NOTIFICATION OF CHANGE OF INDEMNITY BENEFIT PAYMENT TYPE DATE: TO: [NAME OF INJURED EMPLOYEE] [ADDRESS] [CITY, STATE, ZIP] RE: [DATE OF INJURY] [NATURE OF INJURY] [PART OF BODY INJURED] [EMPLOYEE SSN] [TWCC #] [CARRIER NAME/TPA NAME] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] The type of indemnity benefit being paid has changed fromt (**ype of bene* fit being paid***) to (***type of benefit to be paid***) effective (***effective date of change***) because: (***Provide Full and complete statement explaining the action taken_______________________ ______________________________________________________________________________ ___________________________________________________________________________***) You remain entitled to necessary medical benefits related to this injury. You are encouraged to contact your employer regarding any return to work program that would allow you to retukrn to wor within the restrictions prescribed by your treating doctor. If you are expected to be paid benefits for a period of eight weeks or more, you may request that we make your benefit payments by electronic funds transfer directly to your bank account. Also, you may request that we change your benefit payment from a weekly payment to a monthly payment. If you do not agree with the amount of weekly benefits being paid, please contact me: Adjusters Name: ______________________________________________ Toll Free Telephone #: ______________________________________________ Fax #/E-mail Address: ______________________________________________ If we are unable to resolve the issue to your satisfaction, you may contact the Texas Workers Compensation Commission for further assistance. You have the right to request a Benefit Review Conference. You can contact the Commission office handling your claim at 1-800-252-7031. If you would like to receive notices such as this by facsimile or e-mail, please contact me and provide your facsimile number or e-mail address. Please note that making a false or fraudulent workers compensation claim is a crime that mya result in fines and/or imprisonment. Cc: American LegalNet, Inc. www.USCourtForms.comTWCC PLN-7 (Rev. 1/05) Page 1 *N7P1-0105* TEXAS WORKERS COMPENSATION COMMISSION >>>> 2 INSTRUCTIONS: Notification of Change In Benefit Payment Typ(Foe rm PLN7), Rule 124.2(e)(4), and (f): MTC CB) This letter will be used to report a change of benefit typ 0e4 to0 (SIBs), 020 (LIBs) or 010 (DBs) and to report the change from 030 (IIBs) back to 050 (TIBs). Note: The change of bfit typene e to 030 (IIBs) will be reported via the Notification of MMI/IR. This notice should be used to report to the emoyee/represepl ntative or beneficiary a change in income benefit type. This notice may also be used to explain taking credit for benefits already paid. EXAMPLES: Determination of Entitlement to Supplemental Income Benefits. Entitlement to Lifetime Income Benefits after payment of a previous income benefit type. Entitlement to Death Benefits after payment of a previous income benefit type. Remove Paragraph 2 and 3. Changing from Impairment Income Benefits back to Temporary Income Benefits. Provide a full and complete statement of the reason(s) the action was taken. EXAMPLE: Insurance carrier has been notified by the Texas Workers Compensation of your entitlement to Supplemental Income Benefits (SIBs). Attached is your first quarterly payment of SIBs. Insurance carrier has been notified that the treating doctors MMI and IR was disputed and the designated doctor said you were not at MMI, therefore, your Iare bIBs eing changed to TIBs. We are talking credit for the 3 weeks of IIBs paid towards the payment of TIBs that are due. DO NOT SEND THIS LETTER TO THE TEXAS WORKERS COMPENSATION COMMISSION American LegalNet, Inc. www.USCourtForms.comTWCC PLN-7 (Rev. 1/05) Page 2 *N7P2-0105* TEXAS WORKERS COMPENSATION COMMISSION