Numeric listing of workers' compensation forms

Division of Workers Compensation main forms page

Electronic filing: See Electronic filing - online forms for more information about filing your PDF form online. See Electronic filing – XML format for more information about files with multiple submissions.

Numeric listing of workers' compensation forms
TDI form number	Description	Format	Language
DWC001	Employer's First Report of Injury or Illness Rev. 10/05. 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. 02/17	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. 10/05	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	Self-Insured Governmental Entity Coverage Information Rev. 08/12 - For help and an instructional video see “Electronic Filing - Online Forms” page.	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