Texas Department of Insurance

Workers' Compensation


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Workers' Compensation Carrier Forms


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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
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
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
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, para usarse a partir de 12/1/11)		 PDF

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