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. 07/21
|
WORD |
English |
PLN12S
|
Notice of Potential Entitlement to Workers’ Compensation Death Benefits Rev. 07/21
|
WORD |
Spanish |
PLN14
|
Notice of Continuing Investigation Rev. 07/23
|
WORD |
English |
PLN14S
|
Notificación de Investigación en Curso Rev. 07/23
|
WORD |
Spanish |