Workers' compensation employee forms/Formularios de compensación para trabajadores para el empleado
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TDI Form Number | Description | File Format | Language |
---|---|---|---|
DWC003ME |
Employee’s multiple employment wage statement Rev. 05/23 |
English | |
DWC003MES |
Declaración de salario de múltiples trabajos del empleado Rev. 05/23 |
Spanish | |
DWC024 |
Rev. 11/17 |
English | |
DWC024s |
Acuerdo para Disputa de Beneficios Rev. 11/17 |
Spanish | |
DWC025 |
Rev. 11/17 |
English | |
DWC025s |
Acuerdo por Disputa de Beneficios Rev. 11/17 |
Spanish | |
DWC032 |
Request for designated doctor examination Rev. 6/23, for use on or after 6/5/2023 |
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 |
Spanish | |
DWC041 |
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease Rev. 3/07 |
English | |
DWC041 |
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease Rev. 3/07 |
WORD | English |
DWC041S |
Rev. 3/07 |
Spanish | |
DWC041S |
Rev. 3/07 |
WORD | Spanish |
DWC042 |
Claim for workers’ compensation death benefits Rev. 12/23 |
English | |
DWC042S |
Reclamación para obtener beneficios de compensación para trabajadores por causa de muerte Rev. 12/23 |
Spanish | |
DWC044 |
Election to Engage in Arbitration Rev. 06/12 |
English | |
DWC044S |
Elección para Participar en un Arbitraje Rev. 05/12 |
Spanish | |
DWC045 |
Request to schedule, reschedule, or cancel a benefit review conference (BRC) Rev. 07/21 |
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 |
English | |
DWC045AS |
Rev. 10/07, aplicable solamente para las disputas médicas que fueron presentadas antes del 1º de junio del 2012 |
Spanish | |
DWC045S |
Rev. 07/21 |
Spanish | |
DWC045M |
Rev. 07/21 |
English | |
DWC045MS |
Rev. 07/21 |
Spanish | |
DWC046 |
Request to accelerate impairment income benefits Rev. 08/22 |
English | |
DWC046S |
Solicitud para acelerar los beneficios de ingresos de impedimento Rev. 08/22 |
Spanish | |
DWC047 |
Rev. 08/22 |
English | |
DWC047S |
Solicitud para recibir beneficios por adelantado Rev. 08/22 |
Spanish | |
DWC048 |
Request to get reimbursed for travel costs Rev. 07/21 |
English | |
DWC048S |
Solicitud para obtener un reembolso por gastos de viaje Rev. 07/21 |
Spanish | |
DWC049 |
Request to Schedule a Medical Contested Case Hearing (MCCH) Rev. 11/17 |
English | |
DWC049S |
Rev. 11/17 |
Spanish | |
DWC051 |
Request for a lump sum payment of impairment income benefits (IIBs) Rev. 06/23 |
English | |
DWC051S |
Solicitud para recibir un pago en suma total de los beneficios de ingresos de impedimento Rev. 06/23 |
Spanish | |
DWC052 |
Application for Supplemental Income Benefits Rev. 02/17 |
English | |
DWC052S |
Aplicación del trabajador para beneficios de ingresos suplementales Rev. 02/17 |
Spanish | |
DWC053 |
Employee Request to Change Treating Doctor Rev. 03/12 |
English | |
DWC053S |
Solicitud del Empleado para Cambiar de Médico de Tratamiento Rev. 03/12 |
Spanish | |
DWC054 |
Notice to Employee: Intention to Request Division Permission to Adjust Benefits Rev. 02/17 |
English | |
DWC054S |
Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios Rev. 02/17 |
Spanish | |
DWC055 |
Request to Adjust Average Weekly Wage for Seasonal Employee Rev. 02/17 |
English | |
DWC055S |
Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada Rev. 02/17 |
Spanish | |
DWC056 |
Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records Rev. 02/17 |
English | |
DWC057 |
Request to extend the date of maximum medical improvement for an approved spinal surgery Rev. 06/23 |
English | |
DWC057S |
Rev. 06/23 |
Spanish | |
DWC058 |
Request for Interlocutory Order Rev. 09/07 |
English | |
DWC060 |
Medical Fee Dispute Resolution Request Rev. 02/21 |
English | |
DWC060S |
Solicitud para Resolución de Disputas por Honorarios Médicos Rev. 02/21 |
Spanish | |
DWC154 |
Workers' Compensation Complaint Form Rev. 03/16 |
English | |
DWC154S |
Quejas de Compensación para Trabajadores Rev. 03/16 |
Spanish | |
LHL009 |
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 |
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. |
Spanish | |
Sample Notice |
Notice of Underpayment of Income Benefits Rev. 12/11 |
English | |
Sample Notice |
Aviso de Pago Insuficiente de los Beneficios de Ingresos Rev. 12/11 |
Spanish |
For more information, contact: WebStaff@tdi.texas.gov