Form DWC83 "Agreement for Certain Building and Construction Workers" - Texas

What Is DWC Form 83?

DWC Form 83, Agreement for Certain Building and Construction Workers, is a Texas State form used for residential and small commercial construction contractors to establish the obligations between a hiring contractor and the independent contractor being hired in regards to workers' compensation insurance. This document is only applicable to the following construction contractor work: residential structures (including single-family, duplex, triplex, and four-plex dwellings), commercial structures including more than four-family properties, but not in excess of three stories or 20,000 sq. ft., and any appurtenance related to these buildings.

This document must be executed before the hiring contractor's related work is to start. This agreement will be in place for one year from the filing date and is applicable to all work between the hiring contractor and independent contractor. A new filing must be submitted at the end of each year. The DWC and the insurance agent must be given notice, using Form DWC-84, if any subsequent work between these parties is to follow any different agreement.

This Texas DWC Form 83 is issued by the Texas Department of Insurance, Division of Workers' Compensation and the latest form was issued on April 1, 2018. A printable DWC Form 83 version is available for download below.

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How to Fill Out DWC Form 83?

Follow these DWC Form 83 instructions below. Four entities will retain this completed form for their records, with original to be filed with the state of Texas. More details below.

  1. Check only one of the two boxes at the top of the page:
    • The box to the left affirms the agreement of an independent relationship, in which the independent contractor and it's employers are not entitled to worker's compensation coverage by the hiring contractor, and hiring contractor insurance carrier shall not require insurance premiums be paid by the hiring contractor for the independent contractor.
    • The box to the right establishes the agreement that the hiring contractor will purchase workers' compensation insurance for the independent contractor and its employees. Below this box, also check the applicable box whether the hiring contractor will withhold or not the insurance coverage cost from the independent contractor's contract price. Also complete on applicable spaces the term (dates) of agreement, location of each affected job site (or state this is a blanket agreement), and the estimated number of employees affected.
  2. Enter in the applicable spaces the hiring contractor's federal tax ID number and address. Print and sign the hiring contractor's name and enter the date.
  3. Enter in the applicable spaces the independent contractor's federal tax ID number, address. Print and sign the hiring contractor's name and enter the date.
  4. Hiring a contractor to file this completed form, within 10 days of the date of execution, and send it to both the Texas Department of Insurance, Division of Workers' Compensation (the original), and the hiring contractor's workers' compensation insurance carrier. These filings are to be sent by personal delivery or registered certified mail. Both the hiring contractor and independent contractor must also retain a copy.
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Download Form DWC83 "Agreement for Certain Building and Construction Workers" - Texas

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TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION (TDI-DWC)
7551 Metro Center Drive, Suite 100
Austin, Texas 78744
DO NOT SEND THIS AGREEMENT TO TDI-DWC
If you are not certain whether all parties meet the requirements for entering into this agreement, you may wish to consult an attorney.
Texas Workers' Compensation Act, Texas Labor Code, Section 406.141(2) defines "independent contractor" as follows: (2) "Independent contractor" means a person who contracts to perform work or
provide a service for the benefit of another and who: (A) is paid by the job, not by the hour or some other time-measured basis; (B) is free to hire as many helpers as he desires and to determine what each
helper will be paid; and (C) is free to work for other contractors, or to send helpers to work for other contractors, while under contract to the hiring employer.
CHECK
BOX OF STATEMENT THAT APPLIES
JOINT AGREEMENT TO AFFIRM INDEPENDENT
AGREEMENT TO ESTABLISH EMPLOYER-
RELATIONSHIP FOR CERTAIN BUILDING
EMPLOYEE RELATIONSHIP FOR CERTAIN
AND CONSTRUCTION WORKERS
BUILDING AND CONSTRUCTION WORKERS
Notice of Declaration
Notice of Agreement
The undersigned Hiring Contractor and the undersigned Independent Contractor hereby agree
The undersigned Hiring Contractor and the undersigned Independent Contractor
that the Hiring Contractor
will withhold
will not withhold the cost of workers'
hereby declare that the Independent Contractor meets the qualifications of an
compensation insurance coverage from the Independent Contractor's contract price and that the
Independent Contractor under Texas Workers' Compensation Act, Texas Labor
Hiring Contractor will purchase workers' compensation insurance coverage for the Independent
Code, Section 406.141, that the Independent Contractor is not an employee of the
Contractor and the Independent Contractor's employees. Once this agreement is signed, for the
Hiring Contractor, and that:
purpose of providing workers' compensation insurance coverage, the Hiring Contractor will be
the employer of the Independent Contractor and the Independent Contractor's employees. This
(A) the Independent Contractor and the Independent Contractor's employees
agreement makes the Hiring Contractor the employer of the Independent Contractor and the
shall not be entitled to workers' compensation coverage from the Hiring
Independent Contractor's employees only for the purposes of workers' compensation laws of
Texas and for no other purpose.
Contractor; and
(B) the Hiring Contractor's workers' compensation insurance carrier shall not
TERM (DATES) OF AGREEMENT:
FROM: _____________________
require premiums to be paid by the Hiring Contractor for coverage of the
Independent Contractor or the Independent Contractor's employees,
TO: ________________________
helpers, or subcontractors.
__________________________________________________________________
LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS
THIS AGREEMENT APPLIES TO ALL HIRING AGREEMENTS EXECUTED BY THE
IS A BLANKET AGREEMENT):
HIRING CONTRACTOR AND THE INDEPENDENT CONTRACTOR UNTIL THE FIRST
ANNIVERSARY OF THE DATE THE AGREEMENT WAS FILED WITH THE HIRING
_________________________________________________________________
CONTRACTOR’S WORKERS’ COMPENSATION INSURANCE CARRIER, UNLESS A
SUBSEQUENT HIRING AGREEMENT EXPRESSLY STATES THE AGREEMENT DOES
__________________________________________________________________
NOT APPLY. IN THE EVENT THAT A HIRING AGREEMENT TO WHICH THIS
AGREEMENT DOES NOT APPLY IS MADE, THE HIRING CONTRACTOR AND
___________________________________________________________________
INDEPENDENT CONTRACTOR SHALL SO NOTIFY THE TEXAS DEPARTMENT OF
INSURANCE, DIVISION OF WORKERS' COMPENSATION AND THE HIRING
ESTIMATED NUMBER OF EMPLOYEES AFFECTED: _________________
CONTRACTOR'S WORKERS' COMPENSATION INSURANCE CARRIER (IF ANY) IN
WRITING WITHIN 10 DAYS AFTER THE NON-APPLYING AGREEMENT IS MADE.
ONCE THIS AGREEMENT IS SIGNED, THE SUBCONTRACTOR AND THE
THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE
SUBCONTRACTOR'S EMPLOYEES SHALL NOT BE ENTITLED TO WORKERS'
IT IS SIGNED.
COMPENSATION COVERAGE FROM THE HIRING CONTRACTOR UNLESS A
SUBSEQUENT WRITTEN AGREEMENT IS EXECUTED, AND FILED ACCORDING TO
DIVISION RULES, EXPRESSLY STATING THAT THIS AGREEMENT DOES NOT
APPLY.
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.145.
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.144.
Hiring Contractor's Affirmation
If the Hiring Contractor's workers' compensation carrier changes
during the effective period of coverage, it is advisable for the Hiring Contractor
__________________________________
to file this form with the new insurance carrier.
Federal Tax I.D. Number
______________________________________________
______________________
________________________________________________________________
Signature of Hiring Contractor
Date
Address (Street)
________________________________________________________________________
________________________________________________________________
Printed Name of the Hiring Contractor
Address (City, State, Zip)
Independent Contractor's Affirmation
____________________________
Federal Tax I.D. Number
______________________________________________
______________________
________________________________________________________________
Signature of Independent Contractor
Date
Address (Street)
________________________________________________________________________
________________________________________________________________
Printed Name of the Independent Contractor
Address (City, State, Zip)
The Hiring Contractor must retain the original. A legible copy of this agreement must be filed with the hiring contractor’s workers’ compensation insurance carrier within 10
days of the date of execution. An agreement is not considered filed if it is illegible or incomplete. The Independent Contractor should also retain a copy of the agreement.
DWC FORM-83 Rev. 04/18
DIVISION OF WORKERS’ COMPENSATION
TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION (TDI-DWC)
7551 Metro Center Drive, Suite 100
Austin, Texas 78744
DO NOT SEND THIS AGREEMENT TO TDI-DWC
If you are not certain whether all parties meet the requirements for entering into this agreement, you may wish to consult an attorney.
Texas Workers' Compensation Act, Texas Labor Code, Section 406.141(2) defines "independent contractor" as follows: (2) "Independent contractor" means a person who contracts to perform work or
provide a service for the benefit of another and who: (A) is paid by the job, not by the hour or some other time-measured basis; (B) is free to hire as many helpers as he desires and to determine what each
helper will be paid; and (C) is free to work for other contractors, or to send helpers to work for other contractors, while under contract to the hiring employer.
CHECK
BOX OF STATEMENT THAT APPLIES
JOINT AGREEMENT TO AFFIRM INDEPENDENT
AGREEMENT TO ESTABLISH EMPLOYER-
RELATIONSHIP FOR CERTAIN BUILDING
EMPLOYEE RELATIONSHIP FOR CERTAIN
AND CONSTRUCTION WORKERS
BUILDING AND CONSTRUCTION WORKERS
Notice of Declaration
Notice of Agreement
The undersigned Hiring Contractor and the undersigned Independent Contractor hereby agree
The undersigned Hiring Contractor and the undersigned Independent Contractor
that the Hiring Contractor
will withhold
will not withhold the cost of workers'
hereby declare that the Independent Contractor meets the qualifications of an
compensation insurance coverage from the Independent Contractor's contract price and that the
Independent Contractor under Texas Workers' Compensation Act, Texas Labor
Hiring Contractor will purchase workers' compensation insurance coverage for the Independent
Code, Section 406.141, that the Independent Contractor is not an employee of the
Contractor and the Independent Contractor's employees. Once this agreement is signed, for the
Hiring Contractor, and that:
purpose of providing workers' compensation insurance coverage, the Hiring Contractor will be
the employer of the Independent Contractor and the Independent Contractor's employees. This
(A) the Independent Contractor and the Independent Contractor's employees
agreement makes the Hiring Contractor the employer of the Independent Contractor and the
shall not be entitled to workers' compensation coverage from the Hiring
Independent Contractor's employees only for the purposes of workers' compensation laws of
Texas and for no other purpose.
Contractor; and
(B) the Hiring Contractor's workers' compensation insurance carrier shall not
TERM (DATES) OF AGREEMENT:
FROM: _____________________
require premiums to be paid by the Hiring Contractor for coverage of the
Independent Contractor or the Independent Contractor's employees,
TO: ________________________
helpers, or subcontractors.
__________________________________________________________________
LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS
THIS AGREEMENT APPLIES TO ALL HIRING AGREEMENTS EXECUTED BY THE
IS A BLANKET AGREEMENT):
HIRING CONTRACTOR AND THE INDEPENDENT CONTRACTOR UNTIL THE FIRST
ANNIVERSARY OF THE DATE THE AGREEMENT WAS FILED WITH THE HIRING
_________________________________________________________________
CONTRACTOR’S WORKERS’ COMPENSATION INSURANCE CARRIER, UNLESS A
SUBSEQUENT HIRING AGREEMENT EXPRESSLY STATES THE AGREEMENT DOES
__________________________________________________________________
NOT APPLY. IN THE EVENT THAT A HIRING AGREEMENT TO WHICH THIS
AGREEMENT DOES NOT APPLY IS MADE, THE HIRING CONTRACTOR AND
___________________________________________________________________
INDEPENDENT CONTRACTOR SHALL SO NOTIFY THE TEXAS DEPARTMENT OF
INSURANCE, DIVISION OF WORKERS' COMPENSATION AND THE HIRING
ESTIMATED NUMBER OF EMPLOYEES AFFECTED: _________________
CONTRACTOR'S WORKERS' COMPENSATION INSURANCE CARRIER (IF ANY) IN
WRITING WITHIN 10 DAYS AFTER THE NON-APPLYING AGREEMENT IS MADE.
ONCE THIS AGREEMENT IS SIGNED, THE SUBCONTRACTOR AND THE
THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE
SUBCONTRACTOR'S EMPLOYEES SHALL NOT BE ENTITLED TO WORKERS'
IT IS SIGNED.
COMPENSATION COVERAGE FROM THE HIRING CONTRACTOR UNLESS A
SUBSEQUENT WRITTEN AGREEMENT IS EXECUTED, AND FILED ACCORDING TO
DIVISION RULES, EXPRESSLY STATING THAT THIS AGREEMENT DOES NOT
APPLY.
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.145.
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.144.
Hiring Contractor's Affirmation
If the Hiring Contractor's workers' compensation carrier changes
during the effective period of coverage, it is advisable for the Hiring Contractor
__________________________________
to file this form with the new insurance carrier.
Federal Tax I.D. Number
______________________________________________
______________________
________________________________________________________________
Signature of Hiring Contractor
Date
Address (Street)
________________________________________________________________________
________________________________________________________________
Printed Name of the Hiring Contractor
Address (City, State, Zip)
Independent Contractor's Affirmation
____________________________
Federal Tax I.D. Number
______________________________________________
______________________
________________________________________________________________
Signature of Independent Contractor
Date
Address (Street)
________________________________________________________________________
________________________________________________________________
Printed Name of the Independent Contractor
Address (City, State, Zip)
The Hiring Contractor must retain the original. A legible copy of this agreement must be filed with the hiring contractor’s workers’ compensation insurance carrier within 10
days of the date of execution. An agreement is not considered filed if it is illegible or incomplete. The Independent Contractor should also retain a copy of the agreement.
DWC FORM-83 Rev. 04/18
DIVISION OF WORKERS’ COMPENSATION