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Texas Department of Insurance - Division of Workers' Compensation Forms

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Form DWC70 Instructions for Completing the Ada J515 Dental Claim Form for Texas Workers' Compensation Claims - Texas PDF

Form DWC70 Instructions for Completing the Ada J515 Dental Claim Form for Texas Workers' Compensation Claims - Texas
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Form DWC101 Program Review Report for Rejected Risk Employers - Texas PDF

Form DWC101 Program Review Report for Rejected Risk Employers - Texas
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Form DWC105 Accident Prevention Services Worksheet - Texas PDF

Form DWC105 Accident Prevention Services Worksheet - Texas
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Form DWC109 Accident Prevention Services Annual Report - Texas PDF

Form DWC109 Accident Prevention Services Annual Report - Texas
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Form DWC102 Accident Prevention Plan Cover Sheet for Rejected Risk Employer - Texas PDF

Form DWC102 Accident Prevention Plan Cover Sheet for Rejected Risk Employer - Texas
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Form DWC104 Employer Request for DWC Safety Consultation - Texas PDF

Form DWC104 Employer Request for DWC Safety Consultation - Texas
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Form DWC081 Agreement Between General Contractor and Subcontractor to Provide Workers' Compensation Insurance - Texas PDF

Form DWC081 Agreement Between General Contractor and Subcontractor to Provide Workers' Compensation Insurance - Texas
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Form DWC084 Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers - Texas PDF

Form DWC084 Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers - Texas
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Form DWC083 Agreement for Certain Building and Construction Workers - Texas PDF

Form DWC083 Agreement for Certain Building and Construction Workers - Texas
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Form DWC085 Agreement Between General Contractor and Subcontractor to Establish Independent Relationship - Texas PDF

Form DWC085 Agreement Between General Contractor and Subcontractor to Establish Independent Relationship - Texas
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Form DWC156 Prospective Employment Authorization and Certification - Texas PDF

Form DWC156 Prospective Employment Authorization and Certification - Texas
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Form DWC048 Request to Get Reimbursed for Travel Costs - Texas PDF

Form DWC048 Request to Get Reimbursed for Travel Costs - Texas
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Form DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (Brc) - Texas PDF

Form DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (Brc) - Texas
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Form DWC060 Medical Fee Dispute Resolution Request - Texas PDF

Form DWC060 Medical Fee Dispute Resolution Request - Texas
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Form DWC153 Request for Record Check or Copies of Confidential Claim Information - Texas PDF

Form DWC153 Request for Record Check or Copies of Confidential Claim Information - Texas
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Form DWC098 Subsequent Injury Fund Reimbursement Request Form - Pharmaceutical - Texas PDF

Form DWC098 Subsequent Injury Fund Reimbursement Request Form - Pharmaceutical - Texas
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Form DWC097 Subsequent Injury Fund Reimbursement Request Form - Multiple Employment - Texas PDF

Form DWC097 Subsequent Injury Fund Reimbursement Request Form - Multiple Employment - Texas
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Form DWC095 Subsequent Injury Fund Reimbursement Request Form - Overturned Order or Designated Doctor Opinion - Texas PDF

Form DWC095 Subsequent Injury Fund Reimbursement Request Form - Overturned Order or Designated Doctor Opinion - Texas
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Form DWC096 Subsequent Injury Fund Reimbursement Request Form - Refund of Death Benefits - Texas PDF

Form DWC096 Subsequent Injury Fund Reimbursement Request Form - Refund of Death Benefits - Texas
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Form DWC121 Claim Administration Contact Information - Texas PDF

Form DWC121 Claim Administration Contact Information - Texas
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Form DWC032 Request for Designated Doctor Examination - Texas PDF

Form DWC032 Request for Designated Doctor Examination - Texas
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Form DWC005 Employer Notice of No Coverage or Termination of Coverage - Texas PDF

Form DWC005 Employer Notice of No Coverage or Termination of Coverage - Texas
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Form DWC152 Application for Attorney Fees - Texas PDF

Form DWC152 Application for Attorney Fees - Texas
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Form DWC025 Benefit Dispute Settlement - Texas PDF

Form DWC025 Benefit Dispute Settlement - Texas
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Form DWC024 Benefit Dispute Agreement - Texas PDF

Form DWC024 Benefit Dispute Agreement - Texas
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Form DWC002 Employer's Report for Reimbursement of Voluntary Payment - Texas PDF

Form DWC002 Employer's Report for Reimbursement of Voluntary Payment - Texas
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Form DWC057 Request for Extension of Maximum Medical Improvement Date for Spinal Surgery - Texas PDF

Form DWC057 Request for Extension of Maximum Medical Improvement Date for Spinal Surgery - Texas
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Formulario DWC057 Solicitud Para Extension De La Fecha Para Mejoramiento Maximo Medico (Maximum Medical Improvement - Mmi, Por Su Nombre Y Siglas En Inglers) Por Una Cirugia De La Columna Vertebral - Texas (Spanish) PDF

Formulario DWC057 Solicitud Para Extension De La Fecha Para Mejoramiento Maximo Medico (Maximum Medical Improvement - Mmi, Por Su Nombre Y Siglas En Inglers) Por Una Cirugia De La Columna Vertebral - Texas (Spanish)
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Form DWC150 Notice of Representation - Texas PDF

Form DWC150 Notice of Representation - Texas
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Form DWC151 Attorney Application for Web Access - Texas PDF

Form DWC151 Attorney Application for Web Access - Texas
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Form DWC069 Report of Medical Evaluation - Texas PDF

Form DWC069 Report of Medical Evaluation - Texas
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Form DWC026 Request for Reimbursement of Payment Made by Health Care Insurer - Texas PDF

Form DWC026 Request for Reimbursement of Payment Made by Health Care Insurer - Texas
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Form DWC072 Medical Quality Review Panel Application - Texas PDF

Form DWC072 Medical Quality Review Panel Application - Texas
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Form DWC044 Election to Engage in Arbitration - Texas PDF

Form DWC044 Election to Engage in Arbitration - Texas
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Form DWC053 Employee Request to Change Treating Doctor - Texas PDF

Form DWC053 Employee Request to Change Treating Doctor - Texas
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Form DWC030 Austin Representative's Authorized Designees - Texas PDF

Form DWC030 Austin Representative's Authorized Designees - Texas
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Form DWC066 Statement of Pharmacy Services - Texas PDF

Form DWC066 Statement of Pharmacy Services - Texas
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Form DWC064 Medical Interlocutory Order Request - Texas PDF

Form DWC064 Medical Interlocutory Order Request - Texas
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Form DWC205 Locations of Employer's Business(Es) - Texas PDF

Form DWC205 Locations of Employer's Business(Es) - Texas
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Form DWC008 Return-To-Work Reimbursement Program for Employers - Texas PDF

Form DWC008 Return-To-Work Reimbursement Program for Employers - Texas
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