NOTIFICATION OF REINSTATEMENT OF INDEMNITY 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] [EMPLOYER CITY, STATE, ZIP] The payment of (***the type of benefit*** ) in the amount of (***$$$***) has been reinstated effective (***effective date***) because: (***Provide Full and complete statement explaining the action taken_______________________ ______________________________________________________________________________ ___________________________________________________________________________***) You are encouraged to contact your employer regarding any return to work program that will allow you to return to work within your 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 payments from a weekly payment to a monthly payment. If you do not agree with the amount of the 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-10 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS: Notification of Reinstatement of Indemnity Benefit Payments (DWC FORM PLN-10), Rule 124.2(e)(5), and (f):_(MTC: RB) This letter will be used to report the reinstatement of income benefit payments 050 (TIBs), (040) (SIBs), (020) (LIBs) and (010) (DBs). This letter may also be used to report the reinstatement of (030) (IIBs) when the payment of IIBs is being reinstated after the payment of IIBs has previously been suspended. This notice should be used to report to the employee/representative or beneficiary reinstatement of income or death benefit payments. EXAMPLES: • • • Existence of additional disability Division Order (Interlocutory Order, Decision & Order, Appeals Panel Decision) Third party settlement exhausted Provide a full and complete statement of the reason(s) the action was taken. EXAMPLES: • We are reinstating the payment of Temporary Income Benefits due to the employee’s treating doctor excusing the employee from work effective 4/1/02 until further notice. • We have determined entitlement to the subsequent 3rd quarter of Supplemental Income Benefits and we are reinstating the payment. • We are reinstating the payment of Supplemental Income Benefits in accordance with Division Order. • We are reinstating the payment of Lifetime Income Benefits in accordance with Division Order. • We are reinstating the payment of Death Benefits in accordance with Division Order. DO NOT SEND THIS LETTER TO THE TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION DWC FORM PLN-10 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com