Instructions to the insurance carrier:

Notice of Potential Entitlement to Workers’ Compensation Death Benefits (PLN-12) 28 Texas Administrative Code (TAC) Sections 124.8 and 132.17

The insurance carrier must use this notice to notify a person identified as a potential beneficiary about their potential entitlement to receive death benefits and how to file a claim for those benefits.

• The insurance carrier must:
• Provide this notice to the potential beneficiary and the potential beneficiary’s representative (if applicable).
• Send the PLN-12 within seven days of the date the insurance carrier identified or became aware of the identity and means of contacting the potential beneficiary.
• Attach a current version of the DWC Form-042, Claim for workers’ compensation death benefits.
• Send to DWC a copy of the PLN-12 that was sent to the potential beneficiary. Do not send DWC a blank copy of the DWC Form-042.
• Provide a full and complete statement of the facts that justify and serve as the grounds for identifying that person as a potential beneficiary.

Examples:

Our investigation finds that the deceased employee appears to have been the grandfather of the potential beneficiary. The mother of the beneficiary, [Name], was determined to be the daughter of the deceased.

We have identified the deceased employee as the stepfather of the potential beneficiary. We verified that the deceased was legally married to the potential beneficiary’s mother, [Name], at the time of his death.

Format requirements:

You must use a 12-point font size or larger (28 TAC Section 124.2(o)).

Format recommendations:

Information that you send to injured employees must be in plain language. Along with clear writing, it is helpful to the reader when information is in a clean, easy-to-read format. Using easy-to-understand words and clean formatting might increase the length of your letter, but it also might greatly reduce customer service calls. Here are recommendations for formatting letters to injured employees:

• Print only information that applies to the reader. (1) Remove the section “Instructions to the insurance carrier,” and (2) if this letter has more than one option, remove the option that doesn’t apply to the injured employee.
• Choose a clean font style. Avoid highly stylized fonts. Fonts like Segoe, Verdana, and Times New Roman are known to be the easiest to read.
• Avoid italics and underlines. If you want to emphasize text, it’s often better to use bold or a bigger font size.
• Use sufficient and consistent spacing. DWC suggests using 6 pts between paragraphs and bullets and 12 pts between sections.