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You are here: www.tdi.texas.gov . forms . form20employer

Workers' Compensation Employer Forms and Notices

Division of Workers Compensation Main Forms page
Self-Insured Employer Forms and Required Coverage Notices

Workers' Compensation Employer Forms and Notices
TDI Form Number Description File FormatLanguage
DWC001
Employer's First Report of Injury or Illness
Rev. 10/05. This form is submitted by the carrier to DWC.
PDF English
DWC001S
Employer's First Report of Injury or Illness (for state employees)
Rev. 10/05
PDF English
DWC002
Employer's Report for Reimbursement of Voluntary Payment
Rev. 10/05
PDF English
DWC003
Employer's Wage Statement
Rev. 10/05
PDF English
DWC003ME
Employee's Multiple Employment Wage Statement
Rev. 04/16
PDF English
DWC003MES
Declaración de Salario de Múltiples Trabajos del Empleado
Rev. 04/16
PDF Spanish
DWC003S
Declaración de Salario del Empleador
Rev. 10/05
PDF Spanish
DWC003SD
Employer's Wage Statement for School Districts
Rev. 10/05
PDF English
DWC003SDS
Declaración de Salario Para Escuelas de Distrito
Rev. 10/05
PDF Spanish
DWC004
Employer's Contest of Compensability
Rev. 11/08
PDF English
DWC005
Indicates forms available for electronic filing
Employer Notice of No Coverage or Termination of Coverage
Rev. 01/13 - Using Google Chrome or Mozilla Firefox to file electronically? See more at “Electronic Filing - Online Forms” above.
PDF English
DWC005
Employer Notice of No Coverage or Termination of Coverage
Rev. 1/13 - static version for mailing and faxing
PDF English
DWC005s
Notificación del Empleador por No Cobertura o Anulación de la Cobertura
Rev. 1/13
PDF Spanish
DWC006
Supplemental Report of Injury
Rev. 10/05
PDF English
DWC007
Employer’s Report of Non-covered Employee’s Occupational Injury or Disease
Rev. 01/13
PDF English
DWC008
Return-to-Work Reimbursement Program for Employers
Rev. 04/10
WORD English
DWC008
Return-to-Work Reimbursement Program for Employers
Rev. 04/10
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
DWC045
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
Rev. 11/11
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, por su nombre y siglas en inglés)
Rev. 11/11
PDF Spanish
DWC074
Description of Injured Employee’s Employment
Rev. 9/09
PDF English
DWC154
Workers' Compensation Complaint Form
Rev. 03/16
PDF English
DWC154S
Quejas de Compensación para Trabajadores
Rev. 03/16
PDF Spanish
DWC205
Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10
PDF English
DWC205S
Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10
PDF Spanish
New Employee Notice Vietnamese
New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF Vietnamese
New Employee Notice English
New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF English
New Employee Notice Spanish
New Employee Notice
Covered and non-covered employers shall notify their employees of coverage status in writing.
PDF Spanish
Notice 5 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 5 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 5 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 6 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 6 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 6 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
Notice 8 English
Required Workers’ Compensation Coverage
(building or construction projects for governmental entities)
PDF English
Notice 8 Spanish
Required Workers’ Compensation Coverage
(building or construction projects for governmental entities)
PDF Spanish
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 English
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 Spanish

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