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Workers' Compensation Complete Listing of Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

This is a complete listing of all Division of Workers' Compensation Forms. The forms are also available in individual listings.

   

DWC has provided a Form Developer Kit for stakeholders who develop their own forms. Before using these items, please read the Readme file included. Alternate forms must use DWC specifications and be approved for use by the Division.

To order the forms not published on this website, please call Forms Management Customer Services at (512) 804-4240.

Texas Department of Insurance, Division of Workers' Compensation
Open Records
Executive Communication, MS-3
7551 Metro Center Drive
Austin, Texas 78744-1645

open.records@tdi.texas.gov


 

English

Requests for Workers' Compensation Claim File Information
Information in or derived from a claim file regarding a Workers' compensation claimant is confidential and may not be disclosed except as provided in the Texas Workers' Compensation Act. Because of the confidential nature of claimant information, REQUESTS FOR CLAIM FILE INFORMATION WILL NOT BE ACCEPTED VIA INTERNET E-MAIL OR FAX. The following forms for requesting confidential claimant information can be downloaded from this website. These request forms may be hand-delivered or submitted via mail to:

Texas Department of Insurance, Division of Workers' Compensation
7551 Metro Center Drive, MS-92B
Austin, Texas 78744-1609
TDI Form NumberDescriptionFile Format
DWC153 Request for Copies of Confidential Claimant Information
Rev. 10/06
PDF
DWC155 Request for Record Check
Rev. 10/05
PDF
DWC156 Prospective Employment Authorization and Certification
Rev. 10/05
PDF

En Español

Requests for Workers' Compensation Claim File Information
Número del Formulario de TDIDescripciónFormato del Archivo
DWC153s Solicitud para Obtener Copias de la Información Confidencial del Reclamante
Rev. 07/08
PDF
DWC156S Certificación Y Autorización De Un Posible Empleo
Rev. 10/06
PDF

 

English


Carrier Forms
TDI Form NumberDescriptionFile Format
DWC020 Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage
Rev. 10/05
PDF
DWC020A Correction/Revision/Endorsement to Existing Policy
Rev. 10/05
PDF
DWC020SI Self-Insured Governmental Entity Coverage Information
Rev. 08/12
PDF
DWC022 Required Medical Examination (RME) - Request for Agreement / Request for Order
Rev. 7/11
PDF
DWC024 Benefit Dispute Agreement
Rev. 10/05
PDF
DWC025 Benefit Dispute Settlement
Rev. 10/05
PDF
DWC026 Request for Reimbursement of Payment Made by Health Care Insurer
Rev. 01/15 (for use on or after 1/1/15)
PDF
DWC026 Request for Reimbursement of Payment Made by Health Care Insurer
Rev. 05/11 (for use through 12/31/14)
PDF
DWC027 Designation of Insurance Carrier’s Austin Representative
Rev. 12/11
PDF
DWC030 Austin Representative’s Authorized Designees
Rev. 12/11
PDF
DWC031 Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits
Rev. 10/05
PDF
DWC032 Request for Designated Doctor Examination
Rev. 1/13
PDF
DWC033 Carrier's Request for Reduction of Income Benefits Due to Contribution
Rev. 10/05
PDF
DWC035 Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits
Rev. 10/05
PDF
DWC044 Election to Engage in Arbitration
Rev. 06/12
PDF
DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
Rev. 11/11
PDF
DWC045A Request for a Medical Contested Case or SOAH Hearing
Rev. 09/07
PDF
DWC045M Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Rev. 06/12
PDF
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 06/12
PDF
DWC057 Request for Extension of Maximum Medical Improvement Date for Spinal Surgery
Rev. 02/13, for use on or after February 1, 2013
PDF
DWC060 Medical Fee Dispute Resolution Request
Rev. 06/12
PDF
DWC074 Description of Injured Employee’s Employment
Rev. 9/09
PDF
DWC105 Accident Prevention Services Worksheet
Rev. 10/13
PDF
DWC105 Accident Prevention Services Worksheet
Rev. 10/13
WORD
DWC109 Accident Prevention Services Annual Report
Rev. 10/13
PDF
DWC109 Accident Prevention Services Annual Report
Rev. 10/13
WORD
EDI-01 EDI TRADING PARTNER PROFILE
Rev. 12/07
WORD
EDI-02 Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile
Rev. 06/11
PDF
EDI-03 Medical EDI Compliance Coordinator and Trading Partner Notification
Rev. 06/11
PDF

En Español

Carrier Forms
Número del Formulario de TDIDescripciónFormato del Archivo
DWC022S Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden
Rev. 7/11
PDF
DWC024s Acuerdo para Disputa de Beneficios
Rev. 07/08
PDF
DWC025s Acuerdo por Disputa de Beneficios
Rev. 07/08
PDF
DWC031s 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
Rev. 10/05
PDF
DWC032S Solicitud para Obtener un Examen por Parte de un Médico Designado
Rev. 1/13
PDF
DWC044S Elección para Participar en un Arbitraje
Rev. 06/12
PDF
DWC045AS Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés)
Rev. 10/07
PDF
DWC045MS 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 siglas en inglés)
Rev. 06/12
PDF
DWC045S Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference -BRC, por su nombre y siglas en inglés)
Rev. 11/11
PDF
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 06/12
PDF
DWC057S 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
Rev. 02/13, para ser usado en o después del 1º de febrero de 2013
PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 06/12
PDF

 

English


Plain Language Notices
TDI Form NumberDescriptionFile Format
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 10/05
PDF
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 10/05
WORD
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 10/05
PDF
PLN03 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 10/05
WORD
PLN03 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 10/05
PDF
PLN04 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD
PLN04 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 10/05
PDF
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 10/05
PDF
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD
PLN06 Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 10/05
WORD
PLN06 Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 10/05
PDF
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 10/05
WORD
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 10/05
PDF
PLN08 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 10/05
WORD
PLN08 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 10/05
PDF
PLN09 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
WORD
PLN09 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
PDF
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 10/05
WORD
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 10/05
PDF
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
Rev. 10/05
PDF
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
Rev. 10/05
WORD
PLN12 Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
WORD
PLN12 Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
PDF

En Español

Plain Language Notices
Número del Formulario de TDIDescripciónFormato del Archivo
PLN01S Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 01/10
WORD
PLN02S Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD
PLN03S Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 01/10
WORD
PLN04S Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD
PLN05S Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD
PLN06S Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 01/10
WORD
PLN07S Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 01/10
WORD
PLN08S Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 01/10
WORD
PLN09S Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 01/10
WORD
PLN10S Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 01/10
WORD
PLN11S Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
Rev. 01/10
WORD
PLN12S Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores
Rev. 11/12
WORD
PLN12S Aviso Sobre Posible Derecho a Recibir Beneficios por Causa de Muerte de Compensación para Trabajadores
Rev. 11/12
PDF

 

English

Employee Forms
TDI Form NumberDescriptionFile Format
LHL009 Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF

English

Employee Forms
TDI Form NumberDescriptionFile Format
DWC003ME Employee's Multiple Employment Wage Statement
Rev. 10/05
PDF
DWC024 Benefit Dispute Agreement
Rev. 10/05
PDF
DWC025 Benefit Dispute Settlement
Rev. 10/05
PDF
DWC032 Request for Designated Doctor Examination
Rev. 1/13
PDF
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
WORD
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
PDF
DWC042 Beneficiary Claim for Death Benefits
Rev. 4/10
WORD
DWC042 Beneficiary Claim for Death Benefits
Rev. 4/10
PDF
DWC044 Election to Engage in Arbitration
Rev. 06/12
PDF
DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
Rev. 11/11
PDF
DWC045A Request for a Medical Contested Case or SOAH Hearing
Rev. 09/07
PDF
DWC045M Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Rev. 06/12
PDF
DWC046 Employee's Request for Acceleration of Impairment Income Benefits
Rev. 10/05
PDF
DWC047 Employee’s Request for Advance of Benefits
Rev. 03/12
PDF
DWC048 Request for Travel Reimbursement / Solicitud de Reembolso
Rev. 06/06
PDF
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 06/12
PDF
DWC051 Employee's Election for Commuted (Lump Sum) Impairment Income Benefits
Rev. 11/08
PDF
DWC052 Application for Supplemental Income Benefits
Rev. 04/09
PDF
DWC053 Employee Request to Change Treating Doctor
Rev. 03/12
PDF
DWC054 Notice to Employee: Intention to Request Division Permission to Adjust Benefits
Rev. 10/05
PDF
DWC055 Request to Adjust Average Weekly Wage for Seasonal Employee
Rev. 10/05
PDF
DWC056 Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
Rev. 10/05
PDF
DWC057 Request for Extension of Maximum Medical Improvement Date for Spinal Surgery
Rev. 02/13, for use on or after February 1, 2013
PDF
DWC058 Request for Interlocutory Order
Rev. 09/07
PDF
DWC060 Medical Fee Dispute Resolution Request
Rev. 06/12
PDF
Sample Notice Notice of Underpayment of Income Benefits
Rev. 12/11
PDF

En Español

Employee Forms
Número del Formulario de TDIDescripciónFormato del Archivo
LHL009 Request for Review by an IRO
[ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF

En Español

Employee Forms
Número del Formulario de TDIDescripciónFormato del Archivo
DWC003MES Declaración de Salario de Múltiples Trabajos del Empleado
Rev. 10/05
PDF
DWC024s Acuerdo para Disputa de Beneficios
Rev. 07/08
PDF
DWC025s Acuerdo por Disputa de Beneficios
Rev. 07/08
PDF
DWC032S Solicitud para Obtener un Examen por Parte de un Médico Designado
Rev. 1/13
PDF
DWC041S Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
PDF
DWC041S Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
WORD
DWC042S Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
Rev. 4/10
PDF
DWC042S Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
Rev. 4/10
WORD
DWC044S Elección para Participar en un Arbitraje
Rev. 06/12
PDF
DWC045AS Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés)
Rev. 10/07
PDF
DWC045MS 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 siglas en inglés)
Rev. 06/12
PDF
DWC045S Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference -BRC, por su nombre y siglas en inglés)
Rev. 11/11
PDF
DWC046S Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal
Rev. 10/05
PDF
DWC047S Solicitud del Empleado para Obtener Beneficios por Adelantado
Rev. 03/12
PDF
DWC048 Request for Travel Reimbursement / Solicitud de Reembolso
Rev. 06/06
PDF
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 06/12
PDF
DWC051S Elección del Empleado para la Conversión de los Beneficios de Ingresos de Impedimento a un Pago Total
Rev. 02/13
PDF
DWC052S Aplicación del trabajador para beneficios de ingresos suplementales
Rev. 04/09
PDF
DWC053S Solicitud del Empleado para Cambiar de Médico de Tratamiento
Rev. 03/12
PDF
DWC054S Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
Rev. 10/05
PDF
DWC055S Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
Rev. 10/05
PDF
DWC057S 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
Rev. 02/13, para ser usado en o después del 1º de febrero de 2013
PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 06/12
PDF
Sample Notice Aviso de Pago Insuficiente de los Beneficios de Ingresos
Rev. 12/11
PDF

English


Non-Covered Employer Forms and Notices

Employers in the State of Texas are required to post notices to their employees as to whether they do or do not carry workers' compensation insurance. Below you will find the required notice packages which contain the forms and notices you will need (coverage package documents in PDF format only).

TDI Form NumberDescriptionFile Format
DWC005 Employer Notice of No Coverage or Termination of Coverage
Rev. 01/13 File Online
PDF
DWC007 Employer’s Report of Non-covered Employee’s Occupational Injury or Disease
Rev. 01/13
PDF
DWC205 Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10
PDF
New Employee Notice English New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF
Notice 5 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF

En Español

Formularios y Avisos para Empleadores sin Cobertura
Número del Formulario de TDIDescripciónFormato del Archivo
DWC005s Notificación del Empleador por No Cobertura o Anulación de la Cobertura
Rev. 1/13
PDF
DWC205S Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10
PDF
New Employee Notice Spanish New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF
Notice 5 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF

Vietnamese


Non-Covered Employer Forms and Notices

Employers in the State of Texas are required to post notices to their employees as to whether they do or do not carry workers' compensation insurance. Below you will find the required notice packages which contain the forms and notices you will need (coverage package documents in PDF format only).

TDI Form NumberDescriptionFile Format
New Employee Notice Vietnamese New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF
Notice 5 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF

English


Covered Employer Forms and Notices

Employers in the State of Texas are required to post notices to their employees as to whether they do or do not carry workers' compensation insurance. Below you will find the required notice packages which contain the forms and notices you will need (coverage package documents in PDF format only).

Please see the OIEC website to obtain the The Employer's Notification of the Ombudsman Program to Employees.

TDI Form NumberDescriptionFile Format
DWC001 Employer's First Report of Injury or Illness
Rev. 10/05. This form is submitted by the carrier to DWC.
PDF
DWC001S Employer's First Report of Injury or Illness (for state employees)
Rev. 10/05
PDF
DWC002 Employer's Report for Reimbursement of Voluntary Payment
Rev. 10/05
PDF
DWC003 Employer's Wage Statement
Rev. 10/05
PDF
DWC003ME Employee's Multiple Employment Wage Statement
Rev. 10/05
PDF
DWC003SD Employer's Wage Statement for School Districts
Rev. 10/05
PDF
DWC004 Employer's Contest of Compensability
Rev. 11/08
PDF
DWC006 Supplemental Report of Injury
Rev. 10/05
PDF
DWC008 Return-to-Work Reimbursement Program for Employers
Rev. 04/10
WORD
DWC008 Return-to-Work Reimbursement Program for Employers
Rev. 04/10
PDF
DWC020SI Self-Insured Governmental Entity Coverage Information
Rev. 08/12
PDF
DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
Rev. 11/11
PDF
DWC045A Request for a Medical Contested Case or SOAH Hearing
Rev. 09/07
PDF
DWC074 Description of Injured Employee’s Employment
Rev. 9/09
PDF
New Employee Notice English New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF
Notice 6 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF
Notice 8 English Required Workers' Compensation Coverage
(building or construction projects for governmental entities)
PDF
Notice 9 English Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers)
PDF

En Español

Formularios y Avisos para Empleadores con Cobertura
Número del Formulario de TDIDescripciónFormato del Archivo
DWC003MES Declaración de Salario de Múltiples Trabajos del Empleado
Rev. 10/05
PDF
DWC003SDS Declaración de Salario Para Escuelas de Distrito
Rev. 10/05
PDF
DWC045AS Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés)
Rev. 10/07
PDF
DWC045S Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference -BRC, por su nombre y siglas en inglés)
Rev. 11/11
PDF
New Employee Notice Spanish New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF
Notice 6 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF
Notice 8 Spanish Required Workers' Compensation Coverage
(building or construction projects for governmental entities)
PDF
Notice 9 Spanish Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers)
PDF

Vietnamese


Covered Employer Forms and Notices

Employers in the State of Texas are required to post notices to their employees as to whether they do or do not carry workers' compensation insurance. Below you will find the required notice packages which contain the forms and notices you will need (coverage package documents in PDF format only).

Please see the OIEC website to obtain the The Employer's Notification of the Ombudsman Program to Employees.

TDI Form NumberDescriptionFile Format
New Employee Notice Vietnamese New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF
Notice 6 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF

 

English


Health Care Provider/Medical Forms
TDI Form NumberDescriptionFile Format
LHL009 Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF

English


Health Care Provider/Medical Forms
TDI Form NumberDescriptionFile Format
DWC044 Election to Engage in Arbitration
Rev. 06/12
PDF
DWC045M Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Rev. 06/12
PDF
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 06/12
PDF
DWC060 Medical Fee Dispute Resolution Request
Rev. 06/12
PDF
DWC064 Medical Interlocutory Order Request - Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC’s Closed Formulary
Rev. 8/11
PDF
DWC065 Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
Rev. 1/11
PDF
DWC066 Statement of Pharmacy Services
Rev. 12/11
PDF
DWC067 Designated Doctor Certification Application
Rev. 9/12
PDF
DWC068 Designated Doctor Examination Data Report
Rev. 9/12
PDF
DWC069 Report of Medical Evaluation
Rev. 1/15 (for use on or after 1/1/15) Sample Notice for Health Care Provider (PDF, Word)
PDF
DWC069 Report of Medical Evaluation
Rev. 06/11 (for use through 12/31/14) Sample Notice for Health Care Provider (PDF, Word)
PDF
DWC070 Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
Rev. 10/05
PDF
DWC072 Medical Quality Review Panel Application
Rev. 01/13
PDF
DWC073 Work Status Report
Rev. 02/11
PDF
DWC074 Description of Injured Employee’s Employment
Rev. 9/09
PDF

En Español

Health Care Provider/Medical Forms
Número del Formulario de TDIDescripciónFormato del Archivo
LHL009 Request for Review by an IRO
[ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF

En Español

Health Care Provider/Medical Forms
Número del Formulario de TDIDescripciónFormato del Archivo
DWC044S Elección para Participar en un Arbitraje
Rev. 06/12
PDF
DWC045MS 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 siglas en inglés)
Rev. 06/12
PDF
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 06/12
PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 06/12
PDF

 

English

Agreement Forms
TDI Form NumberDescriptionFile Format
DWC081 Agreement Between General Contractor and Sub-Contractor to Provide Worker's Compensation Insurance
Rev. 10/05
PDF
DWC082 Agreement for Motor Carriers and Owner Operators
Rev. 10/05
PDF
DWC083 Agreement for Certain Building and Construction Workers
Rev. 10/05
PDF
DWC084 Exception to Application of Joint Agreement for Certain Building and Construction Workers
Rev. 10/05
PDF
DWC085 Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
Rev. 10/05
PDF

En Español

Agreement Forms
Número del Formulario de TDIDescripciónFormato del Archivo
DWC081S Acuerdo Entre el Contratista General y el Sub Contratista
Rev. 09/07
PDF
DWC083S Acuerdo para Ciertos Trabajadores de Edificación y Construcción
Rev. 09/06
PDF
DWC085S Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente
Rev. 11/06
PDF

 

English


Health & Safety Forms
TDI Form NumberDescriptionFile Format
DWC101 Program Review Report
Rev. 08/06
PDF
DWC101 Program Review Report
Rev. 08/06
WORD
DWC102 Accident Prevention Plan Cover Sheet
Rev. 08/06
WORD
DWC102 Accident Prevention Plan Cover Sheet
Rev. 08/06
PDF
DWC103 Approved Professional Source Safety Consultant Application
Rev. 12/06 - Note: The Approved Professional Source designation applies only to Loss Control Representatives of Texas Mutual Insurance Company as of September 1, 2005.
WORD
DWC104 Employer Request for DWC Safety Consultation
Rev. 08/06
PDF
DWC104 Employer Request for DWC Safety Consultation
Rev. 08/06
WORD
DWC105 Accident Prevention Services Worksheet
Rev. 10/13
PDF
DWC105 Accident Prevention Services Worksheet
Rev. 10/13
WORD
DWC109 Accident Prevention Services Annual Report
Rev. 10/13
PDF
DWC109 Accident Prevention Services Annual Report
Rev. 10/13
WORD

 

English


Other Business Forms
TDI Form NumberDescriptionFile Format
DWC150 Notice of Representation or Withdrawal of Representation
Rev. 10/05
PDF
DWC151 Attorney Application for Web Access
Rev. 10/05
PDF
DWC152 Application for Attorney's Fees
Rev. 10/05
PDF
DWC153 Request for Copies of Confidential Claimant Information
Rev. 10/06
PDF
DWC155 Request for Record Check
Rev. 10/05
PDF
DWC156 Prospective Employment Authorization and Certification
Rev. 10/05
PDF
DWC205 Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10
PDF

En Español

Other Business Forms
Número del Formulario de TDIDescripciónFormato del Archivo
DWC153s Solicitud para Obtener Copias de la Información Confidencial del Reclamante
Rev. 07/08
PDF
DWC156S Certificación Y Autorización De Un Posible Empleo
Rev. 10/06
PDF
DWC205S Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10
PDF

 


Self-Insurance Regulation Forms
TDI Form NumberDescriptionFile FormatLanguage
DWC020SI Self-Insured Governmental Entity Coverage Information
Rev. 08/12
PDFEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
Rev. 1/06
PDFEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
Rev. 1/06
WORDEnglish
DWC215 Surety Bond Amount Rider
Rev. 1/06
PDFEnglish
DWC215 Surety Bond Amount Rider
Rev. 1/06
WORDEnglish
DWC216 Surety Bond Name Change Rider
Rev. 1/06
PDFEnglish
DWC216 Surety Bond Name Change Rider
Rev. 1/06
WORDEnglish
DWC223 Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
WORDEnglish
DWC223 Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
PDFEnglish
DWC224 Documentary Irrevocable Standby Letter of Credit (Confirmation)
Rev. 01/07
WORDEnglish
DWC224 Documentary Irrevocable Standby Letter of Credit (Confirmation)
Rev. 01/07
PDFEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
WORDEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
PDFEnglish
DWC226 Parental Guaranty
Rev. 01/07
WORDEnglish
DWC226 Parental Guaranty
Rev. 01/07
PDFEnglish
DWC227 Parental Guaranty for Less than Wholly Owned Subsidiary
Rev. 01/07
WORDEnglish
DWC227 Parental Guaranty for Less than Wholly Owned Subsidiary
Rev. 01/07
PDFEnglish
DWC228 Power of Attorney
Rev. 01/07
WORDEnglish
DWC228 Power of Attorney
Rev. 01/07
PDFEnglish
Notice 10 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFEnglish
Notice 10 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFSpanish
Notice 10 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFVietnamese
Notice 7 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFEnglish
Notice 7 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFSpanish
Notice 7 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFVietnamese

 


Self-Insurance Regulation Coverage Packages
Employers in the State of Texas who become certified self-insurers are required to post notices to their employees. Below you will find the required notice packages, which contain the forms and notices you will need.
TDI Form NumberDescriptionFile FormatLanguage
DWC020SI Self-Insured Governmental Entity Coverage Information
Rev. 08/12
PDFEnglish
Notice 10 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFEnglish
Notice 10 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFSpanish
Notice 10 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFVietnamese
Notice 7 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFEnglish
Notice 7 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFSpanish
Notice 7 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDFVietnamese

Initial Applications
Self-Insurance Regulation provides an Initial Application Packet for use in applying for a Certificate of Self-Insurance in Texas.

Renewal Applications
All renewal forms for Certified Self-Insurers in Texas are customized for each individual renewal involved. The Self-Insurance program in Texas does not use blank stock forms; however, Self-Insurance Regulation can provide example forms upon request.

Please contact Self-Insurance Regulation by calling (512) 804-4775 or faxing (512) 804-4776 during normal business hours of 8-5 Monday through Friday CST for further information or to request an Initial Application Packet.

Self-Insurance Regulation's mailing address is as follows:
Self-Insurance Regulation
Texas Department of Insurance, Division of Workers' Compensation
7551 Metro Center Drive, MS-60
Austin, Texas 78744-1609

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