Texas Department of Insurance

Workers' Compensation


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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.state.tx.us

 

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) - Effective September 1, 2006, requests for a claim file, medical dispute resolution file, and/or an indemnity resolution file must be made on the newly revised DWC-153 form (10/2006). A requestor must be eligible by statute to receive the		 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 Proof of Coverage
(Rev. 10/06)		 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. 12/10)		 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, for disputes filed on or after June 1, 2012)		 PDF
DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
(Rev. 11/11, for use beginning 12/1/11)		 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, for disputes filed on or after June 1, 2012)		 PDF
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDF
DWC060 Medical Fee Dispute Resolution Request
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDF
DWC074 Description of Injured Employee’s Employment
(Rev. 9/09)		 PDF
DWC105 Accident Prevention Services Worksheet
(Rev. 04/09)		 PDF
DWC109 Accident Prevention Services Annual Report
(Rev. 12/05)		 WORD
DWC109 Accident Prevention Services Annual Report
(Rev. 12/05)		 PDF
DWC-EDI-01 EDI TRADING PARTNER PROFILE
 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. 12/10)		 PDF
DWC044S Elección para Participar en un Arbitraje
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 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, para disputas que son presentadas en o después del 1º de junio de 2012)		 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, para usarse a partir de 12/1/11)		 PDF
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en ingles)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 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)		 WORD
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05)		 PDF
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDF
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORD
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)		 WORD
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDF
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)		 PDF
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05)		 WORD
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)		 PDF
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05)		 WORD
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05)		 WORD
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05)		 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

 

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. 12/10)		 PDF
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
(Rev. 3/07)		 PDF
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
(Rev. 3/07)		 WORD
DWC042 Beneficiary Claim for Death Benefits
(Rev. 4/10)		 PDF
DWC042 Beneficiary Claim for Death Benefits
(Rev. 4/10)		 WORD
DWC042S Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
(Rev. 4/10)		 WORD
DWC044 Election to Engage in Arbitration
(Rev. 10/05, for disputes filed on or before May 31, 2012)		 PDF
DWC044 Election to Engage in Arbitration
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDF
DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
(Rev. 11/11, for use beginning 12/1/11)		 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, for disputes filed on or after June 1, 2012)		 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, for disputes filed on or after June 1, 2012)		 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 for Spinal Surgery
(Rev. 10/05)		 PDF
DWC058 Request for Interlocutory Order
(Rev. 09/07)		 PDF
DWC060 Medical Fee Dispute Resolution Request
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 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. 12/10)		 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
DWC044S Elección para Participar en un Arbitraje
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 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, para disputas que son presentadas en o después del 1º de junio de 2012)		 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, para usarse a partir de 12/1/11)		 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 ingles)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 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 Mejoramiento Máximo Médico por Cirugía de la Columna Vertebral
(Rev. 07/08)		 PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDF
Sample Notice Aviso de Pago Insuficiente de los Beneficios de Ingresos
(Rev. 12/11)		 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, for disputes filed on or after June 1, 2012)		 PDF
DWC045M Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDF
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDF
DWC060 Medical Fee Dispute Resolution Request
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDF
DWC060 Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012)		 PDF
DWC060 Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012)		 WORD
DWC062 Explanation of Benefits
(Rev. 07/07)		 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)		 WORD
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
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
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, para disputas que son presentadas en o después del 1º de junio de 2012)		 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, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDF
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en ingles)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDF
DWC060s Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012)		 PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDF
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012)		 WORD

 

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
 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)		 PDF
DWC102 Accident Prevention Plan Cover Sheet
(Rev. 08/06)		 WORD
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)		 WORD
DWC104 Employer Request for DWC Safety Consultation
(Rev. 08/06)		 PDF
DWC105 Accident Prevention Services Worksheet
(Rev. 04/09)		 PDF
DWC109 Accident Prevention Services Annual Report
(Rev. 12/05)		 WORD
DWC109 Accident Prevention Services Annual Report
(Rev. 12/05)		 PDF

 

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) - Effective September 1, 2006, requests for a claim file, medical dispute resolution file, and/or an indemnity resolution file must be made on the newly revised DWC-153 form (10/2006). A requestor must be eligible by statute to receive the		 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 Proof of Coverage
(Rev. 10/06)		 PDFEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 WORDEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 PDFEnglish
DWC215 Surety Bond Amount Rider
(Rev. 1/06)		 WORDEnglish
DWC215 Surety Bond Amount Rider
(Rev. 1/06)		 PDFEnglish
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)		 PDFEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORDEnglish
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

 


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
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 PDFEnglish
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 WORDEnglish
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 PDFEnglish
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 WORDEnglish
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 PDFSpanish
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 WORDSpanish

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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