court of appeals; the departments of revenue and health; and the workers’ 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. § 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. § 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)
Employee’s Objection To
Office of Administrative Hearings
Workers’ Compensation Division
Discontinuance
PO Box 64620
ED0 2
of Temporary Total, Temporary Partial
St. Paul, MN 55164-0620
(651) 361-7900
or Permanent Total Disability Benefits
DO NOT USE THIS SPACE
Reset
PRINT IN INK or TYPE
ENTER DATES in MM/DD/YYYY FORMAT
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 workers’ 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 department’s
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 workers’ compensation court of appeals; the departments of revenue and health; and the workers’ 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. § 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. § 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)
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
Signature
this
day of
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. § 176.239.
Failure to properly and fully fill out this form, with appropriate documentation, in accordance with workers’ compensation rules of practice, is
2.
not considered proper filing. The Office of Administrative Hearings may refuse to accept this form if it lacks any of the following: employee’s
name, date of injury, WID or social security number, or name of employer/insurer.
The claim must be presented in terms of the Minnesota Workers’ Compensation Act.
3.
4.
If you have more defendants or more injuries than can be listed, this form may be modified accordingly.
A doctor’s report or other information supporting the claim MUST be filed with this form.
5.
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 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.