NOTIFICATION OF FIRST DEATH BENEFIT PAYMENT DATE: TO: [NAME OF BENEFICIARY] [ADDRESS] [CITY, STATE, ZIP] RE: [DATE OF INJURY] [NATURE OF INJURY] [PART OF BODY INJURED] [NAME OF EMPLOYEE] [EMPLOYEE SSN] [CLAIM #] [CARRIER NAME/TPA NAME] [CARRIER CLAIM#] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] Your first payment of workers’ compensation benefits for the period of (***first date of period being paid***) is being issued. The benefit payment is called “Death Benefits” (DBs) and is paid weekly. Your DBs payment, in the amount of (***$$$***), is based on 75% of the reported Average Weekly Wage of (***$$$***). An explanation of your DBs payment is as follows: (***Provide full and complete statement explaining the action taken and explanation of distribution of benefits***) You may request that we make benefit payments by electronic funds transfer directly to your bank account. Also, you may request that we change your DBs from a weekly payment to a monthly payment. If you do not agree with the amount of weekly death 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-5 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS: Notification of First Death Benefit Payment (DWC FORM PLN-5), Rule 124.2(e)(1) and (f):_(MTC: IP) This is the Notification of First Payment letter for benefit type 010 (DBs). This letter is only to be used to report the first indemnity benefit payment made on a claim. Only one notice of initial payment may be sent on a claim but the initial payment benefit type may be TIBs, IIBs, LIBs or DBs. This notice should only be used to report to the beneficiary(ies)/representative the payment of DBs when the payment is the initial payment of indemnity benefits on a claim. Each beneficiary that receives a payment of DBs must be provided a copy of this notice. 1. Include the date income benefits began to accrue. 2. Include the Average Weekly Wage that indemnity benefits are based on. 3. Provide a full and complete statement explaining the action taken. Include the distribution of payments of death benefits, and requirements to remain entitled. EXAMPLES Death benefits are being paid due to the death of Joe Employee. Benefits are being paid as follows: Spouse 100% ($400 week). Death benefits are being paid due to the death of Joe Employee. Benefits are being paid as follows: Spouse 50% ($200 week), Son 25% ($100 week), Daughter 25% ($100 week). Death benefits are being paid due to the death of Joe Employee. Benefits are being paid as follows: Son 50% ($200 week), Daughter 50% ($200 week). DO NOT SEND THIS LETTER TO THE TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION DWC FORM PLN-5 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com