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Workers' Compensation Plain Language Notices

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 Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN01
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 10/05
WORD English
PLN01S
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN01S
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 01/10
WORD Spanish
PLN02
Notice of First Temporary Income Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN02
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD English
PLN02S
Notice of First Temporary Income Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN02S
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD Spanish
PLN03
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 10/05
WORD English
PLN03A
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN03AS
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN03B
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN03BS
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN03C
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN03CS
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN03S
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 08/10
WORD Spanish
PLN04
Notice Regarding Eligibility for Lifetime Income Benefits
Rev. 06/15, for use on or after June 1, 2015
WORD English
PLN04
Notice of Eligibility for Lifetime Income Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN04S
Notice of Eligibility for Lifetime Income Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN04S
Notice Regarding Eligibility for Lifetime Income Benefits
Rev. 06/15
WORD Spanish
PLN05
Notice of First Death Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN05
Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD English
PLN05S
Notice of First Death Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN05S
Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD Spanish
PLN06
Notice of Employer Full Salary Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN06
Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 10/05
WORD English
PLN06S
Notice of Employer Full Salary Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN06S
Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 08/10
WORD Spanish
PLN07
Notice of Change of Indemnity Benefit Type
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN07
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 10/05
WORD English
PLN07S
Notice of Change of Indemnity Benefit Type
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN07S
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 08/10
WORD Spanish
PLN08
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN08
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 10/05
WORD English
PLN08S
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN08S
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 08/10
WORD Spanish
PLN09
Notice of Suspension of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN09
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
WORD English
PLN09S
Notice of Suspension of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN09S
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 08/10
WORD Spanish
PLN10
Notice of Reinstatement of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN10
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 10/05
WORD English
PLN10S
Notice of Reinstatement of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN10S
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 08/10
WORD Spanish
PLN11
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN11S
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 06/15
WORD Spanish
PLN11
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 06/15
WORD English
PLN11S
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN12
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN12
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
WORD English
PLN12S
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN12S
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
WORD Spanish

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