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Workers' Compensation Plain Language Notices


Division of Workers Compensation Main Forms page

 

English


Plain Language Notices
TDI Form NumberDescriptionFile 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 TDIDescripciónFormato 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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Translation by WorldLingo