Form Mn Db02 "Notice of Discontinuance of Workers' Compensation Dependency Benefits" - Minnesota

Form MN DB02 or the "Notice Of Discontinuance Of Workers' Compensation Dependency Benefits" is a form issued by the Minnesota Department of Labor and Industry.

The form was last revised in February 1, 2010 and is available for digital filing. Download an up-to-date Form MN DB02 in PDF-format down below or look it up on the Minnesota Department of Labor and Industry Forms website.

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Reset
Notice of Discontinuance of Workers’
Compensation Dependency Benefits
D B 0 2
PRINT IN INK or TYPE
DO NOT USE THIS SPACE
Enter dates in MM/DD/YYYY format.
WID or SSN
DATE OF INJURY
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
(DATE)
FOR THE FOLLOWING REASON(S):
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
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
1-800-342-5354
St. Paul, MN 55164-0221
MN DB02 (2/10)
(over)
Reset
Notice of Discontinuance of Workers’
Compensation Dependency Benefits
D B 0 2
PRINT IN INK or TYPE
DO NOT USE THIS SPACE
Enter dates in MM/DD/YYYY format.
WID or SSN
DATE OF INJURY
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
(DATE)
FOR THE FOLLOWING REASON(S):
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
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
1-800-342-5354
St. Paul, MN 55164-0221
MN DB02 (2/10)
(over)
THE FOLLOWING BENEFITS HAVE BEEN PAID
FROM
THROUGH
WEEKS
RATE
TOTAL
Dependency Benefits (please attach a copy of
worksheet)
Dependency Benefits Lump Sum (other
Interest Paid
than award for death prior to 10/01/1983)
Attorney Fees Paid
Lump Sum Paid Per Award
Attorney Fees Still Withheld
Total Dependency Benefits Paid
Additional Payment to SCF
Total Burial Expenses Paid
(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)
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