Workers' Compensation Employer Forms
Division of Workers Compensation Main Forms page
Self-Insured Employer Forms and Required Coverage Notices
English
|
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). | ||
| TDI Form Number | Description | File Format |
|---|---|---|
| DWC005 | Employer Notice of No Coverage or Termination of Coverage (Rev. 11/10) |
|
| DWC007 | Non-Covered Employer's Report of Occupational Injury or Illness (Rev. 10/05) |
|
| DWC007SUP | Supplement DWC 7, Non-Covered Employer's Report of Occupational Injury or Illness (Rev. 10/05) |
|
| DWC205 | Locations of Employer’s Business(es) Addendum to DWC Form-005 or DWC Form-020 (Rev. 11/10) |
|
| New Employee Notice English | New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing) |
|
| Notice 5 | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read) |
|
En Español
| Número del Formulario de TDI | Descripción | Formato del Archivo |
|---|---|---|
| DWC005s | Notificación del Empleador por No Cobertura o Anulación de la Cobertura (Rev. 11/10) |
|
| DWC205S | Locaciones del Negocio(s) del Empleador Suplemento para el Formulario DWC005 o Formulario DWC020 (Rev. 11/10) |
|
| New Employee Notice Spanish | New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing) |
|
| Notice 5 Spanish | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read) |
English
|
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. | ||
| TDI Form Number | Description | File Format |
|---|---|---|
| DWC001 | Employer's First Report of Injury or Illness (Rev. 10/05) This form is submitted to by carrier to DWC (with cover sheet and instructions) |
|
| DWC001S | Employer's First Report of Injury or Illness (for state employees) (Rev. 10/05) |
|
| DWC002 | Employer's Report for Reimbursement of Voluntary Payment (Rev. 10/05) |
|
| DWC003 | Employer's Wage Statement (Rev. 10/05) |
|
| DWC003ME | Employee's Multiple Employment Wage Statement (Rev. 10/05) |
|
| DWC003SD | Employer's Wage Statement for School Districts (Rev. 10/05) |
|
| DWC004 | Employer's Contest of Compensability (Rev. 11/08) |
|
| DWC006 | Supplemental Report of Injury (Rev. 10/05) |
|
| DWC008 | Return-to-Work Reimbursement Program for Employers (Rev. 04/10) |
|
| DWC008 | Return-to-Work Reimbursement Program for Employers (Rev. 04/10) |
WORD |
| DWC020SI | Self-Insured Governmental Entity Proof of Coverage (Rev. 10/06) |
|
| DWC045 | Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) (Rev. 11/11, for use beginning 12/1/11) |
|
| DWC045A | Request for a Medical Contested Case or SOAH Hearing (Rev. 09/07) |
|
| DWC074 | Description of Injured Employee’s Employment (Rev. 9/09) |
|
| New Employee Notice English | New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing) |
|
| Notice 6 | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read) |
|
| Notice 8 English | Required Workers' Compensation Coverage (building or construction projects for governmental entities) |
|
| 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) |
|
En Español
| Número del Formulario de TDI | Descripción | Formato del Archivo |
|---|---|---|
| DWC003MES | Declaración de Salario de Múltiples Trabajos del Empleado (Rev. 10/05) |
|
| DWC003SDS | Declaración de Salario Para Escuelas de Distrito (Rev. 10/05) |
|
| 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) |
|
| 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) |
|
| New Employee Notice Spanish | New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing) |
|
| Notice 6 Spanish | Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read) |
|
| Notice 8 Spanish | Required Workers' Compensation Coverage (building or construction projects for governmental entities) |
|
| 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) |
For more information contact:
