Legal Forms >> Minnesota >> Workers' Compensation >> Claims and Reports
Form #:DB02 Former 3205.5. This form is used for an employer to notify the dependent of a deceased worker that their benefits will be discontinued on a specific date. The reason for the discontinuance, as well as a detailed account of benefits, attorney fees, burial expenses, and other payments, should be provided.
Name:Notice of Discontinuance of Workers' Compensation Dependency Benefits (Downloadable PDF) Form Number: DB02 State:Minnesota Statute:N/A Form Category:> Claims and Reports' itemprop="category">Claims and Reports
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