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Workers' Compensation Carrier Forms

Workers' Compensation Carrier Forms
TDI Form Number Description File FormatLanguage
DWC020A
Correction/Revision/Endorsement to Existing Policy
Rev. 10/05
PDF English
DWC020SI
Indicates forms available for electronic filing
Self-Insured Governmental Entity Coverage Information
Rev. 08/12 - Using Google Chrome or Mozilla Firefox to file electronically? See more at “Electronic Filing - Online Forms” above.
PDF English
DWC022
Required Medical Examination (RME) - Request for Agreement / Request for Order
Rev. 7/11
PDF English
DWC022S
Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden
PDF Spanish
DWC024
Benefit Dispute Agreement
Rev. 11/17
PDF English
DWC024s
Acuerdo para Disputa de Beneficios
Rev. 11/17
PDF Spanish
DWC025
Benefit Dispute Settlement
Rev. 11/17
PDF English
DWC025s
Acuerdo por Disputa de Beneficios
Rev. 11/17
PDF Spanish
DWC026
Request for Reimbursement of Payment Made by Health Care Insurer
Rev. 01/15
PDF English
DWC027
Designation of Insurance Carrier’s Austin Representative
Rev. 12/11
PDF English
DWC030
Austin Representative’s Authorized Designees
Rev. 12/11
PDF English
DWC031
Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits
Rev. 02/17
PDF English
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. 02/17
PDF Spanish
DWC032
Request for Designated Doctor Examination
Rev. 1/13
PDF English
DWC032S
Solicitud para Obtener un Examen por Parte de un Médico Designado
Rev. 1/13
PDF Spanish
DWC033
Carrier's Request for Reduction of Income Benefits Due to Contribution
Rev. 02/17
PDF English
DWC035
Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits
Rev. 02/17
PDF English
DWC044
Election to Engage in Arbitration
Rev. 06/12
PDF English
DWC044S
Elección para Participar en un Arbitraje
Rev. 06/12
PDF Spanish
DWC045
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC), or to Proceed Directly to Contested Case Hearing (CCH)
Rev. 07/17
PDF English
DWC045A
Request for a Medical Contested Case or SOAH Hearing
Rev. 09/07, applicable only to medical disputes that were filed prior to June 1, 2012
PDF English
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, aplicable solamente para las disputas médicas que fueron presentadas antes del 1º de junio del 2012
PDF Spanish
DWC045S
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference–BRC), o para Proceder Directamente a una Audiencia para Disputar Beneficios (Contested Case Hearing–CCH)
Rev. 07/17
PDF Spanish
DWC045M
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Rev. 02/17
PDF English
DWC045MS
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios para Apelar la Decisión de una Disputa por Honorarios Médicos
Rev. 02/17
PDF Spanish
DWC049
Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 11/17
PDF English
DWC049S
Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 11/17
PDF Spanish
DWC057
Request for Extension of Maximum Medical Improvement Date for Spinal Surgery
Rev. 02/17
PDF English
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. 02/17
PDF Spanish
DWC060
Medical Fee Dispute Resolution Request
Rev. 06/12
PDF English
DWC060S
Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 06/12
PDF Spanish
DWC074
Description of Injured Employee’s Employment
Rev. 9/09
PDF English
DWC105
Accident Prevention Services Worksheet
Rev. 10/13
PDF English
DWC105
Accident Prevention Services Worksheet
Rev. 10/13
WORD English
DWC109
Accident Prevention Services Annual Report
Rev. 10/13
PDF English
DWC109
Accident Prevention Services Annual Report
Rev. 10/13
WORD English
DWC154
Workers' Compensation Complaint Form
Rev. 03/16
PDF English
EDI-01
EDI Trading Partner Profile
Rev. 10/16
PDF English
EDI-02
Insurance Carrier or Trading Partner Medical Electronic Data Interchange (Edi) Profile
Rev. 10/16
PDF English
EDI-03
Medical EDI Compliance Coordinator and Trading Partner Notification
Rev. 10/16
PDF English

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