NOTIFICATION OF EMPLOYER FULL SALARY PAYMENT 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] We have been notified that your employer is continuing payt of your men pre-injury averae weekly wage g in place of workers compensation Temporary Income BenefiTIBsts ( ). Therefore, you are not entitled to payment of workers compensation TIBs until your employer stops paying your full salary. Explanatory Comments: (free text for explanatory comme___nts)_________________________________ ______________________________________________________________________________________ If you do not agree with the amount of the payments being paid to you by your employer, 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-6 (Rev. 1/05) Page 1 *N6P1-0105* TEXAS WORKERS COMPENSATION COMMISSION >>>> 2 INSTRUCTIONS: Notification of Employer Payment (Form PLN6), Rule 124.2(e)(7) and (f): (MTC: F S) This letter will be used to notify the employee that the carrier is not making payment of income benefits due to the Employer Paid (benefit type 240) payments made by the employer. letter shouThis ld be provided to the employee/representative when the employer is paying full wages to the employee in lieu of workers compensation income benefit payment from the insurance carrier. DO NOT SEND THIS LETTER TO THE TEXAS WORKERS COMPENSATION COMMISSION American LegalNet, Inc. www.USCourtForms.comTWCC PLN-6 (Rev. 1/05) Page 2 *N6P2-0105* TEXAS WORKERS COMPENSATION COMMISSION