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Form |
Description |
| dwc1.pdf | Employer's First Report of Injury or Illness |
| dwc1s.pdf | Employer's First Report of Injury or Illness (for state employees) |
| employee_notice.pdf | Notice - Employee Notice Ombudsman Program |
| OMB49.pdf | Notice of Injured Employee Rights and Responsibilities in the Texas Workers’ Compensation System |
| OMB49SP.pdf | Aviso sobre los Derechos y Responsabilidades para los Empleados Lesionados en el Sistema de Compensación para Trabajadores de Texas |
| IERights.pdf | Injured Employee Rights and Responsibilities |
| IERightsSP.pdf | Aviso sobre los Derechos y Responsabilidades para los Empleados Lesionados |
| dwc2.pdf | Employer's Report for Reimbursement of Voluntary Payment Interim |
| dwc3.pdf | Employer's Wage Statement |
| dwc3me.pdf | Employer's Multiple Employment Wage Statement |
| dwc3mes.pdf | Declaración de Salario de Múltiples Trabajos del Empleado |
| dwc3s.pdf | Employer's Wage Statement (Spanish) |
| dwc3sd.pdf | Employer's Wage Statement for School Districts |
| dwc3sds.pdf | Declaración de Salario Para Escuelas de Distrito |
| dwc4.pdf | Employer's Contest of Compensability Interim |
| dwc5.pdf | Employer's Notice of No Coverage or Termination of Coverage |
| dwc5s.pdf | Aviso del Empleador por No-Cobertura o Anulación de Cobertura (Formulario DWC-005s) |
| dwc6.pdf | Supplemental Report of Injury |
| dwc7.pdf | Employer’s Report of Non-covered Employee’s Occupational Injury or Disease |
| dwc8.pdf | Application for Reimbursement from the Return-to-Work Account for Small Employers |
| dwc20.pdf | Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage |
| dwc20a.pdf | Correction/Revision/Endorsement to Existing Policy |
| dwc20si.pdf | Self-Insured Governmental Entity Coverage Information |
| dwc22.pdf | Required Medical Examination Notice or Request for Order |
| dwc22s.pdf | Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden |
| dwc24.pdf | Benefit Dispute Agreement |
| dwc24s.pdf | Acuerdo Para Disputa De Beneficios |
| dwc25.pdf | Benefit Dispute Settlement |
| dwc25s.pdf | Acuerdo Por Disputa De Beneficios |
| dwc26.pdf | Reimbursement Request Made by Health Care Insurer |
| dwc27.pdf | Designation of Insurance Carrier’s Austin Representative |
| dwc30.pdf | Austin Representative’s Authorized Designees |
| dwc31.pdf | Application for Commission Approval of Change in the Payment Period and/or Purchase of an Annuity |
| dwc31s.pdf | Solicitud para Obtener Aprobación por Parte de la División para un Cambio en el Periodo de Pago y/o Compra de una Pensión Para los Beneficios por Causa de Muerte |
| dwc32.pdf | Request for Designated Doctor Examination |
| dwc32s.pdf | Solicitud para Obtener un Examen por Parte de un Médico Designado |
| dwc33.pdf | Carrier's Request for Reduction of Income Benefits Due to Contribution |
| dwc35.pdf | Application for Commission Approval of the Purchase of an Annuity for Lifetime Income Benefits |
| dwc41.pdf | Employee's Notice of Injury or Occupational Disease and Claim for Compensation |
| dwc41s.pdf | Notificación del Trabajador Lesionado o Afectado por Enfermedad de Trabajo y Reclamo de Compensación |
| dwc42.pdf | Notice of Fatal Injury or Occupational Disease and Claim for Compensation for Death Benefits |
| dwc42s.pdf | Aviso Sobre Fatalidad o Enfermedad Ocupacional y Reclamo para Compensación por Beneficios a Causa de Muerte |
| dwc44.pdf | Election to Engage in Arbitration (For disputes filed on or after June 1, 2012) |
| dwc44s.pdf | Elección para Participar en un Arbitraje (Para disputas que son presentadas en o después del 1º de junio de 2012) |
| dwc45.pdf | Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) |
| dwc45a.pdf | Request For Medical Contested Case or SOAH Hearing |
| dwc45as.pdf | Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés) |
| dwc45m.pdf | Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD) (For disputes filed on or after June 1, 2012) |
| dwc45ms.pdf | Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios para Apelar la Decisión de una Disputa por Honorarios Médicos (Benefit Review Conference to Appeal a Medical Fee Dispute Decision –BRC-MFD, por su nombre y sigl |
| dwc45s.pdf | Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference -BRC, por su nombre y siglas en inglés) |
| dwc46.pdf | Employee's Request for Acceleration of Impairment Income Benefits |
| dwc46s.pdf | Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal |
| dwc47.pdf | Employee's Request for Payment of Advanced Compensation |
| dwc47s.pdf | Solicitud del Trabajador Lesionado Acerca de Pagos Adelantados de Compensación |
| dwc48.pdf | Request for Travel Reimbursement / Solicitud de Reembolso - 6/06 |
| dwc49.pdf | Request to Schedule a Medical Contested Case Hearing (MCCH) (For disputes filed on or after June 1, 2012) - 6/12 |
| dwc49s.pdf | Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en ingles) (Para disputas que son presentadas en o después del 1º de junio de 2012) - 6/12 |
| dwc51.pdf | Employee's Election for Commuted (Lump Sum) Impairment Income Benefits - 11/08 |
| dwc51s.pdf | ELECCIÓN DEL EMPLEADO PARA LA CONVERSIÓN DE LOS BENEFICIOS DE INGRESOS DE IMPEDIMENTO A UN PAGO TOTAL (FORMULARIO DWC-051) |
| dwc52.pdf | Application for Supplemental Income Benefits For SIBs qualifying periods beginning on or after July 1, 2009 (Rev. 04/09) |
| dwc52s.pdf | Aplicación del trabajador para beneficios de ingresos suplementales Para los periodos de calificación de SIBs que empiezan en o después del 1º de julio de 2009 (Rev. 04/09) |
| dwc53.pdf | Employee's Request To Change Treating Doctors - 3/12 |
| dwc53s.pdf | Solicitud del Trabajador para Cambiar de Médico Tratante - 3/12 |
| dwc54.pdf | Notice to Employee: Intention to Request Commission Permission to Adjust Benefits - 10/05 |
| dwc54s.pdf | Aviso ala la Empleadoa: Intencion de Solicitar Permisio a la Comision para Ajuste de Beneficios - 10/05 |
| dwc55.pdf | Request to Adjust Average Weekly Wage for Seasonal Employee - 10/05 |
| dwc55s.pdf | Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada - 10/05 |
| dwc56.pdf | Carrier's Request for Seasonal Wage Information from Texas Work Force Commission - 10/05 |
| dwc57.pdf | Request for Extension of Maximum Medical Improvement for Spinal Surgery - 02/13 |
| dwc57s.pdf | Solicitud para Extensión de la Fecha para el Mejoramiento Máximo Médico (Maximum Medical Improvement -MMI, por su nombre y siglas en inglés) por una Cirugía de la Columna Vertebral ) - 02/13 |
| dwc58.pdf | Request for Interlocutory Order - 9/07 |
| dwc60.pdf | Medical Fee Dispute Resolution Request (For disputes filed on or after June 1, 2012)- 6/12 |
| dwc60s.pdf | Solicitud para Resolución de Disputas por Honorarios Médicos (Para disputas que son presentadas en o después del 1º de junio de 2012) - 6/12 |
| dwc64.pdf | Medical Interlocutory Order Request 8/11 |
| dwc65.pdf | Private Providers of Vocational Rehabilitation Services - 1/11 |
| dwc66.pdf | Statement of Pharmacy Services Services - 12/11 |
| dwc67.pdf | Designated Doctor Certification Application - 9/12 |
| dwc68.pdf | Designated Doctor Examination Data Report - 92 - 9/12 |
| dwc69.pdf | Report of Medical Evaluation - 6/11 |
| dwc70.pdf | Instructions For Completing The ADA J515 Dental Claim Form - 10/05 |
| dwc72.pdf | Medical Quality Review Panel Application (Rev. 01/13, for use on or after January 1, 2013) |
| dwc73.pdf | Work Status Report - 2/11 |
| dwc74.pdf | Description of Injured Employee's Employment - 9/09 |
| dwc81.pdf | Agreement Between General Contractor and Sub-Contractor to Provide Worker'sCompensation Insurance - 10/05 |
| dwc81s.pdf | Acuerdo Entre el Contratista General y el Sub Contratista - 9/07 |
| dwc82.pdf | Agreement for Motor Carriers and Owner Operators - 10/05 |
| dwc83.pdf | Agreement for Certain Building and Construction Workers - 10/05 |
| dwc83s.pdf | Acuerdo para Ciertos Trabajadores de Edificación y Construcción - 9/06 |
| dwc84.pdf | Exception to Application of Joint Agreement for Certain Building and Construction Workers - 10/05 |
| dwc85.pdf | Agreement Between General Contractor and Subcontractor to Establish Independent Relationship - 10/05 |
| dwc85s.pdf | Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente - 11/06 |
| dwc101.pdf | Program Review Report - 8/06 |
| dwc102.pdf | Accident Prevention Plan Cover Sheet - 8/06 |
| dwc103.pdf | Approved Professional Source Safety Consultant Application - 12/06 |
| dwc104.pdf | Employer Request for DWC Safety Consultation - 8/06 |
| dwc105.pdf | Accident Prevention Services Worksheet - 4/09 |
| dwc109.pdf | Accident Prevention Services Annual Report - 12/05 |
| dwc150.pdf | Notice of Withdrawal of Representation - 10/05 |
| dwc151.pdf | Attorney Application for Web Access - 10/05 |
| dwc152.pdf | Application for Attorney's Fees Last form in Master Packet - 10/05 |
| dwc153.pdf | Request for Copies of Confidential Claimant Information - 10/06 |
| dwc153s.pdf | Solicitud para Obtener Copias de la Información Confidencial del Reclamante (Rev. 07/08) |
| dwc155.pdf | Request for Record Check - 10/05 |
| dwc156.pdf | Prospective Employment Authorization and Certification - 10/05 |
| dwc156s.pdf | Prospective Employment Authorization and Certification - 10/06 |
| dwc205.pdf | Locations of Employers' Business(es) - 11/10 |
| dwc205s.pdf | Locaciones del Negocio(s) del Empleador Suplemento para el Formulario DWC005 o Formulario DWC020 - 11/10 |
| dwc210.pdf | Surety Bond for Certified Self-Insurance Liabilities - 1/06 |
| dwc215.pdf | Surety Bond Amount Rider - 1/06 |
| dwc216.pdf | Surety Bond Name Change Rider - 1/06 |
| dwc223.pdf | Documentary Irrevocable Standby Letter of Credit - 01/07 |
| dwc224.pdf | Documentary Irrevocable Standby Letter of Credit ("Confirmation") - 1/07 |
| dwc225.pdf | Self-Insurers Agreement to Post Documentary Irrevocable Standby Letter of Credit - 01/07 |
| dwc226.pdf | Parental Guaranty - 1/07 |
| dwc227.pdf | Parental Guaranty for Less than Wholly Owned Subsidiary - 1/07 |
| dwc228.pdf | Power of Attorney - 1/07 |
| newempnotice.pdf | New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing, for use on or after 1/1/13) |
| newempnotices.pdf | SPANISH New Employee Notice( covered and non-covered employers shall notify their employees of coverage status, in writing, for use on or after 1/1/13) |
| notice5.pdf | For Employers who do not have coverage (must be posted for employees to read, for use on or after 1/1/13) |
| notice5s.pdf | Notice5s Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) |
| notice6.pdf | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) |
| notice6s.pdf | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13)SPANISH |
| notice07.pdf | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) |
| notice07s.pdf | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) |
| notice8e.pdf | Required Workers' Compensation Coverage (building or construction projects for governmental entities) - 10/05 |
| notice8s.pdf | Required Workers' Compensation Coverage (building or construction projects for governmental entities) (Spanish) - 1/06 |
| notice9.pdf | For Work-Related Communicable Diseases - 10/05 |
| notice9s.pdf | For Work-Related Communicable Diseases (Spanish) - 10/06 |
| notice10.pdf | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) |
| notice10s.pdf | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) |
| pln01.pdf | Notice of Denial of Compensability/Liability and Refusal to Pay - 10/05 |
| pln01s.pdf | Notice of Denial of Compensability/Liability and Refusal to Pay - (Spanish) 8/10 |
| pln02.pdf | Notification of First Temporary Income Benefit Payment - 10/05 |
| pln02s.pdf | Notification of First Temporary Income Benefit Payment - (Spanish) 8/10 |
| pln03.pdf | Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment - 10/05 |
| pln03s.pdf | Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment - (Spanish) 8/10 |
| pln04.pdf | Notification of First Lifetime Income Benefit Payment - 10/05 |
| pln04s.pdf | Notification of First Lifetime Income Benefit Payment - (Spanish) 8/10 |
| pln05.pdf | Notification of First Death Income Benefit Payment - 10/05 |
| pln05s.pdf | Notification of First Death Income Benefit Payment - (Spanish) 8/10 |
| pln06.pdf | Notification of Employer Full Salary Payment - 10/05 |
| pln06s.pdf | Notification of Employer Full Salary Payment - (Spanish) 8/10 |
| pln07.pdf | Notification of Change of Indemnity Benefit Payment - 10/05 |
| pln07s.pdf | Notification of Change of Indemnity Benefit Payment - (Spanish) 8/10 |
| pln08.pdf | Notification of Change in Amount of Indemnity Benefit Payment - 10/05 |
| pln08s.pdf | Notification of Change in Amount of Indemnity Benefit Payment - (Spanish) 8/10 |
| pln09.pdf | Notification of Suspension of Indemnity Benefit Payment - 10/05 |
| pln09s.pdf | Notification of Suspension of Indemnity Benefit Payment - (Spanish) 8/10 |
| pln10.pdf | Notification of Reinstatement of Indemnity Benefit Payment - 10/05 |
| pln10s.pdf | Notification of Reinstatement of Indemnity Benefit Payment - (Spanish) 8/10 |
| pln11.pdf | Notification of Disputed Issue(s) and Refusal to Pay - 10/05 |
| pln11s.pdf | Notification of Disputed Issue(s) and Refusal to Pay - (Spanish) 8/10 |
| pln12.pdf | Notice of Potential Entitlement to Workers' Compensation Death Benefits - 11/12 |
| pln12s.pdf | Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores - 11/12 |
| sample_notice.pdf | Notice of Underpayment of Income Benefits 12/11 |
| sample_notice_s.pdf | Aviso de Pago Insuficiente de los Beneficios de Ingresos 12/11 |
| dwc-edi-01.pdf | Trading Partner Profile 12/07 |
| edi002.pdf | Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile - 6/11 |
| edi003.pdf | Medical EDI Compliance Coordinator and Trading Partner Notification - 6/11 |
| lhl009.pdf | Req for review by IRO 3/09 |
| lhl009s.pdf | Req for review by IRO (SP) 3/09 |