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Workers' compensation plain language notices

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TDI Form Number Description File Format Language
PLN01

Notice of Denial of Compensability/Liability and Refusal to Pay Benefits

Rev. 07/21

WORD English
PLN01S

Notice of Denial of Compensability/Liability and Refusal to Pay Benefits

Rev. 07/21

WORD Spanish
PLN02A

Notice of First Temporary Income Benefit Payment

Rev. 07/21

WORD English
PLN02AS

Notice of First Temporary Income Benefit Payment

Rev. 07/21

WORD Spanish
PLN02B

Notice of first payment of income benefits on an acquired claim

Rev. 07/23

WORD English
PLN02BS

Notice of first payment of income benefits on an acquired claim

Rev. 07/23

WORD Spanish
PLN03A

Notice of Maximum Medical Improvement and No Permanent Impairment

Rev. 07/21

WORD English
PLN03AS

Notice of Maximum Medical Improvement and No Permanent Impairment

Rev. 07/21

WORD Spanish
PLN03B

Notice of Maximum Medical Improvement and Permanent Impairment

Rev. 07/21

WORD English
PLN03BS

Notice of Maximum Medical Improvement and Permanent Impairment

Rev. 07/21

WORD Spanish
PLN03C

Notice of Maximum Medical Improvement and Estimated Permanent Impairment

Rev. 07/21

WORD English
PLN03CS

Notice of Maximum Medical Improvement and Estimated Permanent Impairment

Rev. 07/21

WORD Spanish
PLN04

Notice of Eligibility for Lifetime Income Benefits

Rev. 07/21

WORD English
PLN04S

Notice of Eligibility for Lifetime Income Benefits

Rev. 07/21

WORD Spanish
PLN05

Notice of First Death Benefit Payment

Rev. 07/21

WORD English
PLN05S

Notice of First Death Benefit Payment

Rev. 07/21

WORD Spanish
PLN06

Notice of Employer Full Salary Payment

Rev. 07/21

WORD English
PLN06S

Notice of Employer Full Salary Payment

Rev. 07/21

WORD Spanish
PLN07

Notice of Change of Indemnity Benefit Type

Rev. 07/21

WORD English
PLN07S

Notice of Change of Indemnity Benefit Type

Rev. 07/21

WORD Spanish
PLN08

Notice of Change in Amount of Indemnity Benefit Payment

Rev. 07/23

WORD English
PLN08S

Notice of Change in Amount of Indemnity Benefit Payment

Rev. 07/23

WORD Spanish
PLN09

Notice of Suspension of Indemnity Benefits

Rev. 07/21

WORD English
PLN09S

Notice of Suspension of Indemnity Benefits

Rev. 07/21

WORD Spanish
PLN10A

Notice of reinstatement of indemnity benefits

Rev. 07/23

WORD English
PLN10AS

Notice of reinstatement of indemnity benefits

Rev. 07/23

WORD Spanish
PLN10B

Notice of lump sum payment of income or death benefits

Rev. 07/23

WORD English
PLN10BS

Notice of lump sum payment of income or death benefits

Rev. 07/23

WORD Spanish
PLN11

Notice of Disputed Issues and Refusal to Pay Benefits

Rev. 07/23

WORD English
PLN11S

Notice of Disputed Issues and Refusal to Pay Benefits

Rev. 07/23

WORD Spanish
PLN12

Notice of Potential Entitlement to Workers’ Compensation Death Benefits

Rev. 12/23

WORD English
PLN12S

Notice of Potential Entitlement to Workers’ Compensation Death Benefits

Rev. 12/23

WORD Spanish
PLN14

Notice of Continuing Investigation

Rev. 07/23

WORD English
PLN14S

Notificación de Investigación en Curso

Rev. 07/23

WORD Spanish

For more information, contact: WebStaff@tdi.texas.gov