Minnesota Administrative Rules

5222.0400 PROCEDURE.

Subpart 1.

Generally.

The employer or insurer must comply with the procedures set forth in this part by submitting a signed agreement to the commissioner for a finding of permanent total disability.

Subp. 2.

Contents of agreement.

This agreement must state:

A.

the name of the employee;

B.

the employee's Social Security number or workers' compensation identification number assigned by the department;

C.

the name of the employer;

D.

the insurer of the employer, or that the employer is self-insured;

E.

the date of the injury which gave rise to permanent total disability;

F.

the date on which the employee became permanently totally disabled;

G.

the date on which the employee became eligible for government disability benefits;

H.

the date on which the employer or insurer will apply the offset;

I.

the names of the medical and vocational providers submitting the reports showing the employee is permanently totally disabled as of the date stated in item F and the dates of those reports;

J.

the status of the rehabilitation plan as active, inactive, or nonexistent; and

K.

the signatures of the employer or insurer and the employee.

Subp. 3.

[Repealed, 15 SR 1846]

Subp. 4.

Filing of medical reports.

Any medical reports which are identified pursuant to subpart 2, item I, but have not been previously filed with the commissioner, must be attached to the agreement.

Subp. 5.

Filing of rehabilitation reports.

Any reports of qualified rehabilitation consultants which have not been previously filed with the commissioner must be attached to the agreement.

Subp. 6.

Benefit amounts.

The agreement must state the amount of weekly benefits currently received by the employee for government disability, total disability, and supplementary benefits. The agreement must also state the amount of each of these benefits which will be received by the employee if the agreement is approved.

Subp. 7.

Signing of agreement.

The agreement must be signed by an authorized representative of the employer or of the employer's insurer. It must also state the telephone number of each person signing the agreement.

Subp. 8.

Instructions to employee.

The employer or insurer must mail two copies of the agreement with instructions to the employee and, if represented, a copy to the employee's attorney by first class mail, and must so affirm.

Subp. 9.

Filing with commissioner.

A copy signed by the employee must be filed with the commissioner before action will be taken on the request.

Statutory Authority:

MS s 14.388; 175.17; 176.132; 176.83

History:

8 SR 1898; 15 SR 1846; 35 SR 2015

Published Electronically:

July 6, 2011