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Workers' Compensation Plain Language Notices

Division of Workers Compensation Main Forms page

 

English

Plain Language Notices

TDI Form Number	Description	File Format
PLN01	Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d)) Rev. 10/05	PDF
PLN01	Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d)) Rev. 10/05	WORD
PLN02	Notification of First Temporary Income Benefit Payment (124.2(e)(1)) Rev. 10/05	WORD
PLN02	Notification of First Temporary Income Benefit Payment (124.2(e)(1)) Rev. 10/05	PDF
PLN03	Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5)) Rev. 10/05	WORD
PLN03	Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5)) Rev. 10/05	PDF
PLN04	Notification of First Lifetime Income Benefit Payment (124.2(e)(1)) Rev. 10/05	WORD
PLN04	Notification of First Lifetime Income Benefit Payment (124.2(e)(1)) Rev. 10/05	PDF
PLN05	Notification of First Death Benefit Payment (124.2(e)(1)) Rev. 10/05	PDF
PLN05	Notification of First Death Benefit Payment (124.2(e)(1)) Rev. 10/05	WORD
PLN06	Notification of Employer Full Salary Payment (124.2(e)(7)) Rev. 10/05	WORD
PLN06	Notification of Employer Full Salary Payment (124.2(e)(7)) Rev. 10/05	PDF
PLN07	Notification of Change of Indemnity Benefit Type (124.2(e)(4)) Rev. 10/05	WORD
PLN07	Notification of Change of Indemnity Benefit Type (124.2(e)(4)) Rev. 10/05	PDF
PLN08	Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3)) Rev. 10/05	WORD
PLN08	Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3)) Rev. 10/05	PDF
PLN09	Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6)) Rev. 10/05	WORD
PLN09	Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6)) Rev. 10/05	PDF
PLN10	Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5)) Rev. 10/05	WORD
PLN10	Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5)) Rev. 10/05	PDF
PLN11	Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h)) Rev. 10/05	PDF
PLN11	Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h)) Rev. 10/05	WORD
PLN12	Notice of Potential Entitlement to Workers’ Compensation Death Benefits Rev. 11/12	WORD
PLN12	Notice of Potential Entitlement to Workers’ Compensation Death Benefits Rev. 11/12	PDF

En Español

Plain Language Notices

Número del Formulario de TDI	Descripción	Formato del Archivo
PLN01S	Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d)) Rev. 01/10	WORD
PLN02S	Notification of First Temporary Income Benefit Payment (124.2(e)(1)) Rev. 01/10	WORD
PLN03S	Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5)) Rev. 01/10	WORD
PLN04S	Notification of First Lifetime Income Benefit Payment (124.2(e)(1)) Rev. 01/10	WORD
PLN05S	Notification of First Death Benefit Payment (124.2(e)(1)) Rev. 01/10	WORD
PLN06S	Notification of Employer Full Salary Payment (124.2(e)(7)) Rev. 01/10	WORD
PLN07S	Notification of Change of Indemnity Benefit Type (124.2(e)(4)) Rev. 01/10	WORD
PLN08S	Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3)) Rev. 01/10	WORD
PLN09S	Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6)) Rev. 01/10	WORD
PLN10S	Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5)) Rev. 01/10	WORD
PLN11S	Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h)) Rev. 01/10	WORD
PLN12S	Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores Rev. 11/12	WORD
PLN12S	Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores Rev. 11/12	PDF

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