Forms & Sample Documents
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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) | DOC | |
| Incident Analysis Form | DOC | |
| Medical Release of Information | DOC | |
| Network Acknowledgement Form | ||
| Network Acknowledgement Form (Spanish) | ||
| Notice to employees concerning workers' compensation in Texas | ||
| Notice to employees concerning workers' compensation in Texas (Spanish) | ||
| Employee Notice of Ombudsman Services | ||
| Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System | ||
| Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (Spanish) | ||
| DWC-1, Employer's First Report of Injury or Illness | ||
| DWC-2, Employer's Report for Reimbursement of Voluntary Payment | ||
| DWC-3, Employer's Wage Statement | ||
| DWC-3S, Employer's Wage Statement (Spanish) | ||
| DWC-3ME, Employee's Multiple Employment Wage Statement | ||
| DWC-3MES, Employee's Multiple Employment Wage Statement (Spanish) | ||
| DWC-3SD, Employer's Wage Statement for School Districts | ||
| DWC-3SDS, Employer's Wage Statement for School Districts (Spanish) | ||
| DWC-4, Employer's Contest of Compensability | ||
| DWC-6, Supplemental Report of Injury | ||
| DWC-48, Request for Travel Reimbursement | ||
| DWC-53, Employee's Request to Change Treating Doctor - Non Network | ||
| DWC-53, Employee's Request to Change Treating Doctor - Non Network (Spanish) | ||
| DWC-73, Work Status Report | ||
| DWC-74, Description of Injured Employee's Employment | ||
| DWC-81, Agreement Between General Contractor and Subcontractor to Provide Workers’ Compensation Insurance | ||
| DWC-82, Agreement Between Motor Carrier and Owner Operator to Provide Workers’ Compensation Insurance Coverage / Agreement to Require Owner Operator to Act as Employer | ||
| 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 | ||
| 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) | ||
| DWC-84, Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers | ||
| DWC-85, Agreement Between General Contractor and Subcontractor to Establish Independent Relationship | ||
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.