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Workers' compensation plain language notices

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TDI form number Description 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. 11/24 		WORD English
PLN04S Notice of Eligibility for Lifetime Income Benefits
Rev. 11/24 		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. 11/24 (for use on or after 11/21/24) 		WORD English
PLN07S Notice of Change of Indemnity Benefit Type
Rev. 11/24 (for use on or after 11/21/24) 		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

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