The Texas DWC041 form is a crucial document for employees seeking compensation for 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 when they first became aware of the work-related nature of their condition. Properly filling out this form is essential to initiate the claims process and secure the necessary benefits.
If you are ready to fill out the Texas DWC041 form, please click the button below.
When filling out the Texas DWC041 form, there are several important considerations to keep in mind. Here’s a list of things you should and shouldn’t do to ensure your application is processed smoothly.
By following these guidelines, you can help ensure that your claim is handled efficiently and effectively.
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.
Instructions
Attorney General Laredo Tx - The form includes options for guideline or non-guideline support based on income and circumstances.
Txdps Jobs - Fees are non-refundable, and all payments must be made correctly.
The Texas DWC041 form is a crucial document for employees seeking compensation for work-related injuries or occupational diseases. However, it is often accompanied by several other forms and documents that play an important role in the claims process. Below is a list of related documents that may be necessary for a comprehensive claim submission.
Understanding these additional forms can significantly streamline the claims process and ensure that all necessary information is provided to the Division of Workers’ Compensation. Proper documentation not only aids in the swift processing of claims but also helps protect the rights of the injured employee.
When filling out the Texas DWC041 form, individuals often make several common mistakes that can delay the processing of their claims. One frequent error is leaving sections incomplete. The form requires detailed information, including the injured employee's name, Social Security number, and date of birth. Omitting any of these details can lead to significant delays in processing the claim. Ensuring that all boxes are filled out completely is essential for a smooth submission.
Another mistake involves providing inaccurate information regarding the injury. For example, when describing the cause of the injury or the body parts affected, individuals may not provide enough detail. This lack of clarity can result in confusion or misunderstandings about the nature of the injury. It is crucial to be as specific as possible, as this information helps establish the connection between the injury and the employee's work environment.
Additionally, some people fail to include the correct dates related to their injury. The form asks for the date of injury, the date it was reported to the employer, and the first workday missed. If these dates are incorrect or inconsistent with one another, it can complicate the review process. Accuracy in these dates is vital, as they help determine the timeline of events surrounding the claim.
Lastly, individuals sometimes neglect to provide information about their treating doctor or the workers’ compensation healthcare network, if applicable. This information is necessary for the Division of Workers’ Compensation to understand the medical context of the claim. Failing to include the name and contact details of the treating doctor can lead to delays in obtaining medical records or further information needed to process the claim. Providing complete and accurate information from the outset can help streamline the claims process.
This form must be filed within one year of the date of injury or within one year from when the injured employee knew or should have known the injury was work-related. Delays beyond this timeframe may result in the denial of the claim.
A person acting on behalf of the injured employee can also complete this form. This allows for support if the injured individual is unable to do so themselves.
It is important to complete all sections of the form. Missing information can lead to delays in processing the claim or even denial.
Filing the form does not guarantee that benefits will be awarded. The claim will be evaluated based on the circumstances of the injury and other relevant factors.
This form can also be used for claims related to occupational diseases, which may develop over time due to workplace conditions or repetitive activities.
The completed DWC041 form can be sent via mail or fax to the appropriate address. This provides flexibility for the injured employee or their representative.
Filling out the Texas DWC041 form is an important step for employees seeking compensation for work-related injuries or occupational diseases. Here are key takeaways to consider:
Following these guidelines will help facilitate the claims process and ensure that all necessary information is provided for consideration.
After completing the Texas DWC041 form, it is essential to send it to the appropriate address. Ensure all sections are filled out accurately to avoid delays in processing your claim. The information provided will be used to establish your claim and notify relevant parties.