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Workers' compensation employer forms and notices

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TDI form number Description Format Language
DWC001 Employer’s first report of injury or illness
Rev. 10/24. This form is submitted by the carrier to DWC. 		PDF English
DWC001S Employer’s first report of injury or illness (for state employees)
Rev. 01/25 		PDF English
DWC002 Employer’s report for reimbursement of voluntary payment
Rev. 10/24 		PDF English
DWC003 Employer’s wage statement
Rev. 10/22 		PDF English
DWC003ME Employee’s multiple employment wage statement
Rev. 05/23 		PDF English
DWC003MES Declaración de salario de múltiples trabajos del empleado
Rev. 05/23 		PDF Spanish
DWC003S Declaración de salarios del empleador
Rev. 10/22 		PDF Spanish
DWC003SD Employer’s wage statement for school districts
Rev. 07/22 		PDF English
DWC003SDS Declaración de salario del empleador para distritos escolares
Rev. 07/22 		PDF Spanish
DWC004 Employer's Contest of Compensability
Rev. 11/08 		PDF English
DWC005 Non-subscriber notice to Division of Workers’ Compensation
Rev. 01/25 - static version for mailing and faxing 		PDF English
DWC005S Notificación de empleador no suscriptor a la División de Compensación para Trabajadores
Rev. 01/25 		PDF Spanish
DWC006 Supplemental report of injury
Rev. 10/24 		PDF English
DWC007 Employer’s report of noncovered employee’s work-related injury or illness
Rev. 01/25 		PDF English
DWC007S Reporte del empleador para lesiones o enfermedades relacionadas con el trabajo de los empleados sin cobertura
Rev. 01/25 		PDF Spanish
DWC008 Return-to-Work Reimbursement Program for Employers
Rev. 04/10 		PDF English
DWC020SI Governmental entity coverage information
Rev. 08/24 		PDF English
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
DWC074 Description of Injured Employee’s Employment
Rev. 9/09 		PDF English
DWC154 Workers' Compensation Complaint Form
Rev. 03/16 		PDF English
DWC154S Quejas de Compensación para Trabajadores
Rev. 03/16 		PDF Spanish
DWC156 Prospective employment authorization and certification
Rev. 08/21 		PDF English
DWC156S Certificación y autorización de un posible empleo
Rev. 08/21 		PDF Spanish
DWC205 Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10 		PDF English
DWC205S Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10 		PDF Spanish
New Employee Notice Vietnamese New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing 		PDF Vietnamese
New Employee Notice English New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing 		PDF English
New Employee Notice Spanish New Employee Notice
Covered and non-covered employers shall notify their employees of coverage status in writing. 		PDF Spanish
Notice 5 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF English
Notice 5 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Spanish
Notice 5 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Vietnamese
Notice 6 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF English
Notice 6 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Spanish
Notice 6 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Vietnamese
Notice 7 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF English
Notice 7 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Spanish
Notice 7 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Vietnamese
Notice 8 English Required Workers’ Compensation Coverage
(building or construction projects for governmental entities) 		PDF English
Notice 8 Spanish Required Workers’ Compensation Coverage
(building or construction projects for governmental entities) 		PDF Spanish
Notice 9 English Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers) 		PDF English
Notice 9 Spanish Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers) 		PDF Spanish
Notice 10 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF English
Notice 10 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Spanish
Notice 10 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read 		PDF Vietnamese

For more information, contact: WebStaff@tdi.texas.gov