Division of Workers' CompensationBENEFIT NOTICEINSTRUCTION MANUALTitle 8, California Code of Regulations,Sections 9810 through 9815(Revisions effective January 1, 2016)January 2016

BENEFIT NOTICE INSTRUCTION s for Notices Regarding Temporary Disability & SalaryContinuation8Notice Temporary Disability / Salary Continuation Start / Resume11Notice Temporary Disability / Salary Continuation Delay15Notice Temporary Disability / Salary Continuation Denial18Instructions for Benefit Notices for Resumption, Change, &Termination22Notice Resumed Benefit Payment26Notice Change in Rate, Amount or Payment Schedule30Notice Termination of Benefit Payment33Instructions for Notices Regarding Permanent Disability37Notice Permanent Disability Monitor43Notice Permanent Disability Advice47Notice Permanent Disability Denial51Notice Permanent Disability Start / Resume55Instructions for Notice of Denial & Delay of All Workers’ CompensationBenefits58Notice Denial of Workers' Compensation Benefits62Notice Delay of Workers' Compensation Benefits66Instructions for Notices Regarding Dependency (Death) Benefits70Notice Dependency Payment Start74Notice Dependency Payment Change or End77Notice Dependency Payment Delay80Notice Dependency Payment Denial83Benefit Notices-Revised 1/1/16Page 2

BENEFIT NOTICE INSTRUCTION MANUALInstructions for Notices to Provide Panel QMERequest For QME panel under Labor Code Section 4062.1 unrepresented (QME Form 105)Benefit Notices-Revised 1/1/16Page 3English8687

BENEFIT NOTICE INSTRUCTION MANUALINTRODUCTIONThe purpose of this manual is to present advice for accurate and timely completion of benefitnotices and mandatory forms that meet the requirements of the Administrative Director'sregulations. The regulations which govern the requirements for these notices are in Title 8,California Code of Regulations, Chapter 4.5--Division of Workers' Compensation, Subchapter 1-Administrative Director Administrative Rules, Article 8, “Benefit Notices; ClaimsAdministrator’s Duties and Responsibilities; Claim Form and Notice of Potential Eligibility forBenefits; Regulatory Authority of the Administrative Director” Sections 9810-9815 (abbreviated8, CCR §§9810-9815). These regulations are effective as of January 1, 2016. The regulationsapply to all workers' compensation dates of injury, except as otherwise noted. When referencesto the regulations are made, they are by section and subdivision [for example, §9812(a)(1)].The model notices presented in this manual are in English and Spanish and are the result of acombined effort of workers' compensation professionals from insurers, self-insured employers,third-party administrators, and employer and employee representative groups working togetherwith the Division of Workers' Compensation. The intent of this effort is to provide formswhich, if used in conjunction with the instructions provided, will improve communication withthe injured worker and make it easier for the claims administrator to comply with the regulationsgoverning the issuance of benefit notices.Sections 9810(c) and (d) provide that each benefit notice letter, excepting those mandatorynotices set forth in statute or where a specific notice form has been adopted as a regulation, maybe produced on the claims administrator’s letterhead. The notice letters must include the claimsadministrator’s name, mailing address and telephone number and website address if available,name of the employee, employer, the claim number, the date the notice was sent to the employee(or other claimant), and the date of injury. The term “claims administrator” includes theadministrator for an alternative dispute resolution (ADR) program as established under LaborCode §3201.5 or 3201.7. The name, mailing address, and phone number of the individualclaims representative responsible for the payment and adjusting of the claim must be clearlyshown, except where there is a clearly documented reason to believe that disclosure of the claimsrepresentative’s name presents or may present a security concern towards the personal safety ofthe claims representative, in which case, an alternate but specific claims department name andtelephone number may be identified in lieu of the claims representative’s name and telephonenumber.Various events in the life of a workers' compensation claim trigger the requirement to issue anotice to the employee or claimant. There are required contents for each notice. If theemployer offers additional disability benefits in addition to those provided by law under workers'compensation, the claims administrator may incorporate the information within the noticesrequired by these regulations. Section 9810(a) provides that where a claim is subject to an ADRprogram as described above, the contents of any required notice that would be inconsistent withthe provisions of the ADR agreement must be modified to be consistent with the ADRagreement.Benefit Notices-Revised 1/1/16Page 4

BENEFIT NOTICE INSTRUCTION MANUALA single benefit notice may encompass multiple events. Information required to be given to theemployee at each event is in the model notices presented in this manual. Information (otheroptions) not relevant to the particular notice should be deleted. However, the required contentsof these regulations for the specific event addressed in the notice should remain in the notice.The format and language in the model notices are not required to be issued as presented in thismanual with the exception of those mandatory forms created to address retraining and/or returnto work for dates of injury on and after January 1, 2004.The model notices may be revised to fit an individual claims administrator's preferences with theexception of the mandatory forms mentioned above. Each model notice has (1) requiredinformation and (2) optional information specific to the event being addressed in the notice.Regulations require that specific enclosures shall be sent with some notices. Section 9810(d)requires “each benefit notice shall refer the employee (by chapter number and internet url) tothe appropriate chapter of the publication “Workers’ Compensation in California: A Guidebookfor Injured Workers” that addresses the benefit(s) to which the notice pertains, and shall advisethe employee that a complete copy of the Guidebook may be obtained on the Division ofWorkers’ Compensation’s website juredWorkerGuidebook.htmlor by contacting an information and assistance (I&A) officer of the Division of Workers’Compensation.”Claims administrators may continue to use notices that were used before this manual waspublished as long as those notices meet the current requirements set forth in Title 8, CaliforniaCode of Regulations, Section 9810(a) provided that where a claim is subject to an ADR programas described above, the contents of any required notice that would be inconsistent with theprovisions of the ADR agreement must be modified to be consistent with the ADR agreement.The claims administrator is responsible for compliance with the regulations governing theissuance of benefit notices; however, benefit notices using the model notices devised by theAdministrative Director and available on the Division’s website are presumed to be adequatenotices to the employee and, unless modified, shall not be subject to audit penalties.The Benefit Notice Manual can be accessed via internet, as well as the model benefit notices andthe mandatory notices. The DIR Informational Internet address is: home page.htmAll benefit notices that are not mandatory by statute or these regulations require the “employee’s(or claimant’s) remedies” defined in §9811(g) and provided in 9810(e). There is separatemandatory language for notices subject to an alternative dispute resolution (ADR) programunder Labor Code §§3201.5 or 3201.7. This language complies with the requirements of§9810(d) that “all notices clearly state that additional information may be obtained from theInformation and Assistance Officer and clearly indicate the name and telephone number of theperson responsible for the payment and adjusting of the claim”. For notices not subject to ADRcriteria, the last two sentences of this section should be completed as is appropriate to the notice.Benefit Notices-Revised 1/1/16Page 5

BENEFIT NOTICE INSTRUCTION MANUALOther Requirements and Definitions Section 9810(g): Every benefit notice shall have a title at the top of the first page thatclearly identifies the subject of the notice. The notice shall also contain the following statementin bold font at the end of the notice: “Keep this notice. It contains important information aboutyour workers’ compensation benefits.” Section 9810(h): The claims administrator shall provide copies to the employee, uponrequest, of all medical reports relevant to any benefit notice issued, or which are not required tobe provided along with a notice and have not yet been provided to the employee other thanpsychiatric reports which the physician has recommended not be provided to the employee. Section 9810(i): The claims administrator shall send a copy of each benefit notice, andany enclosures not previously served on the attorney, concurrently to the attorney of anyrepresented employee. Upon the documented written agreement of the attorney, all benefitnotices, including attachments, may be sent electronically in lieu of by mail. Section 9810(k): Copies of all benefit notices sent to employees shall be maintained bythe claims administrator in the claims file. In lieu of retaining a copy of any attachments to thenotice, the claims administrator may identify the attachments by name and revision date on thenotice. These copies may be maintained in paper or electronic form. Section 9810(l): All benefit notices shall be made available in English and Spanish, asappropriate. Section 9810(m): Where the claims administrator offers the service, and upon thedocumented written agreement of the employee, all benefit notices, including attachments, maybe sent electronically to the employee in lieu of by mail. The employee’s agreement may bedocumented by provision of a personal email address on the claim form (DWC Form 1) andchecking the box agreeing to receive benefit notices electronically. An employee may elect tochange the form in which he or she receives benefit notices by giving written notice to the claimsadministrator.Section 9810(n): When the method of service of the benefit notice is electronic, in lieu ofregular mail, service shall be through the use of a secure, encrypted email system. The claimsadministrator shall maintain a log of service dates, and receipt acknowledgements, for eachbenefit notice sent electronically on each claims file, and will produce this log upon demand tothe employee, the employee’s attorney, if represented and the DWC Audit Unit. If the claimsadministrator receives notice that an electronic benefit notice was not delivered to the emailaddress provided by the employee, or attorney, if represented, they shall then send the benefitnotice to the employee and attorney by regular mail within one (1) business day of receipt of thefailed electronic delivery notice.Benefit Notices-Revised 1/1/16Page 6

BENEFIT NOTICE INSTRUCTION MANUAL Section 9811(c): “Date of knowledge of Injury and disability” means the date theemployer had knowledge of (1) a worker's injury or claim of injury, and (2) the worker's inabilityor claimed inability to work because of the injury.Benefit Notices-Revised 1/1/16Page 7

BENEFIT NOTICE INSTRUCTION MANUALNOTICES REGARDING TEMPORARY DISABILITY& SALARY CONTINUATION BENEFITS8 CCR §§9812(a) through (d) and §9814NOTE TO CLAIMS ADMINISTRATOR: If using the model notice(s) inapplicableoptions and/or language should be deleted to avoid a confusing message to the employeeand any parties copied with the notice.Title 8, California Code of Regulations (CCR) §9812(a) and §9814 address the requirements fornotices addressing the start, delay, and denial of temporary disability (TD) payment and/or theprovision of salary continuation in lieu of TD. Title 8, CCR, §§9812(b) through (d) addressindemnity benefit resumption, change, and termination.Instructions for completing the form: On all forms, complete the first and last sections asrequired by §9810(c). This regulation requires documentation of provision of any attachmentssent with the notices. Attachments required with the TD notices may include the medical reportupon which the determination is based; and/or a brief explanation of the employer’s specificsalary continuation (for claims with salary continuation in lieu of TD).PAYMENT START / RESUME– TD/SALARY CONTINUATIONRequirements for the notice are in §9812(a)(1) for the first payment. Section 9814 provides thesalary continuation notice requirements.The model notice addresses the start payment of temporary disability indemnity or salarycontinuation: Complete all non-optional sections of the form. Complete the first section asappropriate for temporary disability indemnity payments. Choose the language appropriate foreither temporary disability or salary continuation, and for temporary total or temporary partialdisability (TPD/wage loss). The first payment of TD must include “all indemnity then due”through the date of the payment. Be aware that TPD payments are due on a biweekly basis, justas TTD payments are due.If payments are being resumed following a period of time in which temporary disability benefitsor salary continuation in lieu of temporary disability has not been provided, use the NoticeRegarding Indemnity Benefits Payment Resume, as described in §9812(b).§9810(d) requires all notices to refer the employee (by chapter number and url) to theappropriate chapter of the publication “Workers’ Compensation in California: A Guidebook forInjured Workers” that addresses the benefit(s) to which the noti