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 |