Form DWC1S "Employers First Report of Injury or Illness" - Texas

What Is Form DWC1S?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2005;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWC1S by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form DWC1S "Employers First Report of Injury or Illness" - Texas

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Mail this form to:
STATE OFFICE OF RISK MANAGEMENT
P. O. Box 13777
Austin, Texas 78711
CLAIM #
Please read instruction sheet CAREFULLY,
giving special attention to items marked
with an asterisk (*).
SORM CLAIM #
EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS
1. Name (Last, First, M.I.)
2. Sex
15. Date of Injury (m-d-y)
16. Time of Injury
17. Date Lost Time Began
F
M
(m-d-y)
-
-
:
am
pm
-
-
3. Social Security Number
4. Home Phone
5. Date of Birth (m-d-y)
18. Nature of Injury*
19. Part of Body Injured or Exposed*
(
)
-
-
6. Does the Employee Speak English?
If No, Specify Language
20. How and Why Accident/Injury Occurred*
YES
NO
7. Employee Telephone #
21. Was employee
22. Worksite Location of Injury (stairs, dock, etc.)*
8. Block no longer used
doing his/her YES
regular job?
NO
9. Mailing Address
Street or P.O. Box
23. Address Where Injury or Exposure Occurred Name of business if incident
occurred on a business site
City
State
Zip Code
County
Street or P.O. Box
County
10. Marital Status
City
State
Zip Code
Married
Widowed
Separated
Single
Divorced
11. Number of Dependent Children
12. Spouse's Name
24. Cause of Injury (fall, tool, machine, etc.)*
13. Doctor's Name
Telephone #
25. List Witnesses (Name, Telephone #
14. Doctor's Mailing Address (Street or P.O.Box)
26. Return to work
27. Did employee
28. Supervisor's
29. Date Reported
date (m-d-y)
die?
Name
(m-d-y)
City
State
Zip Code
YES
NO
30. Date of Hire (m-d-y)
31. Was employee hired or recruited in Texas?
32. Length of Service in Current Position
33. Length of Service in Occupation
YES
NO
Years
Months ______
Years
Months ______
34. State Payroll Classification Code
35. Occupation of Injured Worker
36. Rate of Pay at this Job
37. Full Work Week is:
38. Last Paycheck was:
39. Is employee an Owner, Partner,
$______ Hourly $
Weekly
or Corporate Officer?
$
Monthly
Hours
Days
$_____________
YES
NO x
40. Name and Title of Person Completing Form
41. Name of Agency
Claims Coordinator
42. Agency Mailing Address and Telephone Number
43. Agency Location Code
Street or P.O. Box
Telephone
______ ______ ______ / _______ ______ _______ / ______ _______ _______
(
)
City
State
Zip Code
Name of Location: ____________________________________________
44. Federal Tax Identification Number
45. Primary North American Industrial Classification System
46. Specific NAICS Code
47. Comptroller Agency Code
Sector Code (NAICS) (2 digits)
48. Workers' Comp
ensation Insurance Company
49. Policy Number
State Office of Risk Management
TXSTATEPOL001
50. Did you request accident prevention services in past 12 months?
52. Number of Hours of Sick/Annual Leave Credted to Employee or Date of Injury
YES
NO
If yes, did you receive them?
YES
NO
51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING)
DWC FORM-1S (Rev. 10/05) Page 1
DIVISION OF WORKERS’ COMPENSATION
Mail this form to:
STATE OFFICE OF RISK MANAGEMENT
P. O. Box 13777
Austin, Texas 78711
CLAIM #
Please read instruction sheet CAREFULLY,
giving special attention to items marked
with an asterisk (*).
SORM CLAIM #
EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS
1. Name (Last, First, M.I.)
2. Sex
15. Date of Injury (m-d-y)
16. Time of Injury
17. Date Lost Time Began
F
M
(m-d-y)
-
-
:
am
pm
-
-
3. Social Security Number
4. Home Phone
5. Date of Birth (m-d-y)
18. Nature of Injury*
19. Part of Body Injured or Exposed*
(
)
-
-
6. Does the Employee Speak English?
If No, Specify Language
20. How and Why Accident/Injury Occurred*
YES
NO
7. Employee Telephone #
21. Was employee
22. Worksite Location of Injury (stairs, dock, etc.)*
8. Block no longer used
doing his/her YES
regular job?
NO
9. Mailing Address
Street or P.O. Box
23. Address Where Injury or Exposure Occurred Name of business if incident
occurred on a business site
City
State
Zip Code
County
Street or P.O. Box
County
10. Marital Status
City
State
Zip Code
Married
Widowed
Separated
Single
Divorced
11. Number of Dependent Children
12. Spouse's Name
24. Cause of Injury (fall, tool, machine, etc.)*
13. Doctor's Name
Telephone #
25. List Witnesses (Name, Telephone #
14. Doctor's Mailing Address (Street or P.O.Box)
26. Return to work
27. Did employee
28. Supervisor's
29. Date Reported
date (m-d-y)
die?
Name
(m-d-y)
City
State
Zip Code
YES
NO
30. Date of Hire (m-d-y)
31. Was employee hired or recruited in Texas?
32. Length of Service in Current Position
33. Length of Service in Occupation
YES
NO
Years
Months ______
Years
Months ______
34. State Payroll Classification Code
35. Occupation of Injured Worker
36. Rate of Pay at this Job
37. Full Work Week is:
38. Last Paycheck was:
39. Is employee an Owner, Partner,
$______ Hourly $
Weekly
or Corporate Officer?
$
Monthly
Hours
Days
$_____________
YES
NO x
40. Name and Title of Person Completing Form
41. Name of Agency
Claims Coordinator
42. Agency Mailing Address and Telephone Number
43. Agency Location Code
Street or P.O. Box
Telephone
______ ______ ______ / _______ ______ _______ / ______ _______ _______
(
)
City
State
Zip Code
Name of Location: ____________________________________________
44. Federal Tax Identification Number
45. Primary North American Industrial Classification System
46. Specific NAICS Code
47. Comptroller Agency Code
Sector Code (NAICS) (2 digits)
48. Workers' Comp
ensation Insurance Company
49. Policy Number
State Office of Risk Management
TXSTATEPOL001
50. Did you request accident prevention services in past 12 months?
52. Number of Hours of Sick/Annual Leave Credted to Employee or Date of Injury
YES
NO
If yes, did you receive them?
YES
NO
51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING)
DWC FORM-1S (Rev. 10/05) Page 1
DIVISION OF WORKERS’ COMPENSATION
DWC FORM-1S Instructions
PLEASE COMPLETE ALL APPLICABLE FIELDS. Most fields are self-explanatory; however, the following items may require
more attention:
Item 4: If no home phone, please give a phone number where the employee can be reached.
Item 7: Employees work phone number.
Item 8: This information is no longer required.
Item 13: This information should include the doctor’s telephone number.
Item 15: This should be the actual date of injury, or (for occupational diseases) the date the employee knew or should have
known the condition was work-related.
Item 17: This should be the first full day of lost-time from work. (Please note that the date of injury is not considered the first day
of lost time.) Mark NLT or N/A if there is no lost time.
Item 18: List the nature of the injury. Examples include: burn, cut, or sprain.
Item 19: List specific body part, which side of body is affected, e.g., chin, right leg, left upper arm, etc. If more than one body
part is affected, list each part.
Item 20: Describe in detail. Use additional sheet of paper if necessary.
Item 24: This should state the specific substance or exposure that directly inflicted the injury such as a tool, chemical (list the
name of the chemical), or machine.
Item 26: The date should be entered even if the employee has returned to work even for a portion of the day. If the employee
has returned to work making less than his or her pre-injury wage, a DWC FORM-6 must also be submitted.
Item 28: This is the employee’s immediate supervisor. Please include a work telephone number.
Item 29: This is the date the employee reported the injury to the employer as work related.
Item 34: This 4-digit code corresponds to the primary occupation in which the employee was engaged at the time of the injury or
exposure. This code is from the state payroll classification table and is available from the State Comptroller of Public Accounts.
Item 43: This 9-digit code represents the location of the agency unit that employed the injured worker at the time of their injury or
exposure. The first three digits will be 100 for state agencies or 200 for county entities. The second three digits are the agency
code. The third three digits are the location code as established by each agency. Contact the SORM’s Risk Assessment and
Loss Prevention section for information about or changes to your agency location code(s).
Item 44: This 9-digit code is assigned to each agency by the Internal Revenue Service for employment, tax, and reporting
purposes.
Item 45: This 2-digit code is assigned to each agency according to its primary business activity. For specific questions regarding
your NAICS code, call your local Texas Workforce Commission (TWC).
Item 46: This is a 3- or 4-digit code for the specific subsector of the business activity of the agency.
Item 47: This is the state agency code number assigned by the State Comptroller of Public Accounts.
Item 51: This must be the signature and title of the claims coordinator. If signed by someone other than the claims coordinator,
he or she must list his or her title and state that it was signed for the claims coordinator. The date must also be included.
Item 52: Enter the number of sick/annual leave hours credited to the employee as of the date of injury.
Distribution:
State Office of Risk Management
Fax a copy or mail the original to:
P.O. Box 13777
State Office of Risk Management
Austin, TX 78711-3777
Mail a copy to the claimant.
Retain a copy for your file.
DWC FORM-1S (Rev. 10/05) Page 2
DIVISION OF WORKERS’ COMPENSATION
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