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] [CLAIM #] [CARRIER NAME/TPA NAME] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] The type of indemnity benefit being paid has changed from (***type of benefit 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 return to work 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: Adjuster’s Name: Toll Free Telephone #: Fax #/E-mail Address: ______________________________________________ ______________________________________________ ______________________________________________ If we are unable to resolve the issue to your satisfaction, you may contact the Texas Department of Insurance, Division of Workers’ Compensation for further assistance. You have the right to request a Benefit Review Conference. You can contact the Division 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 may result in fines and/or imprisonment. Cc: DWC FORM PLN-7 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS: Notification of Change In Benefit Payment Type (DWC FORM PLN-7), Rule 124.2(e)(4), and (f): MTC CB) This letter will be used to report a change of benefit type to 040 (SIBs), 020 (LIBs) or 010 (DBs) and to report the change from 030 (IIBs) back to 050 (TIBs). Note: The change of benefit type to 030 (IIBs) will be reported via the “Notification of MMI/IR”. This notice should be used to report to the employee/representative 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 Division of 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 doctor’s MMI and IR was disputed and the designated doctor said you were not at MMI, therefore, your IIBs are being 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 DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION DWC FORM PLN-7 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com