Texas Mutual Insurance Company - Providers of Workers' Comp Insurance

Forms & Sample Documents

Click on the links below to open a copy of the form or sample document. If you have any problem printing the forms, check our tips for downloading and printing forms.

REMEMBER: You may report an injury and submit an Employer's Wage Statement online.

The Office of Injured Employee Counsel adopted a rule that requires employers to post the employee notice of ombudsman services in their workplace.

Form Format
Bona Fide Offer of Employment Letter (Sample, English) DOC PDF
Bona Fide Offer of Employment Letter (Sample, Spanish) DOC PDF
Incident Analysis Form DOC PDF
Medical Release of Information DOC PDF
Network Acknowledgement Form   PDF
Network Acknowledgement Form (Spanish)   PDF
Notice to employees concerning workers' compensation in Texas   PDF
Notice to employees concerning workers' compensation in Texas (Spanish)   PDF
Employee Notice of Ombudsman Services (English)   PDF
Employee Notice of Ombudsman Services (Spanish)   PDF
First Fill form   PDF
Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (English, Spanish, Chinese, Korean, Vietnamese)   PDF
Ownership Changes - ERM-14   ONLINE
Policyholder Online Self-Administration Form DOC  
Sample Drug Policy DOC PDF
DWC-1, Employer's First Report of Injury or Illness ONLINE PDF
DWC-2, Employer's Report for Reimbursement of Voluntary Payment   PDF
DWC-3, Employer's Wage Statement ONLINE PDF
DWC-3S, Employer's Wage Statement (Spanish)   PDF
DWC-3ME, Employee's Multiple Employment Wage Statement   PDF
DWC-3MES, Employee's Multiple Employment Wage Statement (Spanish)   PDF
DWC-3SD, Employer's Wage Statement for School Districts   PDF
DWC-3SDS, Employer's Wage Statement for School Districts (Spanish)   PDF
DWC-4, Employer's Contest of Compensability   PDF
DWC-6, Supplemental Report of Injury   PDF
DWC-48, Request for Travel Reimbursement   PDF
DWC-53, Employee's Request to Change Treating Doctor - Non Network   PDF
DWC-53, Employee's Request to Change Treating Doctor - Non Network (Spanish)   PDF
DWC-73, Work Status Report   PDF
DWC-74, Description of Injured Employee's Employment   PDF
DWC-81, Agreement Between General Contractor and Subcontractor to Provide Workers' Compensation Insurance   PDF
DWC-82, Agreement Between Motor Carrier and Owner Operator to Provide Workers' Compensation Insurance Coverage / Agreement to Require Owner Operator to Act as Employer   PDF
DWC-83, Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers / Agreement to Establish Employer-Employee Relationship for Certain Building and Construction Workers   PDF
DWC-83S, Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers / Agreement to Establish Employer-Employee Relationship for Certain Building and Construction Workers (Spanish)   PDF
DWC-84, Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers   PDF
DWC-85, Agreement Between General Contractor and Subcontractor to Establish Independent Relationship   PDF

More forms on the Web

For more forms related to workers’ compensation insurance or general workplace issues, visit the appropriate agency’s website, listed below.


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