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
TDI Form Number	Description	File Format
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
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 TDI	Descripción	Formato 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 Number	Description	File 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. 05/11	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. 04/09	PDF
DWC105	Accident Prevention Services Worksheet Rev. 10/13 (for use on or after 10/1/2013)	PDF
DWC109	Accident Prevention Services Annual Report Rev. 12/05	PDF
DWC109	Accident Prevention Services Annual Report Rev. 10/13 (for use on or after 10/1/2013)	PDF
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 TDI	Descripción	Formato 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 Number	Description	File 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 TDI	Descripción	Formato 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 Number	Description	File 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 Number	Description	File 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
DWC042S	Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte Rev. 4/10	WORD
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 TDI	Descripción	Formato 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 TDI	Descripción	Formato 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	WORD
DWC041S	Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional Rev. 3/07	PDF
DWC042S	Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte Rev. 4/10	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
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
TDI Form Number	Description	File Format
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).
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
New Employee Notice Vietnamese	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 TDI	Descripción	Formato 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
TDI Form Number	Description	File Format
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).
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
TDI Form Number	Description	File Format
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.
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
New Employee Notice Vietnamese	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 TDI	Descripción	Formato 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
TDI Form Number	Description	File Format
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.
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 Number	Description	File 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 Number	Description	File 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. 6/11 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 TDI	Descripción	Formato 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 TDI	Descripción	Formato 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 Number	Description	File 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 TDI	Descripción	Formato 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 Number	Description	File Format
DWC101	Program Review Report Rev. 08/06	WORD
DWC101	Program Review Report Rev. 08/06	PDF
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. 04/09	PDF
DWC105	Accident Prevention Services Worksheet Rev. 10/13 (for use on or after 10/1/2013)	PDF
DWC109	Accident Prevention Services Annual Report Rev. 12/05	PDF
DWC109	Accident Prevention Services Annual Report Rev. 10/13 (for use on or after 10/1/2013)	PDF

English

Other Business Forms
TDI Form Number	Description	File 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

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Other Business Forms
Número del Formulario de TDI	Descripción	Formato 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 Number	Description	File Format	Language
DWC020SI	Self-Insured Governmental Entity Coverage Information Rev. 08/12	PDF	English
DWC210	Surety Bond for Certified Self-Insurance Liabilities Rev. 1/06	PDF	English
DWC210	Surety Bond for Certified Self-Insurance Liabilities Rev. 1/06	WORD	English
DWC215	Surety Bond Amount Rider Rev. 1/06	PDF	English
DWC215	Surety Bond Amount Rider Rev. 1/06	WORD	English
DWC216	Surety Bond Name Change Rider Rev. 1/06	PDF	English
DWC216	Surety Bond Name Change Rider Rev. 1/06	WORD	English
DWC223	Documentary Irrevocable Standby Letter of Credit Rev. 01/07	WORD	English
DWC223	Documentary Irrevocable Standby Letter of Credit Rev. 01/07	PDF	English
DWC224	Documentary Irrevocable Standby Letter of Credit (Confirmation) Rev. 01/07	WORD	English
DWC224	Documentary Irrevocable Standby Letter of Credit (Confirmation) Rev. 01/07	PDF	English
DWC225	Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit Rev. 01/07	WORD	English
DWC225	Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit Rev. 01/07	PDF	English
DWC226	Parental Guaranty Rev. 01/07	WORD	English
DWC226	Parental Guaranty Rev. 01/07	PDF	English
DWC227	Parental Guaranty for Less than Wholly Owned Subsidiary Rev. 01/07	WORD	English
DWC227	Parental Guaranty for Less than Wholly Owned Subsidiary Rev. 01/07	PDF	English
DWC228	Power of Attorney Rev. 01/07	WORD	English
DWC228	Power of Attorney Rev. 01/07	PDF	English
Notice 10 English	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	English
Notice 10 Spanish	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Spanish
Notice 10 Vietnamese	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Vietnamese
Notice 7 English	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	English
Notice 7 Spanish	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Spanish
Notice 7 Vietnamese	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Vietnamese

Self-Insurance Regulation Coverage Packages
TDI Form Number	Description	File Format	Language
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.
DWC020SI	Self-Insured Governmental Entity Coverage Information Rev. 08/12	PDF	English
Notice 10 English	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	English
Notice 10 Spanish	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Spanish
Notice 10 Vietnamese	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Vietnamese
Notice 7 English	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	English
Notice 7 Spanish	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Spanish
Notice 7 Vietnamese	Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read	PDF	Vietnamese
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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