NOTIFICATION OF FIRST TEMPORARY 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] [TWCC #] [CARRIER NAME/TPA NAME] [CARRIER CLAIM#] [EMPLOYER NAME] [EMPLOYER ADDRESS] YER CITY, STATE, ZIP Your first payment of workers compensation benefits for the period of (***first day of period being paid***) to (***last day of period being paid***) is being issued. The benefit payment is called Temporary Income BenefiTIBsts () and is paid weekly. TIBs begin after you have had lost wages for more than 7 days. TIBs began on (***date of eighth day of disability***) which was your eighth day of disability. The TIBs weekly benefit amount of (***$$$***) is based on the reported Average Weekly Wage of (***$$$***). Please inform us within 3 days if you: Start earning income again from any employer; or Have any change in earnings resulting from yoinjuur ry, either an increase or decrease; or Have an offer of employment at any wage level. You are encouraged to contact your employer regarding anyrn to retu work program that will allow you 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 TIBs from a weekly payment to a monthly payment. Explanatory Comments: (free text for explanatory comme___nts)_________________________________ ______________________________________________________________________________________ If you do not agree with the amount of weeklincy ome benefits being paid, 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 facsimile or e-mail, please contact me and provide your facsimile numr e-maber oil 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-2 (Rev. 1/05) Page 1 *N2P1-0105* TEXAS WORKERS COMPENSATION COMMISSION >>>> 2 INSTRUCTIONS: Notification of First Payment (Form PLN2), Rule 124.2 (e)(1) and (f):_(MTC: IP) This is the Notification of First Payment letter for benefit type 050TIBs ( ). 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 initial payment of TIBs indemnity benefits on a claim. 1. Provide this letter to the employee upon the initiation of temporary income benefits. 2. Include the start and end dates for the period being paid. 3. Include the date income benefits began to accrue (8th day of disability). 4. Include the TIBs rat.e 5. Include the Average Weekly Wage that payment of income benefits is based on. DO NOT SEND THIS LETTER TO THE TEXA S WORKERS COMPENSATION COMMISSION American LegalNet, Inc. www.USCourtForms.comTWCC PLN-2 (Rev. 1/05) Page 2 *N2P2-0105* TEXAS WORKERS COMPENSATION COMMISSION