Employer Forms

Find common forms used during the claims process and throughout your policy period.

Form Format
Claims and Return to Work
DWC-1, Employer's First Report of Injury or Illness Online PDF
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 and Pharmacy
For injures on or after January 1, 2018
WorkWell, TX-Notice of Network Requirements English Spanish
WorkWell, TX-Network Acknowledgement Form English Spanish
 
For injuries on or before December 31, 2017
Texas Star Network-Notice of Network Requirements English Spanish
Texas Star Network-Network Acknowledgement Form English Spanish
 
For all prescriptions
Pharmacy First Fill Form English Spanish
Notices
Notice to employees concerning workers' compensation in Texas English Spanish
Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (English, Spanish, Chinese, Korean, Vietnamese)   Online
Employee Notice of Ombudsman Services English Spanish
Policy and Texas Mutual Online (TMO)
Ownership Changes - ERM-14 Online
Policyholder Online Self-Administration Form DOC PDF
Texas Department of Insurance, Department of Workers' Compensation
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 English Spanish
DWC-3SD, Employer's Wage Statement for School Districts English Spanish
DWC-4, Employer's Contest of Compensability   PDF
DWC-5, Employer Notice of No Coverage or Termination of Coverage   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-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