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Form

Description

dwc1.pdf Employer's First Report of Injury or Illness
dwc1s.pdf Employer's First Report of Injury or Illness (for state employees)
employee_notice.pdf Notice - Employee Notice Ombudsman Program
employee_notice_sp.pdf Notice - Employee Notice Ombudsman Program (Spanish)
OMB49.pdf Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System
OMB49SP.pdf Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (Spanish)
IERights.pdf Injured Employee Rights and Responsibilities
IERightsSP.pdf Injured Employee Rights and Responsibilities (Spanish)
dwc2.pdf Employer's Report for Reimbursement of Voluntary Payment Interim
dwc3.pdf Employer's Wage Statement
dwc3s.pdf Employer's Wage Statement (Spanish)
dwc3me.pdf Employer's Multiple Employment Wage Statement
dwc3mes.pdf Employer's Multiple Employment Wage Statement (Spanish)
dwc3sd.pdf Employer's Wage Statement for School Districts
dwc3sds.pdf Employer's Wage Statement for School Districts (Spanish)
dwc4.pdf Employer's Contest of Compensability Interim
dwc5.pdf Employer's Notice of No Coverage or Termination of Coverage
dwc5s.pdf Employer's Notice of No Coverage or Termination of Coverage (Spanish)
dwc6.pdf Supplemental Report of Injury
dwc7.pdf Employer's Report of Non-covered Employee's Occupational Injury or Disease
dwc8.pdf Application for Reimbursement from the Return-to-Work Account for Small Employers
dwc20.pdf Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage
dwc20a.pdf Correction/Revision/Endorsement to Existing Policy
dwc20si.pdf Self-Insured Governmental Entity Coverage Information
dwc22.pdf Required Medical Examination Notice or Request for Order
dwc22s.pdf Required Medical Examination Notice or Request for Order (Spanish)
dwc24.pdf Benefit Dispute Agreement
dwc24s.pdf Benefit Dispute Agreement (Spanish)
dwc25.pdf Benefit Dispute Settlement
dwc25s.pdf Benefit Dispute Settlement (Spanish)
dwc26.pdf Reimbursement Request Made by Health Care Insurer (for use through 12/31/14)
dwc26_2015.pdf Request for Reimbursement of Payment Made by Health Care Insurer (for use on or after 1/1/2015)
dwc27.pdf Designation of Insurance Carrier's Austin Representative
dwc30.pdf Austin Representative's Authorized Designees
dwc31.pdf Application for Commission Approval of Change in the Payment Period and/or Purchase of an Annuity
dwc31s.pdf Application for Commission Approval of Change in the Payment Period and/or Purchase of an Annuity (Spanish)
dwc32.pdf Request for Designated Doctor Examination
dwc32s.pdf Request for Designated Doctor Examination (Spanish)
dwc33.pdf Carrier's Request for Reduction of Income Benefits Due to Contribution
dwc35.pdf Application for Commission Approval of the Purchase of an Annuity for Lifetime Income Benefits
dwc41.pdf Employee's Notice of Injury or Occupational Disease and Claim for Compensation
dwc41s.pdf Employee's Notice of Injury or Occupational Disease and Claim for Compensation (Spanish)
dwc42.pdf Claim for Workers'Compensation Death Benefits
dwc42s.pdf Claim for Workers' Compensation Death Benefits (Spanish)
dwc44.pdf Election to Engage in Arbitration (For disputes filed on or after June 1, 2012)
dwc44s.pdf Election to Engage in Arbitration (For disputes filed on or after June 1, 2012) (Spanish)
dwc45.pdf Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
dwc45s.pdf Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) (Spanish)
dwc45a.pdf Request for Medical Contested Case or SOAH Hearing
dwc45as.pdf Request for Medical Contested Case or SOAH Hearing (Spanish)
dwc45m.pdf Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD) (For disputes filed on or after June 1, 2012)
dwc45ms.pdf Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD) (For disputes filed on or after June 1, 2012) (Spanish)
dwc46.pdf Employee's Request for Acceleration of Impairment Income Benefits
dwc46s.pdf Employee's Request for Acceleration of Impairment Income Benefits (Spanish)
dwc47.pdf Employee's Request for Payment of Advanced Compensation
dwc47s.pdf Employee's Request for Payment of Advanced Compensation (Spanish)
dwc48.pdf Request to Get Reimbursed for Travel Costs
dwc48s.pdf Request to Get Reimbursed for Travel Costs(Spanish)
dwc49.pdf Request to Schedule a Medical Contested Case Hearing (MCCH) (For disputes filed on or after June 1, 2012)
dwc49s.pdf Request to Schedule a Medical Contested Case Hearing (MCCH) (For disputes filed on or after June 1, 2012) (Spanish)
dwc51.pdf Employee's Election for Commuted (Lump Sum) Impairment Income Benefits
dwc51s.pdf Employee's Election for Commuted (Lump Sum) Impairment Income Benefits (Spanish)
dwc52.pdf Application for Supplemental Income Benefits For SIBs Qualifying Periods beginning on or after July 1, 2009
dwc52s.pdf Application for Supplemental Income Benefits for SIBs Qualifying Periods Beginning on or after July 1, 2009 (Spanish)
dwc53.pdf Employee's Request to Change Treating Doctors
dwc53s.pdf Employee's Request to Change Treating Doctors (Spanish)
dwc54.pdf Notice to Employee: Intention to Request Commission Permission to Adjust Benefits
dwc54s.pdf Notice to Employee: Intention to Request Commission Permission to Adjust Benefits (Spanish)
dwc55.pdf Request to Adjust Average Weekly Wage for Seasonal Employee
dwc55s.pdf Request to Adjust Average Weekly Wage for Seasonal Employee (Spanish)
dwc56.pdf Carrier's Request for Seasonal Wage Information from Texas Work Force Commission
dwc57.pdf Request for Extension of Maximum Medical Improvement for Spinal Surgery
dwc57s.pdf Request for Extension of Maximum Medical Improvement for Spinal Surgery (Spanish)
dwc58.pdf Request for Interlocutory Order
dwc60.pdf Medical Fee Dispute Resolution Request (For disputes filed on or after June 1, 2012)
dwc60s.pdf Medical Fee Dispute Resolution Request (For disputes filed on or after June 1, 2012) (Spanish)
dwc64.pdf Medical Interlocutory Order Request
dwc65.pdf Private Providers of Vocational Rehabilitation Services
dwc66.pdf Statement of Pharmacy Services Services
dwc067.pdf Designated Doctor Certification Application * For use on or after 9/1/2016 *
dwc68.pdf Designated Doctor Examination Data Report
dwc69.pdf DWC069 Report of Medical Evaluation
dwc70.pdf Instructions for Completing the ADA J515 Dental Claim Form
dwc72.pdf Medical Quality Review Panel Application (for use on or after January 1, 2013)
dwc73.pdf Work Status Report
dwc74.pdf Description of Injured Employee's Employment
dwc81.pdf Agreement Between General Contractor and Sub-Contractor to Provide Workers' Compensation Insurance
dwc81s.pdf Agreement Between General Contractor and Sub-Contractor to Provide Workers' Compensation Insurance (Spanish)
dwc82.pdf Agreement for Motor Carriers and Owner Operators
dwc83.pdf Agreement for Certain Building and Construction Workers
dwc83s.pdf Agreement for Certain Building and Construction Workers (Spanish)
dwc84.pdf Exception to Application of Joint Agreement for Certain Building and Construction Workers
dwc85.pdf Agreement between General Contractor and Subcontractor to Establish Independent Relationship
dwc85s.pdf Agreement between General Contractor and Subcontractor to Establish Independent Relationship (Spanish)
dwc101.pdf Program Review Report
dwc102.pdf Accident Prevention Plan Cover Sheet
dwc103.pdf Approved Professional Source Safety Consultant Application
dwc104.pdf Employer Request for DWC Safety Consultation
dwc105.pdf Accident Prevention Services Worksheet
dwc109.pdf Accident Prevention Services Annual Report
dwc150.pdf Notice of Representation
dwc150a.pdf Notice of Withdrawal of Representation
dwc150as.pdf Notice of Withdrawal of Representation (Spanish Version)
dwc150s.pdf Notice of Representation (Spanish)
dwc151.pdf Attorney Application for Web Access
dwc152.pdf Application for Attorney's Fees
dwc153.pdf Request for Copies of Confidential Claimant Information
dwc153s.pdf Request for Copies of Confidential Claimant Information (Spanish)
dwc154.pdf Workers' Compensation Complaint Form
dwc154s.pdf Workers' Compensation Complaint Form(Spanish)
dwc155.pdf Request for Record Check
dwc156.pdf Prospective Employment Authorization and Certification
dwc156s.pdf Prospective Employment Authorization and Certification (Spanish)
dwc205.pdf Locations of Employers' Business
dwc205s.pdf Locations of Employers' Business (Spanish)
dwc210.pdf Surety Bond for Certified Self-Insurance Liabilities
dwc215.pdf Surety Bond Amount Rider
dwc216.pdf Surety Bond Name Change Rider
dwc223.pdf Documentary Irrevocable Standby Letter of Credit
dwc224.pdf Documentary Irrevocable Standby Letter of Credit ("Confirmation")
dwc225.pdf Self-Insurers Agreement to Post Documentary Irrevocable Standby Letter of Credit
dwc226.pdf Parental Guaranty
dwc227.pdf Parental Guaranty for Less than Wholly Owned Subsidiary
dwc228.pdf Power of Attorney
dwc230suretybond.pdf Surety Bond for Assumed Certified Self-Insurance Liabilities
newempnotice.pdf New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing, for use on or after 1/1/13)
newempnotices.pdf New Employee Notice(covered and non-covered employers shall notify their employees of coverage status, in writing, for use on or after 1/1/13) (Spanish)
notice5.pdf For Employers who do not have coverage (must be posted for employees to read, for use on or after 1/1/13)
notice5s.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) (Spanish)
notice6.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13)
notice6s.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) (Spanish)
notice07.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13)
notice07s.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13)(Spanish)
notice8.pdf Required Workers' Compensation Coverage (building or construction projects for governmental entities)
notice8s.pdf Required Workers' Compensation Coverage (building or construction projects for governmental entities) (Spanish)
notice9.pdf For Work-Related Communicable Diseases
notice9s.pdf For Work-Related Communicable Diseases (Spanish)
notice10.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13)
notice10s.pdf Notice to Employees Concerning Workers' Compensation in Texas (must be posted for employees to read, for use on or after 1/1/13) (Spanish)
pln01.pdf Notice of Denial of Compensability/Liability and Refusal to Pay
pln01s.pdf Notice of Denial of Compensability/Liability and Refusal to Pay (Spanish)
pln02.pdf Notification of First Temporary Income Benefit Payment
pln02s.pdf Notification of First Temporary Income Benefit Payment (Spanish)
pln03.pdf Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment
pln03s.pdf Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (Spanish)
pln04.pdf Notice Regarding Eligibility for Lifetime Income Benefits(for use on or after June 1, 2015)
pln04s.pdf Notice Regarding Eligibility for Lifetime Income Benefits(for use on or after June 1, 2015) (Spanish)
pln05.pdf Notification of First Death Income Benefit Payment
pln05s.pdf Notification of First Death Income Benefit Payment (Spanish)
pln06.pdf Notification of Employer Full Salary Payment
pln06s.pdf Notification of Employer Full Salary Payment (Spanish)
pln07.pdf Notification of Change of Indemnity Benefit Payment
pln07s.pdf Notification of Change of Indemnity Benefit Payment (Spanish)
pln08.pdf Notification of Change in Amount of Indemnity Benefit Payment
pln08s.pdf Notification of Change in Amount of Indemnity Benefit Payment - (Spanish)
pln09.pdf Notification of Suspension of Indemnity Benefit Payment
pln09s.pdf Notification of Suspension of Indemnity Benefit Payment (Spanish)
pln10.pdf Notification of Reinstatement of Indemnity Benefit Payment
pln10s.pdf Notification of Reinstatement of Indemnity Benefit Payment (Spanish)
pln11.pdf Notification of Disputed Issue(s) and Refusal to Pay (To be used after 6/2015)
pln11s.pdf Notification of Disputed Issue(s) and Refusal to Pay - (Spanish) (To be used after 6/2015) (Spanish)
pln12.pdf Notice of Potential Entitlement to Workers' Compensation Death Benefits
pln12s.pdf Notice of Potential Entitlement to Workers' Compensation Death Benefits (Spanish)
sample_notice.pdf Notice of Underpayment of Income Benefits
sample_notice_s.pdf Notice of Underpayment of Income Benefits (Spanish)
dwc-edi-01.pdf Trading Partner Profile
edi002.pdf Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile
edi003.pdf Medical EDI Compliance Coordinator and Trading Partner Notification
lhl009.pdf Req for review by IRO
lhl009s.pdf Req for review by IRO (Spanish)