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Blank Texas Dwc041 PDF Template

The Texas DWC041 form is a crucial document used by employees to file a claim for compensation due to work-related injuries or occupational diseases. This form must be submitted by the injured employee or a designated representative within one year of the injury or the date the employee became aware of the work-related nature of their condition. Completing this form accurately is essential for ensuring that you receive the benefits to which you are entitled.

Open Form

Contents

Form Example

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

If no, specify language

Do you speak English?

Married

Widowed

Separated

Single

Divorced

Marital status

Do you have an attorney or other representation?

Yes

If yes, name of representative

Have you returned to work?

Yes

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

Yes

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

Page 1 of 1

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.

DWC041 Rev. 03/07

Instructions

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Common mistakes

Incomplete Information: Many individuals fail to fill out all required fields on the DWC041 form. Missing information can delay the processing of the claim. Ensure every section, including personal details, injury information, and employer data, is completed thoroughly.
Incorrect Dates: Providing inaccurate dates, such as the date of injury or the date the injury was reported, is a common mistake. These dates are crucial for determining the eligibility of the claim and must be precise.
Not Specifying Work Status: Claimants often overlook the work status section. Clearly indicating whether the employee has returned to work, and if so, under what conditions, is essential. This information helps assess the impact of the injury on employment.
Missing Signature: Failing to sign the form can result in immediate rejection. The signature of the injured employee or their representative is required to validate the claim. Double-check that this step is not overlooked.

Key takeaways

Filling out the Texas DWC041 form is an important step for employees seeking compensation for work-related injuries. Here are some key takeaways to keep in mind:

Timely Filing: Submit the form within one year of your injury or from when you realized the injury might be work-related.
Complete Information: Fill out all sections of the form accurately. Missing information can delay your claim.
Claim Numbers: After submitting the form, you will receive a DWC claim number. This number is essential for tracking your claim.
Contact Information: Include your current contact details. This ensures that you receive all necessary communications regarding your claim.
Work Status: Clearly indicate whether you have returned to work and if you are performing regular or restricted duties.
Employer Details: Provide accurate information about your employer at the time of the injury. This helps in processing your claim.
Doctor Information: If you have a treating doctor for your injury, include their name and contact details. This information is crucial for your medical records.
Seek Help: If you have questions while completing the form, don’t hesitate to contact the Division of Workers' Compensation for assistance.

By keeping these points in mind, you can ensure a smoother process when filing your claim for workers’ compensation in Texas.

⇓ Texas Dwc041 PDF

Steps to Using Texas Dwc041

Filling out the Texas DWC041 form requires careful attention to detail. This form is essential for initiating a claim for workers’ compensation benefits. Ensure that all sections are completed accurately to avoid delays in processing your claim.

Obtain the Form: Download the Texas DWC041 form from the Texas Department of Insurance website or request a physical copy.
Complete the Injured Employee Information: Fill in your name, social security number, date of birth, address, phone number, and email address. Indicate your sex, race/ethnicity, marital status, and whether you have legal representation.
Provide Work Status Details: Indicate if you have returned to work and the date if applicable. Specify your occupation at the time of injury and your pre-tax wages.
Fill Out Injury Information: State the date and time of the injury, the first workday missed, and when the injury was reported to your employer. Describe the injury's cause and the body parts affected.
Document Employer Information: Include the name, address, and phone number of your employer at the time of injury, along with your supervisor's name.
Provide Doctor Information: Enter the name, phone number, and address of your treating doctor, as well as the name of any workers’ compensation health care network.
Sign and Date the Form: Ensure that you or your representative signs and dates the form. Print your name clearly beneath your signature.
Submit the Form: Send the completed form to the address provided on the form: Texas Department of Insurance, Division of Workers’ Compensation, 7551 Metro Center Dr. Ste. 100, MS-94, Austin, TX 78744-1609.

After submitting the form, you will receive a DWC claim number. The Division of Workers’ Compensation will send you information regarding your claim and notify your employer and their insurance carrier. Keep a copy of the completed form for your records.