The Texas DWC041 form serves as the official document for an employee to file a claim for compensation due to a work-related injury or occupational disease. This form must be completed and submitted by the injured employee or their representative within one year of the injury or when the employee becomes aware that their condition may be work-related. Understanding the details and requirements of this form is crucial for ensuring that your claim is processed effectively and timely.
The Texas DWC041 form is a crucial document for individuals seeking workers' compensation benefits due to work-related injuries or occupational diseases. This form must be completed and submitted by the injured employee or their representative within one year of the injury or the date they became aware that their condition was work-related. It collects essential information, including the employee's personal details, injury specifics, employer information, and treating doctor details. Accurate completion of the form is vital, as it initiates the claims process with the Texas Department of Insurance, Division of Workers’ Compensation. Upon receipt, the Division assigns a claim number and notifies both the employer and the insurance carrier. It is important to provide all requested information, as incomplete submissions may delay the processing of the claim. If assistance is needed while filling out the form, individuals can contact their local Division Field Office for support. Understanding the DWC041 form is a significant step in ensuring that employees receive the benefits they are entitled to following a work-related incident.
T e x a s De pa rt m e nt Of I nsura nc e
Division of Workers’ Compensation
Records Processing
7551 Metro Center Dr. Ste.100 • MS-94 Austin, TX 78744-1609
(800) 252-7031 (512) 804-4378 fax www.tdi.state.tx.us
DWC Claim#
Carrier Claim#
äSend the completed form to this address.
Employee's Claim for Compensation for a Work-Related Injury
or Occupational Disease (DWC Form-041)
Claim for workers’ compensation must be filed by the injured employee or by a person acting on the injured employee’s behalf within one year of the date of injury or within one year from the date the injured employee knew or should have known the injury or disease may be work-related.
I. INJURED EMPLOYEE INFORMATION
Name (First, Middle, Last )
Social Security Number
Date of birth (mm / dd / yyyy)
Address (street, city/town, state, zip code, county, country)
Phone Number
E-Mail address
Sex
Male
Female
Race / Ethnicity
White, not of Hispanic Origin
Black, not of Hispanic Origin
Hispanic
Asian or Pacific Islander
Yes
No
If no, specify language
Do you speak English?
Married
Widowed
Separated
Single
Divorced
Marital status
Do you have an attorney or other representation?
If yes, name of representative
Have you returned to work?
If returned to work, date returned (mm/dd/yyyy)
Work status
Regular
Restricted
Occupation at time of injury
Date of hire (mm / dd / yyyy)
Hired or recruited in Texas
Pre-tax wages (at the time of injury)
$
hourly
weekly
monthly
II. INJURY INFORMATION
I am reporting an
injury or
occupational disease
Date of injury (mm / dd / yyyy)
Time of injury
First work day missed (mm / dd / yyyy)
Date injury was reported to the employer (mm / dd / yyyy)
Where did the injury occur? County
State
Country
If accident occurred outside of Texas, on what date did you leave Texas? (mm/dd/yyyy)
Witness(es) to the injury (list by name)
Describe cause of injury or occupational disease, including how it is work related
Body part(s) affected by the injury
If injury is the result of an occupational disease:
1. On what date was the employee last exposed to the cause of the occupational disease? (mm / dd / yyyy)
2. When did you first know occupational disease was work related? (mm / dd / yyyy)
III. EMPLOYER INFORMATION (at the time of injury)
Employer name
Employer address (street, city/town, state, zip code, county, country)
Employer phone number
Supervisor name
IV. DOCTOR INFORMATION
Name of treating doctor
Phone number
Address (street, city/town, state, zip code)
Name of workers’ compensation health care network, if any
Signature of injured employee or person filling out this form on behalf of injured employee
Date
Printed name of injured employee or person filling out form on behalf of injured employee
DWC041 Rev. 03/07
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Information about Employee's Claim for Compensation for a Work-Related
Injury or Occupational Disease (DWC Form-041)
A claim for Workers' Compensation benefits must be filed with the Division of Workers’ Compensation (Division) by the injured employee (you), or by a person acting on the injured employee's (your) behalf within one year of the injury or within one year from the date you knew or should have known the injury or disease may be work related; UNLESS good cause exists for the failure to timely file a claim, or the employer or the employer's insurance carrier does not contest the claim.
Upon receipt of your completed DWC Form-041, or other notice of your injury, the Division will create a claim and establish a DWC claim number for you, and the Division will mail information regarding workers’ compensation in Texas to you. The Division will also notify your employer and the employer’s workers’ compensation insurance carrier.
SPECIAL INSTRUCTIONS AND INFORMATION FOR COMPLETING THE DWC Form-041
General Instructions
•Complete all boxes in the DWC Form-041.
•If you have questions about completing this form, please call your local Division Field Office at 1-800-252-7031.
Injured Employee Information
•Work Status information
oIf you have returned to your regular job and you are performing the same duties as you were before your injury,
check the “Regular” box.
oIf you have been released to work with restrictions by a doctor, check “Restricted.”
Injury Information
•An injury is damage to your body that was caused by a single incident, accident, or event.
•An occupational disease is an illness or injury related to or caused by the work you do, and may include injuries to your body that are the result of repetitive activities you performed on the job over a period of time.
Employer Information
•Provide information about your employer at the time you were injured.
Doctor Information
•If you already have a workers’ compensation treating doctor, provide the name and address of the doctor.
•If you are covered under a workers’ compensation healthcare network, provide the name of the network.
Contacting Texas Department of Insurance, Division of Workers’ Compensation
If you have questions about filling out this form or workers’ compensation in Texas, please call your local Division Field Office at 1-800-252-7031.
NOTE: With few exceptions, you are entitled, on request, to be informed about the information that the Division collects or maintains about you and your workers’ compensation claim. Under §552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under §559.004 of the Texas Government Code you are entitled to have the Division correct information the Division creates about you or your workers’ compensation claim that is incorrect. For more information, call the Division’s Open Records section at 512-804-4437.
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