Workers' Compensation Forms
As of September 1, 2005, the Division of Workers' Compensation (DWC) forms have been renamed. Forms previously titled in the format TWCC-(Form #) are now titled DWC- (Form #). The form numbers have not changed.
If you have questions concerning DWC forms or processes involving the forms, please refer to the Forms Frequently Asked Questions (FAQ).
DWC has provided a Form Developer Kit for stakeholders who develop their own forms. Before using these items, please read the Readme file included. Alternate forms must use DWC specifications and be approved for use by the Division.
DWC is not currently accepting forms submitted electronically.
To order the forms not published on this website, please call Forms Management Customer Services at (512) 804-4240.
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Texas Department of Insurance, Division of Workers' Compensation
Open Records
Executive Communication, MS-3
7551 Metro Center Drive
Austin, Texas 78744-1609
open.records@tdi.state.tx.us
Requests for Workers' Compensation Claim File Information
Information in or derived from a claim file regarding a Workers' compensation claimant is confidential and may not be disclosed except as provided in the Texas Workers' Compensation Act. Because of the confidential nature of claimant information, REQUESTS FOR CLAIM FILE INFORMATION WILL NOT BE ACCEPTED VIA INTERNET E-MAIL OR FAX. The following forms for requesting confidential claimant information can be downloaded from this website. These request forms may be hand-delivered or submitted via mail to:
Texas Department of Insurance, Division of Workers' Compensation
7551 Metro Center Drive, MS-92B
Austin, Texas 78744-1609 |
| Form# |
Description |
PDF |
| DWC153 |
Request for Copies of Confidential Claimant Information (Rev. 10/06)
Effective September 1, 2006, requests for a claim file, medical dispute resolution file, and/or an indemnity resolution file must be made on the newly revised DWC-153 form (10/2006). A requestor must be eligible by statute to receive the requested information. |
dwc153.pdf |
| DWC-155 |
Request for Record Check (Rev. 10/05) |
dwc155.pdf |
| DWC-156 |
Prospective Employment Authorization and Certification (Rev. 10/05) |
dwc156.pdf |
| Form# |
Description |
Word |
PDF |
| PLN1 |
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d)) (Rev. 10/05) |
pln01.doc |
pln01.pdf |
| PLN2 |
Notification of First Temporary Income Benefit Payment (124.2(e)(1)) (Rev. 10/05) |
pln02.doc |
pln02.pdf |
| PLN3 |
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5)) (Rev. 10/05) |
pln03.doc |
pln03.pdf |
| PLN4 |
Notification of First Lifetime Income Benefit Payment (124.2(e)(1)) (Rev. 10/05) |
pln04.doc |
pln04.pdf |
| PLN5 |
Notification of First Death Benefit Payment (124.2(e)(1)) (Rev. 10/05) |
pln05.doc |
pln05.pdf |
| PLN6 |
Notification of Employer Full Salary Payment (124.2(e)(7)) (Rev. 10/05) |
pln06.doc |
pln06.pdf |
| PLN7 |
Notification of Change of Indemnity Benefit Type (124.2(e)(4)) (Rev. 10/05) |
pln07.doc |
pln07.pdf |
| PLN8 |
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3)) (Rev. 10/05) |
pln08.doc |
pln08.pdf |
| PLN9 |
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6)) (Rev. 10/05) |
pln09.doc |
pln09.pdf |
| PLN10 |
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5)) (Rev. 10/05) |
pln10.doc |
pln10.pdf |
| PLN11 |
Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h)) (Rev. 10/05) |
pln11.doc |
pln11.pdf |
EMPLOYEE FORMS
| Form# |
Description |
PDF |
| DWC-41 |
Employee's Notice of Injury or Occupational Disease and Claim for Compensation (Rev. 10/05)
Related Resources:
|
dwc41.pdf |
| DWC-41S |
Notificación del Trabajador Lesionado o Afectado por Enfermedad de Trabajo y Reclamo de Compensación (Rev. 10/05)
Recursos Relacionados:
|
dwc41s.pdf
|
| DWC-41A |
Form DWC-41, Supplement A - Beneficiary's Claim for Compensation (Rev. 10/05) |
dwc41a.pdf |
| DWC-41AS |
Formulario DWC-41s, Suplemento A - Reclamo de Compensación Beneficiario (Rev. 10/05) |
dwc41as.pdf
|
| DWC-42 |
Notice of Fatal Injury or Occupational Disease/Claim for Compensation for DeathBenefits |
DISCONTINUED please see Advisory 2004-12 |
| DWC-42s |
Notice of Fatal Injury or Occupational Disease/Claim for Compensation for DeathBenefits |
DISCONTINUED please see Advisory 2004-12 |
| DWC-44 |
Election to Engage in Arbitration (Rev. 10/05) |
dwc44.pdf |
| DWC-45 |
Request for a Benefit Review Conference Interim (Rev. 10/05) |
dwc45.pdf |
| DWC-46 |
Employee's Request for Acceleration of Impairment Income Benefits (Rev. 10/05) |
dwc46.pdf |
| DWC-46S |
Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal (Rev. 10/05) |
dwc46s.pdf |
| DWC-47 |
Employee's Request for Payment of Advanced Compensation (Rev. 10/05) |
dwc47.pdf |
| DWC-47S |
Solicitud del Trabajador Lesionado Acerca de Pagos Adelantados de Compensación (Rev. 10/05) |
dwc47s.pdf |
| DWC048 |
Request for Travel Reimbursement / Solicitud de Reembolso (Rev. 06/06) |
dwc048trvlreim.pdf |
| DWC-49 |
Request for Prospective Review of Medical Care Not Requiring Preauthorization (Rev. 10/05) |
dwc49.pdf |
| DWC-51 |
Employee's Election for Commuted (Lump Sum) Impairment Income Benefits (Rev. 10/05) |
dwc51.pdf |
| DWC-52 |
Application for Supplemental Income Benefits (Rev. 10/05) |
dwc52.pdf |
| DWC-52S |
Aplicación del trabajador para beneficios de ingresos suplementales (Rev. 10/05) |
dwc52s.pdf |
| DWC-53 |
Employee's Request To Change Treating Doctors (Rev. 10/05)
|
dwc53.pdf |
| DWC-53S |
Solicitud del Trabajador para Cambiar de Médico Tratante (Rev. 10/05) |
dwc53s.pdf |
| DWC-54 |
Notice to Employee: Intention to Request Division Permission to Adjust Benefits (Rev. 10/05) |
dwc54.pdf |
| DWC-54S |
Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios (Rev. 10/05)
|
dwc54s.pdf |
| DWC-55 |
Request to Adjust Average Weekly Wage for Seasonal Employee (Rev. 10/05) |
dwc55.pdf |
| DWC-55S |
Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada (Rev. 10/05) |
dwc55s.pdf |
| DWC-56 |
Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records (Rev. 10/05) |
dwc56.pdf |
| DWC-57 |
Request for Extension of Maximum Medical Improvement for Spinal Surgery (Rev. 10/05) |
dwc57.pdf |
| DWC058 |
Request for Interlocutory Order (Rev. 08/06) |
dwc058interloc.pdf |
AGREEMENT FORMS
| Form# |
Description |
PDF |
| DWC-81 |
Agreement Between General Contractor and Sub-Contractor to Provide Worker's Compensation Insurance (Rev. 10/05) |
dwc81.pdf |
| DWC-82 |
Agreement for Motor Carriers and Owner Operators (Rev. 10/05) |
dwc82.pdf |
| DWC083 |
Agreement for Certain Building and Construction Workers (Rev. 10/05) |
dwc83.pdf |
| DWC083S |
Acuerdo para Ciertos Trabajadores de Edificación y Construcción (Rev. 09/06) |
dwc083sagree.pdf |
| DWC-84 |
Exception to Application of Joint Agreement for Certain Building and Construction Workers (Rev. 10/05) |
dwc84.pdf |
| DWC-85 |
Agreement Between General Contractor and Subcontractor to Establish Independent Relationship (Rev. 10/05) |
dwc85.pdf |
| DWC085S |
Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente |
dwc085sagree.pdf |
Initial Applications
Self-Insurance Regulation provides an Initial Application Packet for use in applying for a Certificate of Self-Insurance in Texas.
Renewal Applications
All renewal forms for Certified Self-Insurers in Texas are customized for each individual renewal involved. The Self-Insurance program in Texas does not use blank stock forms; however, Self-Insurance Regulation can provide example forms upon request.
Please contact Self-Insurance Regulation by calling (512) 804-4775 or faxing (512) 804-4776 during normal business hours of 8-5 Monday through Friday CST for further information or to request an Initial Application Packet.
Self-Insurance Regulation's mailing address is as follows:
Self-Insurance Regulation
Texas Department of Insurance, Division of Workers' Compensation
7551 Metro Center Drive, MS-60
Austin, Texas 78744-1609
For more information contact: Webstaff@tdi.state.tx.us
Texas Department of Insurance
