Numeric Listing of Workers' Compensation Forms. Division of Workers Compensation Main Forms page Electronic Filing: Forms available for electronic filing are indicated by . See Electronic Filing - Online Forms for more information about filing your PDF form online. This form is submitted by the carrier to DWC. PDFEnglish. DWC0. Employer's Report for Reimbursement of Voluntary Payment. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 03. Employer's Wage Statement. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 03. MEEmployee's Multiple Employment Wage Statement. Withdraw from partnership with a Notice of Withdrawal from Partnership form. Easily create, print or download in minutes. All states available. An independent school in Yiewsley. Includes a message from the principal, virtual tour, curriculum details, and information on admissions and vacancies.
Rev. 0. 4/1. 6. PDFEnglish. DWC0. 03. MESDeclaraci. PDFSpanish. DWC0. SDeclaraci. 1. 0/0. PDFSpanish. DWC0. SDEmployer's Wage Statement for School Districts. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 03. SDSDeclaraci. PDFSpanish. DWC0. Employer's Contest of Compensability. Rev. 1. 1/0. 8. PDFEnglish. DWC0. 05. Employer Notice of No Coverage or Termination of Coverage. Rev. 0. 1/1. 3 - For help and an instructional video see “Electronic Filing - Online Forms” above. PDFEnglish. DWC0. Supplemental Report of Injury. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 07. Employer’s Report of Non- covered Employee’s Occupational Injury or Disease. Rev. 0. 1/1. 3. PDFEnglish. DWC0. 08. Return- to- Work Reimbursement Program for Employers. Rev. 0. 4/1. 0. WORDEnglish. DWC0. 08. Return- to- Work Reimbursement Program for Employers. Rev. 0. 4/1. 0. PDFEnglish. DWC0. 20. Insurance Carrier's Notice of Coverage/Cancellation/Non- Renewal of Coverage. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 20. ACorrection/Revision/Endorsement to Existing Policy. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 20. SISelf- Insured Governmental Entity Coverage Information. Rev. 0. 8/1. 2 - Using Google Chrome or Mozilla Firefox to file electronically? PDFEnglish. DWC0. SExamen M. 0. 3/1. PDFEnglish. DWC0. Acuerdo para Disputa de Beneficios. Rev. 0. 3/1. 7. PDFSpanish. DWC0. 25. Benefit Dispute Settlement. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 25s. Acuerdo por Disputa de Beneficios. Rev. 0. 2/1. 7. PDFSpanish. DWC0. 26. Request for Reimbursement of Payment Made by Health Care Insurer. Rev. 0. 1/1. 5. PDFEnglish. DWC0. 27. Designation of Insurance Carrier’s Austin Representative. Rev. 1. 2/1. 1. PDFEnglish. DWC0. 30. Austin Representative’s Authorized Designees. Rev. 1. 2/1. 1. PDFEnglish. DWC0. 31. Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 31s. Solicitud para Obtener Aprobaci. PDFSpanish. DWC0. Request for Designated Doctor Examination. Rev. 1/1. 3. PDFEnglish. DWC0. 32. SSolicitud para Obtener un Examen por Parte de un M. PDFSpanish. DWC0. Carrier's Request for Reduction of Income Benefits Due to Contribution. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 35. Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 41. Employee's Claim for Compensation for a Work- Related Injury or Occupational Disease. Rev. 3/0. 7. PDFEnglish. DWC0. 41. Employee's Claim for Compensation for a Work- Related Injury or Occupational Disease. Rev. 3/0. 7. WORDEnglish. DWC0. 41. SReclamo del Empleado para Compensaci. PDFSpanish. DWC0. SReclamo del Empleado para Compensaci. WORDSpanish. DWC0. Claim for Workers’ Compensation Death Benefits. Rev. 0. 3/1. 6. WORDEnglish. DWC0. 42. Claim for Workers’ Compensation Death Benefits. Rev. 0. 3/1. 6. PDFEnglish. DWC0. 42. SReclamaci. WORDSpanish. DWC0. SReclamaci. 3/1. 6. PDFSpanish. DWC0. Election to Engage in Arbitration. Rev. 0. 6/1. 2. PDFEnglish. DWC0. 44. SElecci. PDFSpanish. DWC0. Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)Rev. PDFEnglish. DWC0. ARequest for a Medical Contested Case or SOAH Hearing. Rev. 0. 9/0. 7, applicable only to medical disputes that were filed prior to June 1, 2. PDFEnglish. DWC0. ASSolicitud para una Audiencia para Disputar Beneficios M. PDFSpanish. DWC0. MRequest to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC- MFD)Rev. PDFEnglish. DWC0. MSSolicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisi. PDFSpanish. DWC0. Employee's Request for Acceleration of Impairment Income Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 46. SSolicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal. Rev. 0. 2/1. 7. PDFSpanish. DWC0. 47. Employee’s Request for Advance of Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 47. SSolicitud del Empleado para Obtener Beneficios por Adelantado. Rev. 0. 2/1. 7. PDFSpanish. DWC0. 48. Request to Get Reimbursed for Travel Costs. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 48. SSolicitud para Obtener un Reembolso por Gastos de Viaje. Rev. 0. 2/1. 7. PDFSpanish. DWC0. 49. Request to Schedule a Medical Contested Case Hearing (MCCH)Rev. PDFEnglish. DWC0. SSolicitud para Programar una Audiencia para Disputar Beneficios M. PDFSpanish. DWC0. Employee's Election for Commuted (Lump Sum) Impairment Income Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 51. SElecci. PDFSpanish. DWC0. Application for Supplemental Income Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 52. SAplicaci. PDFSpanish. DWC0. Employee Request to Change Treating Doctor. Rev. 0. 3/1. 2. PDFEnglish. DWC0. 53. SSolicitud del Empleado para Cambiar de M. PDFSpanish. DWC0. Notice to Employee: Intention to Request Division Permission to Adjust Benefits. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 54. SAviso al/a la Empleado/a: Intencion de Solicitar permiso a la Divisi. PDFSpanish. DWC0. Request to Adjust Average Weekly Wage for Seasonal Employee. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 55. SSolicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada. Rev. 0. 2/1. 7. PDFSpanish. DWC0. 56. Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 57. Request for Extension of Maximum Medical Improvement Date for Spinal Surgery. Rev. 0. 2/1. 7. PDFEnglish. DWC0. 57. SSolicitud para Extensi. PDFSpanish. DWC0. Request for Interlocutory Order. Rev. 0. 9/0. 7. PDFEnglish. DWC0. 60. Medical Fee Dispute Resolution Request. Rev. 0. 6/1. 2. PDFEnglish. DWC0. 60. SSolicitud para Resoluci. PDFSpanish. DWC0. Medical Interlocutory Order Request - Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI- DWC’s Closed Formulary. Rev. 8/1. 1. PDFEnglish. DWC0. 65. Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services. Rev. 1/1. 1. PDFEnglish. DWC0. 66. Statement of Pharmacy Services. Rev. 1. 2/1. 1. PDFEnglish. DWC0. 67. Designated Doctor Certification Application Rev. PDFEnglish. DWC0. Designated Doctor Examination Data Report. Rev. 2/1. 7. PDFEnglish. DWC0. 69. Report of Medical Evaluation. Rev. 1/1. 5 (for use on or after 1/1/1. PDFEnglish. DWC0. Instructions For Completing The ADA J5. Dental Claim Form For Texas Workers' Compensation Claims. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 72. Medical Quality Review Panel Application. Rev. 0. 1/1. 3. PDFEnglish. DWC0. 73. Work Status Report. Rev. 0. 2/1. 1. PDFEnglish. DWC0. 74. Description of Injured Employee’s Employment. Rev. 9/0. 9. PDFEnglish. DWC0. 81. Agreement Between General Contractor and Sub- Contractor to Provide Worker's Compensation Insurance. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 81. SAcuerdo Entre el Contratista General y el Sub Contratista. Rev. 0. 9/0. 7. PDFSpanish. DWC0. 82. Agreement for Motor Carriers and Owner Operators. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 83. Agreement for Certain Building and Construction Workers. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 83. SAcuerdo para Ciertos Trabajadores de Edificaci. PDFSpanish. DWC0. Exception to Application of Joint Agreement for Certain Building and Construction Workers. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 85. Agreement Between General Contractor and Subcontractor to Establish Independent Relationship. Rev. 1. 0/0. 5. PDFEnglish. DWC0. 85. SAcuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relaci. PDFSpanish. DWC1. Program Review Report. Rev. 0. 8/0. 6. WORDEnglish. DWC1. 01. Program Review Report. Rev. 0. 8/0. 6. PDFEnglish. DWC1. 02. Accident Prevention Plan Cover Sheet. Rev. 0. 8/0. 6. WORDEnglish. DWC1. 02. Accident Prevention Plan Cover Sheet. Rev. 0. 8/0. 6. PDFEnglish. DWC1. 03. Approved Professional Source Safety Consultant Application. Rev. 1. 2/0. 6 - Note: The Approved Professional Source designation applies only to Loss Control Representatives of Texas Mutual Insurance Company as of September 1, 2. WORDEnglish. DWC1. Employer Request for DWC Safety Consultation. Rev. 0. 8/0. 6. PDFEnglish. DWC1. 05. Accident Prevention Services Worksheet. Rev. 1. 0/1. 3. WORDEnglish. DWC1. 05. Accident Prevention Services Worksheet. Rev. 1. 0/1. 3. PDFEnglish. DWC1. 09. Accident Prevention Services Annual Report. Rev. 1. 0/1. 3. WORDEnglish. DWC1. 09. Accident Prevention Services Annual Report. Rev. 1. 0/1. 3. PDFEnglish. DWC1. 50. Notice of Representation. Rev. 1. 2/1. 6. PDFEnglish. DWC1. 50. ANotice of Withdrawal of Representation. Rev. 1. 2/1. 6. PDFEnglish. DWC1. 50. ASAviso de Anulaci. PDFSpanish. DWC1. SAviso de Representaci. PDFSpanish. DWC1. Attorney Application for Web Access. Rev. 1. 2/1. 6. PDFEnglish. DWC1. 52. Application for Attorney Fees. Rev. 1. 2/1. 6. PDFEnglish. DWC1. 53. Request for Copies of Confidential Claimant Information. Rev. 1. 0/0. 6. PDFEnglish. DWC1. 53s. Solicitud para Obtener Copias de la Informaci. PDFEnglish. DWC1. Workers' Compensation Complaint Form. Rev. 0. 3/1. 6. PDFEnglish. DWC1. 54. SQuejas de Compensaci. PDFSpanish. DWC1. Request for Record Check. Rev. 1. 0/0. 5. PDFEnglish. DWC1. 56. Prospective Employment Authorization and Certification. Rev. 1. 0/0. 5. PDFEnglish. DWC1. 56. SCertificaci. PDFSpanish. DWC2. Locations of Employer’s Business(es)Addendum to DWC Form- 0. DWC Form- 0. 20 - Rev. PDFEnglish. DWC2. SLocaciones del Negocio(s) del Empleador. Suplemento para el Formulario DWC0. Formulario DWC0. 20 - Rev. PDFSpanish. DWC2. Surety Bond for Certified Self- Insurance Liabilities. Rev. 1/0. 6. WORDEnglish. DWC2. 10. Surety Bond for Certified Self- Insurance Liabilities.
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