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Workers' Compensation Plain Language Notices

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Division of Workers Compensation Main Forms page

Workers' Compensation Plain Language Notices
TDI Form Number Description File FormatLanguage
PLN01S Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 01/10
WORDSpanish
PLN02S Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORDSpanish
PLN03S Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 01/10
WORDSpanish
PLN04S Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORDSpanish
PLN05S Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 01/10
WORDSpanish
PLN06S Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 01/10
WORDSpanish
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 10/05
WORDEnglish
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 10/05
PDFEnglish
PLN07S Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 01/10
WORDSpanish
PLN08S Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 01/10
WORDSpanish
PLN09S Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 01/10
WORDSpanish
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 10/05
WORDEnglish
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 10/05
PDFEnglish
PLN10S Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 01/10
WORDSpanish
PLN11S Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
Rev. 01/10
WORDSpanish
PLN12 Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
WORDEnglish
PLN12 Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
PDFEnglish
PLN12S Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores
Rev. 11/12
WORDSpanish
PLN12S Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores
Rev. 11/12
PDFSpanish
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 10/05
WORDEnglish
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 10/05
PDFEnglish
PLN03 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 10/05
WORDEnglish
PLN03 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 10/05
PDFEnglish
PLN04 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 10/05
WORDEnglish
PLN04 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 10/05
PDFEnglish
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 10/05
WORDEnglish
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 10/05
PDFEnglish
PLN06 Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 10/05
WORDEnglish
PLN06 Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 10/05
PDFEnglish
PLN08 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 10/05
WORDEnglish
PLN08 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 10/05
PDFEnglish
PLN09 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
WORDEnglish
PLN09 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
PDFEnglish
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 10/05
WORDEnglish
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 10/05
PDFEnglish
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
Rev. 10/05
WORDEnglish
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
Rev. 10/05
PDFEnglish


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Last updated: 09/17/2014

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Translation by WorldLingo