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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
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
PLN01S
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 01/10
WORDSpanish
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
PLN02S
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORDSpanish
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
PLN03S
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 01/10
WORDSpanish
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
PLN04S
Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORDSpanish
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
PLN05S
Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 01/10
WORDSpanish
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
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
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
PLN08S
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 01/10
WORDSpanish
PLN09
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
PDFEnglish
PLN09
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
WORDEnglish
PLN09S
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 01/10
WORDSpanish
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
PLN10S
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 01/10
WORDSpanish
PLN11
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 06/15
PDFEnglish
PLN11
Aviso Sobre Asunto(s) en Disputa y Denegación para Pagar Beneficios
Rev. 06/15
PDFSpanish
PLN11
Aviso Sobre Asunto(s) en Disputa y Denegación para Pagar Beneficios
Rev. 06/15
WORDSpanish
PLN11
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 06/15
WORDEnglish
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
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


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Last updated: 09/17/2014

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