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Workers' compensation carrier forms

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TDI Form Number Description File Format Language
DWC020A Correction/Revision/Endorsement to Existing Policy
Rev. 10/05 		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, for use on or after 6/5/2023 		PDF English
DWC032S Solicitud para obtener un examen por parte de un médico designado
Rev. 06/23, para usar a partir del 5 de junio de 2023 		PDF Spanish
DWC033 Request to reduce income benefits due to contribution
Rev. 05/22 		PDF English
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
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
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
DWC074 Description of Injured Employee’s Employment
Rev. 9/09 		PDF English
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
DWC105 Accident prevention services worksheet
Rev. 11/21 		PDF English
DWC105 Accident prevention services worksheet
Rev. 11/21 		WORD English
DWC109 Accident prevention services annual report
Rev. 11/21 		PDF English
DWC109 Accident prevention services annual report
Rev. 11/21 		WORD English
DWC121 Claim Administration Contact Information
Rev. 3/20 		PDF English
DWC154 Workers' Compensation Complaint Form
Rev. 03/16 		PDF English
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

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