NOTIFICATION OF FIRST LIFETIME INCOME BENEFIT 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] Your first payment of workers’ compensation benefits for the period of (***first day of period being paid***) is being issued. The benefit payment is called “Lifetime Income Benefits” (LIBs) and is paid weekly. The amount of your LIBs payment is based on 75% of the reported Average Weekly Wage of (***$$$***). Each year on (***accrual anniversary date***) the LIBs weekly benefit amount will increase by 3%. 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 LIBs from a weekly payment to a monthly payment. Explanatory Comments: (free text for explanatory comments)_____________________________ ______________________________________________________________________________ If you do not agree with the amount of weekly income 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-4 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS: Notification of First Lifetime Income Benefit Payment (DWC FORM PLN-2, PLN-4 and PLN-5,), Rule 124.2(e)(1) and (f):_(MTC: IP) This is the Notification of First Payment letter for benefit type 020 (LIBs). 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 injured employee/representative the payment of LIBs when the payment is the initial payment of indemnity benefits on a claim. 1. Provide the date Lifetime Income Benefits began to accrue. 2. Provide the Average Weekly Wage that income benefits are based on. DO NOT SEND THIS LETTER TO THE TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION DWC FORM PLN-4 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com