NOTICE OF DENIAL OF COMPENSABILITY/LIABILITY AND REFUSAL TO PAY BENEFITS 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] [CARRIER CLAIM #] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] On (date of carrier receipt of notice of injury) we received notice that you reported an on the job injury. We are denying r you claim for workers compensation benefits. Workers compensation benefits, including medical benefits, are not being paid because: (***Provide full and complete statement explaining the action taken________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________________***) If you do not agree with the denial and refusal to pay benefits, 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 facsime or e-milail, 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 may result in fines and/or imprisonment. Cc: American LegalNet, Inc. www.USCourtForms.comTWCC PLN-1 (Rev. 1/05) Page 1 *N1P1-0105* TEXAS WORKERS COMPENSATION COMMISSION >>>> 2 INSTRUCTIONS: Notification of Denial of Compensability/Liability and Refusal to Pay Benefits (Form PLN1) Rule 124.2(d); (MTC: 0 4) This letter must be used to notify the employee/representativ the ane Cdommission of the carriers denial of compensability of, or liability for, an injury. It must be filed in addition to the 148/04 or A49/04 in order to provide the basis of the dispute when a denial ofcompensa bility/liability is filed with the Commission. Provide a full and complete statement of te facts shurrounding the claim that justify and serve as the grounds for the denial of compensability or liability for the claim. EXAMPLES: Our investigation finds th einjured worker sustained the injury at his sons little league game when he fell off the bleachers. He was taken to the local hospital by amancebul. Video tape of accident and news broadcast are available for review by interested parties. We deny liability for the injury due to lack of workers compensation insurance coverage by the employer. We have never provided workers compensation coverage to the employer and are not liable for payment of benefits. NOTE: A statement that simply states a conclusion such as liability in question, compensability in dispute or under investigation is insufficient grounds fothr e information required per Rule 124.2(h). Denials must be based upon information a carrier has obtained or verified, not what it has not been able to verify. MAIL THIS FORM TO TWCC IN LIEU OF A TWCC 21 WHEN YOU HAVE FILED AN ELECTRONIC MTC 04 American LegalNet, Inc. www.USCourtForms.comTWCC PLN-1 (Rev. 1/05) Page 2 *N1P2-0105* TEXAS WORKERS COMPENSATION COMMISSION