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 online or submit an Employer’s Wage Statement.

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

NEW: WorkWell, TX forms available below.

  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
Texas Star Network-Notice of Network Requirements English Spanish
Texas Star Network-Network Acknowledgement Form English Spanish
WorkWell, TX-Notice of Network Requirements English Spanish
WorkWell, TX-Network Acknowledgement Form English Spanish
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 Spanish
First Fill form   PDF
Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (English, Spanish, Chinese, Korean, Vietnamese)   ONLINE
Ownership Changes - ERM-14 ONLINE
Policyholder Online Self-Administration Form DOC PDF
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 PDF
DWC-3S, Employer's Wage Statement (Spanish) PDF
DWC-3ME, Employee's Multiple Employment Wage Statement English Spanish
DWC-3SD, Employer's Wage Statement for School Districts English Spanish
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 English Spanish
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 English Spanish
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.