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TDI Forms

Workers' Compensation Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

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.

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 | Employer Forms | Carrier Forms | Employee Forms | Medical Forms | Agreement Forms | Health & Safety Forms | Other Business Forms | Self-Insurance Regulation Forms

 


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
TDI Form Number Description File Format
DWC-153 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		 PDF
DWC-155 Request for Record Check
(Rev. 10/05)		 PDF
DWC-156 Prospective Employment Authorization and Certification
(Rev. 10/05)		 PDF
DWC-156S Certificación Y Autorización De Un Posible Empleo
(Rev. 10/06)		 PDF

 


Employer Non-Coverage Package

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
DWC-205 Locations of Employers' Business(es)
(Rev. 10/05)		 PDF
DWC-5 Employer's Notice of No Coverage or Termination of Coverage
(Rev. 10/05)		 PDF
DWC-7 Non-Covered Employer's Report of Occupational Injury and Illness
(Rev. 10/05)		 PDF
DWC-7SUP Supplement DWC 7, Non-Covered Employer's Report of Occupational Injury and Illness
(Rev. 10/05)		 PDF
New Employee Notice English New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing)		 PDF
New Employee Notice Spanish New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing)		 PDF
Notice 5 English Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDF
Notice 5 Rules Notice to Employees Concerning Workers' Compensation in Texas
 PDF
Notice 5 Spanish Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDF

 


Employer Coverage Package
TDI Form Number Description File Format
New Employee Notice English New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing)		 PDF
New Employee Notice Spanish New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing)		 PDF
Notice 6 English Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDF
Notice 6 Rules Notice to Employees Concerning Workers' Compensation in Texas
 PDF
Notice 6 Spanish Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDF
Notice 8 English Required Workers' Compensation Coverage
(building or construction projects for governmental entities)		 PDF
Notice 8 Spanish Required Workers' Compensation Coverage
(building or construction projects for governmental entities)		 PDF
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
Notice 9 Rules 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
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

 


Employer Forms
TDI Form Number Description File Format
DWC-1 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)		 PDF
DWC-1S Employer's First Report of Injury or Illness (for state employees)
(Rev. 10/05)		 PDF
DWC-2 Employer's Report for Reimbursement of Voluntary Payment Interim
(Rev. 10/05)		 PDF
DWC-3 Employer's Wage Statement
(Rev. 10/05)		 PDF
DWC-3ME Employee's Multiple Employment Wage Statement
(Rev. 10/05)		 PDF
DWC-3MES Declaración de Salario de Múltiples Trabajos del Empleado
(Rev. 10/05)		 PDF
DWC-3S Declaración de Salario del Empleador
(Rev. 10/05)		 PDF
DWC3SD Employer's Wage Statement for School Districts
(Rev. 10/05)		 PDF
DWC-3SDS Declaración de Salario Para Escuelas de Distrito
(Rev. 10/05)		 PDF
DWC-4 Employer's Contest of Compensability Interim
(Rev. 10/05)		 PDF
DWC-5 Employer's Notice of No Coverage or Termination of Coverage
(Rev. 10/05)		 PDF
DWC-6 Supplemental Report of Injury instructions
(Rev. 10/05)		 PDF
DWC-7 Non-Covered Employer's Report of Occupational Injury and Illness
(Rev. 10/05)		 PDF
DWC-7SUP Supplement DWC 7, Non-Covered Employer's Report of Occupational Injury and Illness
(Rev. 10/05)		 PDF
DWC-8 Application for Reimbursement from the Return-to-Work Account for Small Employers
(Rev. 02/06)		 WORD

 


Carrier Forms
TDI Form Number Description File Format
DWC-20 Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage
(Rev. 10/05)		 PDF
DWC-20A Correction/Revision/Endorsement to Existing Policy
(Rev. 10/05)		 PDF
DWC-20SI Self-Insured Governmental Entity Proof of Coverage
(Rev. 10/06)		 PDF
DWC-21 Payment of Compensation or Notice of Refused or Disputed Claim Interim
(Rev. 10/05)		 PDF
DWC-22 Required Medical Examination Notice or Request for Order
(Rev. 10/05)		 PDF
DWC-24 Benefit Dispute Agreement cover sheet
(Rev. 10/05)		 PDF
DWC-25 Benefit Dispute Settlement
(Rev. 10/05)		 PDF
DWC-27 Carrier Representative Information Submission Form
(Rev. 10/05)		 PDF
DWC-31 Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits
(Rev. 10/05)		 PDF
DWC-32 Request for Designated Doctor
(Rev. 1/07)		 PDF
DWC-32 Request for Designated Doctor
(Rev. 1/07)		 WORD
DWC-32S Solicitud Para Obtener Un Médico Designado
(Rev. 1/07)		 PDF
DWC-32S Solicitud Para Obtener Un Médico Designado
(Rev. 1/07) 		WORD
DWC-33 Carrier's Request for Reduction of Income Benefits Due to Contribution
(Rev. 10/05)		 PDF
DWC-35 Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits
(Rev. 10/05)		 PDF

 


Plain Language Notices
TDI Form Number Description File Format
PLN1 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05)		 WORD
PLN1 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05)		 PDF
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05)		 WORD
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05)		 PDF
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05)		 PDF
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05)		 WORD
PLN2 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDF
PLN2 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORD
PLN3 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 10/05)		 WORD
PLN3 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 10/05)		 PDF
PLN4 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDF
PLN4 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORD
PLN5 Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDF
PLN5 Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORD
PLN6 Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 10/05)		 WORD
PLN6 Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 10/05)		 PDF
PLN7 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05)		 PDF
PLN7 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05)		 WORD
PLN8 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 10/05)		 WORD
PLN8 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 10/05)		 PDF
PLN9 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 10/05)		 PDF
PLN9 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 10/05)		 WORD

 


Employee Forms
TDI Form Number Description File Format
DWC-41 Employee's Notice of Injury or Occupational Disease and Claim for Compensation
(Rev. 10/05)		 PDF
DWC-41A Form DWC-41, Supplement A - Beneficiary's Claim for Compensation
(Rev. 10/05)		 PDF
DWC-41AS Formulario DWC-41s, Suplemento A - Reclamo de Compensación Beneficiario
(Rev. 10/05)		 PDF
DWC-41S Notificación del Trabajador Lesionado o Afectado por Enfermedad de Trabajo y Reclamo de Compensación
(Rev. 10/05)		 PDF
DWC-44 Election to Engage in Arbitration
(Rev. 10/05)		 PDF
DWC-45 Request for a Benefit Review Conference Interim
(Rev. 10/05)		 PDF
DWC-46 Employee's Request for Acceleration of Impairment Income Benefits
(Rev. 10/05)		 PDF
DWC-46S Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal
(Rev. 10/05) 		PDF
DWC-47 Employee's Request for Payment of Advanced Compensation
(Rev. 10/05)		 PDF
DWC-47S Solicitud del Trabajador Lesionado Acerca de Pagos Adelantados de Compensación
(Rev. 10/05)		 PDF
DWC-48 Request for Travel Reimbursement / Solicitud de Reembolso
(Rev. 06/06)		 PDF
DWC-49 Request for Prospective Review of Medical Care Not Requiring Preauthorization
(Rev. 10/05)		 PDF
DWC-51 Employee's Election for Commuted (Lump Sum) Impairment Income Benefits
(Rev. 10/05)		 PDF
DWC-52 Application for Supplemental Income Benefits
(Rev. 10/05)		 PDF
DWC-52S Aplicación del trabajador para beneficios de ingresos suplementales
(Rev. 10/05)		 PDF
DWC-53 Employee's Request To Change Treating Doctors
(Rev. 10/05)		 PDF
DWC-53S Solicitud del Trabajador para Cambiar de Médico Tratante
(Rev. 10/05)		 PDF
DWC-54 Notice to Employee: Intention to Request Division Permission to Adjust Benefits
(Rev. 10/05)		 PDF
DWC-54S Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
(Rev. 10/05)		 PDF
DWC-55 Request to Adjust Average Weekly Wage for Seasonal Employee
(Rev. 10/05)		 PDF
DWC-55S Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
(Rev. 10/05)		 PDF
DWC-56 Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
(Rev. 10/05)		 PDF
DWC-57 Request for Extension of Maximum Medical Improvement for Spinal Surgery
(Rev. 10/05)		 PDF
DWC-58 Request for Interlocutory Order
(Rev. 08/06)		 PDF

 


Medical Forms
TDI Form Number Description File Format
DWC-60 Medical Dispute Resolution Request / Response
(Rev. 01/07) - Table of Disputed Services		 PDF
DWC-62 Explanation of Benefits
(Rev. 10/05)		 PDF
DWC-65 Private Providers of Vocational Rehabilitation Services
(Rev. 11/06)		 WORD
DWC-66 Statement of Pharmacy Services
(Rev. 10/05)		 PDF
DWC-67 Instructions for Completing the CMS- 1500
(Rev. 10/05) - The CMS-1500 can be obtained from the CMS website - http://www.cms.hhs.gov/		 PDF
DWC-68 Instructions for Completing the UB - 92
(Rev. 10/05) - The UB-92 (HCFA-1450) can be obtained from the CMS website - http://www.cms.hhs.gov/		 PDF
DWC-69 Report of Medical Evaluation
Sample Notice for Health Care Provider		 PDF
DWC-70 Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
(Rev. 10/05)		 PDF
DWC-73 Work Status Report and Instructions
(Rev. 10/05)		 PDF
DWC-75 Non-ADL Doctor Request for Case-By-Case Exception
(Rev. 10/05)		 PDF

 


Agreement Forms
TDI Form Number Description File Format
DWC-81 Agreement Between General Contractor and Sub-Contractor to Provide Worker's Compensation Insurance
(Rev. 10/05)		 PDF
DWC-82 Agreement for Motor Carriers and Owner Operators
(Rev. 10/05)		 PDF
DWC-83 Agreement for Certain Building and Construction Workers
(Rev. 10/05)		 PDF
DWC-83S Acuerdo para Ciertos Trabajadores de Edificación y Construcción
(Rev. 09/06)		 PDF
DWC-84 Exception to Application of Joint Agreement for Certain Building and Construction Workers
(Rev. 10/05)		 PDF
DWC-85 Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
(Rev. 10/05)		 PDF
DWC-85S Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente
 PDF

 


Health & Safety Forms
TDI Form Number Description File Format
DWC-101 Accident Prevention Plan Cover Sheet
(Rev. 08/06)		 WORD
DWC-101 Program Review Report
(Rev. 08/06)		 PDF
DWC-102 Accident Prevention Plan Cover Sheet
(Rev. 08/06)		 PDF
DWC-102 Accident Prevention Plan Cover Sheet
(Rev. 08/06)		 WORD
DWC-103 Approved Professional Source Safety Consultant Application
(Rev. 12/06)		 WORD
DWC-104 Employer Request for DWC Safety Consultation
(Rev. 08/06)		 PDF
DWC-104 Employer Request for DWC Safety Consultation
(Rev. 08/06)		 PDF
DWC-105 Accident Prevention Services Worksheet
(Rev. 10/05)		 WORD
DWC-105 Accident Prevention Services Worksheet
(Rev. 10/05)		 PDF
DWC-109 Accident Prevention Services Annual Report
(Rev. 12/05)		 PDF
DWC-109 Accident Prevention Services Annual Report
(Rev. 12/05)		 PDF

 


Other Business Forms
TDI Form Number Description File Format
DWC-150 Notice of Representation or Withdrawal of Representation
(Rev. 10/05)		 PDF
DWC-151 Attorney Application for Web Access
(Rev. 10/05)		 PDF
DWC-152 Application for Attorney's Fees
(Rev. 10/05) - Page 2		 PDF
DWC-152 Application for Attorney's Fees
(Rev. 10/05) - Page 1		 PDF
DWC-152 Application for Attorney's Fees
(Rev. 10/05) - Cover		 PDF
DWC-152 Application for Attorney's Fees
(Rev. 10/05) - Page 4		 PDF
DWC-152 Application for Attorney's Fees
(Rev. 10/05) - Instructions		 PDF
DWC-152 Application for Attorney's Fees
(Rev. 10/05) - Page 3		 PDF
DWC-153 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		 PDF
DWC-155 Request for Record Check
(Rev. 10/05)		 PDF
DWC-156 Prospective Employment Authorization and Certification
(Rev. 10/05)		 PDF
DWC-156S Certificación Y Autorización De Un Posible Empleo
(Rev. 10/06)		 PDF
DWC-205 Locations of Employers' Business(es)
(Rev. 10/05)		 PDF

 


Self-Insurance Regulation Forms
TDI Form Number Description File Format
DWC-210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 WORD
DWC-210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 PDF
DWC-215 Surety Bond Amount Rider
(Rev. 1/06)		 WORD
DWC-215 Surety Bond Amount Rider
(Rev. 1/06)		 PDF
DWC-216 Surety Bond Name Change Rider
(Rev. 1/06)		 WORD
DWC-216 Surety Bond Name Change Rider
(Rev. 1/06)		 PDF
DWC-223 Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORD
DWC-223 Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 PDF
DWC-224 Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07)		 WORD
DWC-224 Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07)		 PDF
DWC-225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 PDF
DWC-225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORD
DWC-226 Parental Guaranty
(Rev. 01/07)		 WORD
DWC-226 Parental Guaranty
(Rev. 01/07)		 PDF
DWC-227 Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07)		 WORD
DWC-227 Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07)		 PDF
DWC-228 Power of Attorney
(Rev. 01/07)		 PDF
DWC-228 Power of Attorney
(Rev. 01/07)		 WORD

 


Self-Insurance Regulation Coverage Packages
Employers in the State of Texas who become certified self-insurers are required to post notices to their employees. Below you will find the required notice packages, which contain the forms and notices you will need.
TDI Form Number Description File Format
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 WORD
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 PDF
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 PDF
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 WORD
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 PDF
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 WORD

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

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