Date Employee Address City, State, Zip Date of Injury Claim Number Claims Administrator Address City, State, Zip Telephone Number Employer NOTICE REGARDING TEMPORARY DISABILITY BENEFITS (Claims Administrator's Name) is handling your workers' compensation claim on behalf of (Employer). This notice is to advise you of the status of temporary disability payments for your workers' compensation injury of Only the items completed below concern your benefits at this time. Payments are through beginning being resumed for temporary disability for the period from The first payment is enclosed sent separately included in your paycheck. Your weekly compensation rate is $ based on your earnings of $ per week. You may receive less if you are earning partial wages. Payments will be sent to you every two weeks on and will continue until you are able to return to work or your medical condition becomes permanent and stationary. Although liability for your workers' compensation injury has been accepted, I cannot pay you temporary disability benefits at this time because Payments are ending because Benefits paid to you total $ salary continuation From From . Benefits were paid to you as: temporary partial disability: through through Please see the attached for (additional) periods paid. Additionally, you have received 10% self-imposed increases totalling $ Included in this amount is an overpayment totalling $ the overpayment against . We are asserting credit for at $ at $ temporary per week per week total disability The State of California requires that you be given the following information: If you disagree with the decision, you may consult with a State Information and Assistance Officer at 1-800-736-7401 or call your local Information and Assistance Officer at . You may also consult with and be represented by an attorney, and/or apply to have your case heard by the Workers' Compensation Appeals Board. If you have questions, call me at Sincerely, , Claims Examiner Enc.: Benefits Pamphlet TD Fact Sheet Employee Claim Form Applicant's Attorney 3/96 DWC 500-A 2002 © American LegalNet, Inc. Explanation of salary continuation Payment Record cc: