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] [CLAIM #] [CARRIER NAME/TPA NAME] [CARRIER CLAIM #] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] We have been notified that your employer is continuing payment of your pre-injury average weekly wage in place of workers’ compensation Temporary Income Benefits (TIBs). 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 comments)____________________________________ ______________________________________________________________________________________ If you do not agree with the amount of the payments being paid to you by your employer, 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-6 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS: Notification of Employer Payment (DWC FORM PLN-6), Rule 124.2(e)(7) and (f): (MTC: FS) 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. This letter should 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 DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION DWC FORM PLN-6 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com