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Numeric listing of workers' compensation forms

Division of Workers Compensation main forms page 

Electronic filing: See Electronic filing - online forms for more information about filing your PDF form online. 

TDI form number Description Format Language
DWC001
Employer’s first report of injury or illness
Rev. 10/24. 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. 10/24
PDF English
DWC003
Employer’s wage statement
Rev. 10/22
PDF English
DWC003ME
Employee’s multiple employment wage statement
Rev. 05/23
PDF English
DWC003MES
Declaración de salario de múltiples trabajos del empleado
Rev. 05/23
PDF Spanish
DWC003S
Declaración de salarios del empleador
Rev. 10/22
PDF Spanish
DWC003SD
Employer’s wage statement for school districts
Rev. 07/22
PDF English
DWC003SDS
Declaración de salario del empleador para distritos escolares
Rev. 07/22
PDF Spanish
DWC004
Employer's Contest of Compensability
Rev. 11/08
PDF English
DWC005
Employer Notice of No Coverage or Termination of Coverage
Rev. 02/18 - For help and an instructional video see “Electronic Filing - Online Forms” page.
PDF English
DWC005
Employer Notice of No Coverage or Termination of Coverage
Rev. 02/18 - static version for mailing and faxing
PDF English
DWC005s
Aviso del Empleador de No Cobertura o de Cancelación de la Cobertura
Rev. 02/18
PDF Spanish
DWC006
Supplemental report of injury
Rev. 10/24
PDF English
DWC007
Employer’s report of noncovered employee’s work-related injury or illness
Rev. 02/22
PDF English
DWC007S
Reporte del empleador para lesiones o enfermedades relacionadas con el trabajo de los empleados sin cobertura
Rev. 02/22
PDF Spanish
DWC008
Return-to-Work Reimbursement Program for Employers
Rev. 04/10
PDF English
DWC020A
Correction/Revision/Endorsement to Existing Policy
Rev. 10/05
PDF English
DWC020SI
Governmental entity coverage information
Rev. 08/24
PDF English
DWC022
Request for a required medical examination (RME)
Rev. 06/23
PDF English
DWC022S
Solicitud para un examen médico requerido
Rev. 06/23
PDF Chinese
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. 03/22
PDF English
DWC029
Request for standard detailed data reports
Rev. 03/22
PDF English
DWC031
Request to change payment period or purchase an annuity
Rev. 06/23
PDF English
DWC031s
Solicitud para cambiar el periodo de pago o para la compra de una anualidad
Rev. 06/23
PDF Spanish
DWC032
Request for designated doctor examination
Rev. 6/23
PDF English
DWC032S
Solicitud para obtener un examen por parte de un médico designado
Rev. 06/23
PDF Spanish
DWC033
Request to reduce income benefits due to contribution
Rev. 05/22
PDF English
DWC041
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
PDF English
DWC041
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
WORD English
DWC041S
Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
PDF Spanish
DWC041S
Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
WORD Spanish
DWC042
Claim for workers’ compensation death benefits
Rev. 12/23
PDF English
DWC042S
Reclamación para obtener beneficios de compensación para trabajadores por causa de muerte
Rev. 12/23
PDF Spanish
DWC044
Election to Engage in Arbitration
Rev. 06/12
PDF English
DWC044S
Elección para Participar en un Arbitraje
Rev. 05/12
PDF Spanish
DWC045
Request to schedule, reschedule, or cancel a benefit review conference (BRC)
Rev. 07/21
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. 07/21
PDF Spanish
DWC045M
Request to schedule, reschedule, or cancel a benefit review conference to appeal a medical fee dispute decision (BRC-MFD)
Rev. 07/21
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 (benefit review conference to appeal a medical fee dispute decision -BRC-MFD, por su nombre y
Rev. 07/21
PDF Spanish
DWC046
Request to accelerate impairment income benefits
Rev. 08/22
PDF English
DWC046S
Solicitud para acelerar los beneficios de ingresos de impedimento
Rev. 08/22
PDF Spanish
DWC047
Request to advance benefits
Rev. 08/22
PDF English
DWC047S
Solicitud para recibir beneficios por adelantado
Rev. 08/22
PDF Spanish
DWC048
Request to get reimbursed for travel costs
Rev. 07/21
PDF English
DWC048S
Solicitud para obtener un reembolso por gastos de viaje
Rev. 07/21
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
DWC051
Request for a lump sum payment of impairment income benefits (IIBs)
Rev. 06/23
PDF English
DWC051S
Solicitud para recibir un pago en suma total de los beneficios de ingresos de impedimento
Rev. 06/23
PDF Spanish
DWC052
Supplemental Income Benefits (SIBs) Application
Rev. 07/24
PDF English
DWC052S
Solicitud para recibir beneficios de ingresos suplementarios (SIBs)
Rev. 07/24
PDF English
DWC053
Employee Request to Change Treating Doctor
Rev. 03/12
PDF English
DWC053S
Solicitud del Empleado para Cambiar de Médico de Tratamiento
Rev. 03/12
PDF Spanish
DWC054
Notice to Employee: Intention to Request Division Permission to Adjust Benefits
Rev. 02/17
PDF English
DWC054S
Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
Rev. 02/17
PDF Spanish
DWC055
Request to Adjust Average Weekly Wage for Seasonal Employee
Rev. 02/17
PDF English
DWC055S
Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
Rev. 02/17
PDF Spanish
DWC056
Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
Rev. 02/17
PDF English
DWC057
Request to extend the date of maximum medical improvement for an approved spinal surgery
Rev. 06/23
PDF English
DWC057S
Solicitud para extender la fecha del mejoramiento máximo médico para una cirugía aprobada de la columna vertebral
Rev. 06/23
PDF Spanish
DWC058
Request for Interlocutory Order
Rev. 09/07
PDF English
DWC060
Medical Fee Dispute Resolution Request
Rev. 02/21
PDF English
DWC060S
Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 02/21
PDF Spanish
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 English
DWC066
Statement of Pharmacy Services
Rev. 12/11
PDF English
DWC067
Designated doctor certification application
Rev. 4/23
PDF English
DWC068
Designated doctor examination data report
Rev. 6/23
PDF English
DWC069
Report of Medical Evaluation
Rev. 1/15
PDF English
DWC070
Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
Rev. 10/05
PDF English
DWC072
Medical Quality Review Panel Application
Rev. 01/13
PDF English
DWC073
Work Status Report
Rev. 09/19
PDF English
DWC073s
Reporte de Estado de Trabajo
Rev. 09/19
PDF Spanish
DWC074
Description of Injured Employee’s Employment
Rev. 9/09
PDF English
DWC081
Agreement between general contractor and subcontractor to provide workers' compensation insurance
Rev. 10/21
PDF English
DWC081S
Acuerdo entre el contratista general y el subcontratista para proporcionar un seguro de compensación para trabajadores
Rev. 10/21
PDF Spanish
DWC082
Agreement between motor carrier and owner operator to provide workers' compensation insurance | Agreement to require owner operator to act as employer
Rev. 02/22
PDF English
DWC082S
Acuerdo entre el transportista y el propietario operador para proporcionar un seguro de compensación para trabajadores Acuerdo para requerir que el propietario operador actúe como empleador
Rev. 02/22
PDF Spanish
DWC083
Joint agreement to affirm independent relationship for certain building and construction workers | Agreement to establish employer-employee relationship for certain building and construction workers
Rev. 10/21
PDF English
DWC083S
Acuerdo en conjunto para afirmar la relación independiente de ciertos trabajadores de edificación y construcción | Acuerdo para establecer la relación de empleador-empleado para ciertos trabajadores de edificación y construcción
Rev. 10/21
PDF Spanish
DWC084
Exception to application of joint agreement to affirm independent relationship for certain building and construction workers
Rev. 10/21
PDF English
DWC084S
Excepción a la aplicación del acuerdo en conjunto para afirmar la relación independiente de ciertos trabajadores de edificación y construcción
Rev. 10/21
PDF Spanish
DWC085
Agreement between general contractor and subcontractor to establish independent relationship
Rev. 10/21
PDF English
DWC085S
Acuerdo entre el contratista general y el subcontratista para establecer una relación independiente
Rev. 10/21
PDF Spanish
DWC095
SIF Reimbursement Request Form - Overturned Order or Designated Doctor Opinion
Rev. 01/21
PDF English
DWC096
SIF Reimbursement Request Form – Refund of Death Benefits
Rev. 01/21
PDF English
DWC097
SIF Reimbursement Request Form – Multiple Employment
Rev. 01/21
PDF English
DWC098
SIF Reimbursement Request Form – Pharmaceutical
Rev. 01/21
PDF English
DWC101
Program review report for rejected risk employers
Rev. 11/21
PDF English
DWC101
Program review report for rejected risk employers
Rev. 11/21
WORD English
DWC102
Accident prevention plan cover sheet for rejected risk employer
Rev. 11/21
PDF English
DWC102
Accident prevention plan cover sheet for rejected risk employer
Rev. 11/21
WORD English
DWC104
Employer request for DWC safety consultation
Rev. 11/21
PDF English
DWC104
Employer request for DWC safety consultation
Rev. 11/21
WORD English
DWC105
Accident prevention services worksheet
Rev. 07/24
PDF English
DWC105
Accident prevention services worksheet
Rev. 07/24
WORD English
DWC109
Accident prevention services annual report
Rev. 07/24
PDF English
DWC109
Accident prevention services annual report
Rev. 07/24
WORD English
DWC120
Designation of administrative services company administrator
Rev. 03/22
PDF English
DWC121
Claim Administration Contact Information
Rev. 3/20
PDF English
DWC150
Notice of Representation
Rev. 12/16
PDF English
DWC150A
Notice of Withdrawal of Representation
Rev. 11/17
PDF English
DWC150AS
Aviso de Anulación de Representación Legal
Rev. 11/17
PDF Spanish
DWC150S
Aviso de Representación Legal
Rev. 12/16
PDF Spanish
DWC151
Attorney Application for Web Access
Rev. 12/16
PDF English
DWC152
Application for Attorney Fees
Rev. 11/17
PDF English
DWC153
Request for Record Check or Copies of Confidential Claim Information
Rev. 02/21
PDF English
DWC153s
Solicitud para Obtener Verificación de Expedientes o Copias de Información Confidencial de la Reclamación
Rev. 02/21
PDF Spanish
DWC154
Workers' Compensation Complaint Form
Rev. 03/16
PDF English
DWC154S
Quejas de Compensación para Trabajadores
Rev. 03/16
PDF Spanish
DWC156
Prospective employment authorization and certification
Rev. 08/21
PDF English
DWC156S
Certificación y autorización de un posible empleo
Rev. 08/21
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
EDI-02
Insurance carrier or trading partner medical electronic data interchange (EDI) profile
Rev. 04/22
PDF English
EDI-03
Claim and medical EDI compliance coordinator and medical EDI trading partner notification
Rev. 02/22
PDF English
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
LHL009 Spanish
Solicitud para una revisión por parte de una Organización de Revisión Independiente
[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica.
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
Notice 10 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 10 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 10 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
PLN01
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 07/21
WORD English
PLN01S
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 07/21
WORD Spanish
PLN02A
Notice of First Temporary Income Benefit Payment
Rev. 07/21
WORD English
PLN02AS
Notice of First Temporary Income Benefit Payment
Rev. 07/21
WORD Spanish
PLN02B
Notice of first payment of income benefits on an acquired claim
Rev. 07/23
WORD English
PLN02BS
Notice of first payment of income benefits on an acquired claim
Rev. 07/23
WORD Spanish
PLN03A
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 07/21
WORD English
PLN03AS
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 07/21
WORD Spanish
PLN03B
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 07/21
WORD English
PLN03BS
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 07/21
WORD Spanish
PLN03C
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 07/21
WORD English
PLN03CS
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 07/21
WORD Spanish
PLN04
Notice of Eligibility for Lifetime Income Benefits
Rev. 07/21
WORD English
PLN04S
Notice of Eligibility for Lifetime Income Benefits
Rev. 07/21
WORD Spanish
PLN05
Notice of First Death Benefit Payment
Rev. 07/21
WORD English
PLN05S
Notice of First Death Benefit Payment
Rev. 07/21
WORD Spanish
PLN06
Notice of Employer Full Salary Payment
Rev. 07/21
WORD English
PLN06S
Notice of Employer Full Salary Payment
Rev. 07/21
WORD Spanish
PLN07
Notice of Change of Indemnity Benefit Type
Rev. 07/21
WORD English
PLN07S
Notice of Change of Indemnity Benefit Type
Rev. 07/21
WORD Spanish
PLN08
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 07/23
WORD English
PLN08S
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 07/23
WORD Spanish
PLN09
Notice of Suspension of Indemnity Benefits
Rev. 07/21
WORD English
PLN09S
Notice of Suspension of Indemnity Benefits
Rev. 07/21
WORD Spanish
PLN10A
Notice of reinstatement of indemnity benefits
Rev. 07/23
WORD English
PLN10AS
Notice of reinstatement of indemnity benefits
Rev. 07/23
WORD Spanish
PLN10B
Notice of lump sum payment of income or death benefits
Rev. 07/23
WORD English
PLN10BS
Notice of lump sum payment of income or death benefits
Rev. 07/23
WORD Spanish
PLN11
Notice of Disputed Issues and Refusal to Pay Benefits
Rev. 07/23
WORD English
PLN11S
Notice of Disputed Issues and Refusal to Pay Benefits
Rev. 07/23
WORD Spanish
PLN12
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 12/23
WORD English
PLN12S
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 12/23
WORD Spanish
PLN14
Notice of Continuing Investigation
Rev. 07/23
WORD English
PLN14S
Notificación de Investigación en Curso
Rev. 07/23
WORD Spanish
Sample Notice
Notice of Underpayment of Income Benefits
Rev. 12/11
PDF English
Sample Notice
Aviso de Pago Insuficiente de los Beneficios de Ingresos
Rev. 12/11
PDF Spanish

For more information, contact: WebStaff@tdi.texas.gov