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Blank Texas Notice PDF Form

The Texas Notice form, officially known as the DWC005, serves as an important document for employers regarding their workers' compensation insurance status. This form is used to notify the Texas Department of Insurance about the lack of coverage or the termination of existing coverage, in accordance with the Texas Workers' Compensation Act. Employers must complete and submit this form to ensure compliance with state regulations and to inform employees about their insurance status.

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The Texas Notice form, officially known as the Employer Notice of No Coverage or Termination of Coverage (DWC Form-005), plays a crucial role in the state's workers' compensation framework. This form is essential for employers who either lack workers' compensation insurance or have terminated their existing coverage. It requires the employer to specify effective dates for the coverage status, which cannot exceed one year. Additionally, the form includes a statement of no coverage or termination, where employers must indicate whether they do not have coverage or have ended their policy, providing details such as the policy number and termination date. Employers must also report any work-related injuries or diseases that have occurred since the last notice was filed. To ensure compliance, the form mandates the inclusion of primary employer information, including the business name and Federal Employer ID Number. It is imperative that all sections of the form are completed accurately, as failure to do so may result in administrative penalties. Employers must file this form during specific periods, such as annually or within a certain number of days after hiring employees or terminating coverage. Understanding the requirements and timelines associated with the Texas Notice form is essential for employers to navigate their responsibilities under the Texas Workers' Compensation Act effectively.

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DWC005
DWC005 Rev. 01/25 Page 1 of 4
Non-subscriber notice to Division of Workers’ Compensation
Este formulario está disponible en español en el sitio web de la División en
www.tdi.texas.gov/forms/dwc/dwc005snocov.pdf
Para obtener asistencia en español, llame a la División al 800-252-7031.
If you would like to file online using your smartphone, tablet, computer, or an XML file upload, go to.
www.tdi.texas.gov/wc/forms/onlinefiling.html
Part 1. Parent company or single location business information
1. Business name
2. Federal employer identification number (FEIN)
3. Mailing address (street or PO box, city, state, ZIP code)
4. North American Industry Classification
System code (NAICS.com) (business type)
5. Contact name (first, last)
6. Contact phone number
7. Contact email
8. Date completed (mm/dd/yyyy)
9. Effective dates (date range cannot be more than one year)
Effective from (mm/dd/yyyy) to (mm/dd/yyyy)
10. Reason for filing
a. Annual filing, between February 1 and April 30 each year. (required for all non-subscribers)
b. Business terminated workers’ compensation coverage and became a non-subscriber:
Policy number Policy ended on (mm/dd/yyyy)
Insurance company
Insurer informed of termination on (mm/dd/yyyy)
Employees were (or will be) notified on (mm/dd/yyyy)
c. Closed business on (mm/dd/yyyy) and will no longer send notices to the Texas
Department of Insurance, Division of Workers’ Compensation (DWC).
d. Any other business changes since last notice to DWC, such as adding or removing a location, and
business name and address changes.
11. Business locations
Use the Other business locations page at the end of this form to list all locations and subsidiaries of the
employer named in item 1 above that are not covered by a workers’ compensation insurance policy.
DWC005
DWC005 Rev. 01/25 Page 2 of 4
Part 2. Compliance with non-subscriber requirements
By filing this form with DWC, the non-subscriber affirms they do not have workers’ compensation coverage
and will:
• File non-subscriber notices between February 1 and April 30 of each calendar year.
• Notify new and existing employees of no workers’ compensation coverage or termination of
coverage by:
o Giving written notice of non-coverage to new employees.
o Giving written notice that coverage was terminated, including the date that it was terminated.
o Posting written notice at employee workplaces in English, Spanish, and any other language
that is appropriate by using Notice 5.
o Placing the notice where employees can see it regularly.
• Report work-related injuries or illnesses monthly by using DWC Form-007, Employer’s report of
noncovered employee’s work-related injury or illness if the employer has five or more employees and
(1) you know of a work-related illness, or (2) you know of a work-related injury that either:
o Caused the employee to miss one or more days of work.
o Resulted in a death.
Note: Get employee forms and notices at http://www.tdi.texas.gov/forms/form20employer.html.
12. Contact signature (first, last)
13. Contact title
DWC005
DWC005 Rev. 01/25 Page 3 of 4
FAQ
Non-subscriber notice to Division of Workers’ Compensation
What is a non-subscriber?
A non-subscriber is a Texas employer who does not have workers’ compensation insurance coverage or has
terminated their workers’ compensation coverage and has one or more employees.
Who must file the DWC Form-005, Non-subscriber notice to Division of Workers’ Compensation (DWC Form-
005)?
You must file this form if you are a non-subscriber and have one or more employees who are not exempt from
workers' compensation coverage. However, if your employees are exempt from coverage (for example, certain
domestic workers, and certain farm and ranch workers) you don’t have to file.
Where do I send this form?
• Online: tdi.texas.gov/wc/nonsubscribers.html
• Email: coverage.verification@tdi.texas.gov
• Fax: 512-804-4146
• Create a profile in TXCOMP and upload documents.
When do I file the DWC Form-005?
• Within 30 days of hiring your first employee.
• Within 10 days of terminating your workers’ compensation coverage.
• Within 10 days of DWC asking you to file it.
• Between February 1 and April 30 of each calendar year.
I have already filed a DWC Form-005. Do I have to file another one?
Yes. File a new DWC Form-005 between February 1 and April 30 of each calendar year.
What is a NAICS code?
North American Industry Classification System (NAICS) code is a numeric code that describes a business. To find your
NAICS code, go to www.naics.com/search/, enter a keyword to describe your business, and select the appropriate
code.
How can I change the locations I already reported on my DWC Form-005?
To add, delete, or update one or more business locations, complete a new DWC Form-005.
Are any fields optional?
No. You must complete all fields.
Is the workers’ compensation carrier also required to send a report to DWC when I terminate coverage with
them?
Yes. An insurance carrier must file a notice with DWC within 10 days. Texas Administrative Code §110.1
Note: With few exceptions, on your request, you are entitled to:
• Be informed about the information DWC collects about you;
• Receive and review the information (Government Code Sections 552.021 and 552.023); and
• Have DWC correct information that is incorrect (Government Code Section 559.004).
For more information, contact DWCLegalServi[email protected]exas.gov or refer to the Corrections Procedure section at
www.tdi.texas.gov.
DWC005
DWC005 Rev. 01/25 Page 4 of 4
Other business locations
Use more pages as needed.
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
Check one:
☐
Add
☐
Delete
☐
Change
Effective date (mm/dd/yyyy)
Business name
FEIN
Address (street or PO box, city, state, ZIP code)
⇓ Texas Notice PDF

Document Specs

Fact Name Description
Governing Law The Texas Notice form is governed by the Texas Workers' Compensation Act, specifically Sections 406.004 and 406.007 of the Texas Labor Code.
Purpose This form serves as a notification for employers who do not have workers' compensation insurance or have terminated their existing coverage.
Submission Methods Employers can submit the form electronically, via fax, or by mail to the Texas Department of Insurance.
Filing Deadlines The form must be filed annually between February 1st and April 30th, or within specific time frames related to employee hiring or policy termination.
Effective Dates The effective dates indicated on the form cannot exceed a one-year period.
Reportable Injuries Employers must report any work-related injuries or diseases that occurred since the last filing of the form.
NAICS Code The form requires a six-digit NAICS code, which classifies the employer's business type.
Mandatory Fields All fields in the form are mandatory, including employer information and details about coverage status.
Employee Notification Employers must notify employees about the lack of coverage through a posted notice in multiple languages.
Non-Covered Employers Employers without coverage may need to file additional forms, such as the DWC Form-007, for reporting work-related injuries.
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