Content Overview
The Texas DWC041 form is a crucial document for employees seeking workers' compensation benefits after a work-related injury or occupational disease. This form must be submitted by the injured employee or a designated representative within one year of the injury or when the employee becomes aware of a work-related condition. Key sections of the DWC041 include personal information about the injured employee, details regarding the injury itself, and information about the employer at the time of the incident. Completing the form accurately is essential, as it initiates the claims process with the Texas Division of Workers’ Compensation. Upon receipt, the Division will assign a claim number and provide important information about the workers' compensation system. Additionally, the form requires specifics about the treating doctor and any relevant health care networks. Adhering to the instructions and providing complete information can significantly impact the outcome of the claim.
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DWC041 Rev. 03/07 Page 1 of 1
DWC Claim#
Carrier Claim#
Texas Department Of Insurance
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.sta
te.tx.us
ä Send 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
Do you speak English? Yes No If no, specify language
Marital status Married Widowed Separated Single Divorced
Do you have an attorney or other representation? Yes No If yes, name of representative
Have you returned to work? Yes No 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 No 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 Instructions
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
o If you have returned to your regular job and you are performing the same duties as you were before your injury,
check the “Regular” box.
o If 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.
Form Specifications
| Fact Name | Details |
|---|---|
| Filing Deadline | A claim must be filed within one year of the injury date or from when the employee knew or should have known the injury was work-related. |
| Governing Law | The DWC Form-041 is governed by Texas Labor Code § 408.001. |
| Claim Creation | Upon receipt of the completed form, the Division of Workers' Compensation will create a claim and assign a DWC claim number. |
| Contact Information | For questions, individuals can call the Texas Department of Insurance at 1-800-252-7031. |
Texas Dwc041: Usage Guidelines
Once the Texas DWC041 form is completed, it should be sent to the address provided at the top of the form. This initiates the process for filing a claim for workers' compensation benefits. The Division of Workers' Compensation will then create a claim number and send you further information regarding your claim.
- Begin by filling out the Injured Employee Information section. Include your full name, Social Security number, date of birth, and contact details such as your address, phone number, and email address.
- Indicate your sex and race/ethnicity. Specify if you speak English and your marital status. If applicable, provide the name of your attorney or representative.
- Next, answer whether you have returned to work. If you have, include the date you returned and your work status (regular or restricted). Also, provide your occupation at the time of injury and your date of hire.
- In the Injury Information section, state the date and time of your injury. Include the first workday you missed and the date you reported the injury to your employer.
- Specify where the injury occurred, including the county, state, and country. If the accident occurred outside of Texas, provide the date you left Texas.
- List any witnesses to the injury by name and describe how the injury or occupational disease occurred, including how it is work-related. Mention the body parts affected.
- If your injury is due to an occupational disease, provide the date of last exposure to the cause and when you first recognized it as work-related.
- Move on to the Employer Information section. Fill in your employer's name, address, phone number, and the name of your supervisor at the time of injury.
- In the Doctor Information section, include the name and phone number of your treating doctor, as well as their address. If applicable, provide the name of the workers' compensation healthcare network.
- Finally, sign and date the form. Print your name or the name of the person filling out the form on behalf of the injured employee.
Once completed, ensure all sections are filled accurately before mailing the form to the specified address. This will help facilitate the processing of your claim efficiently.
Your Questions, Answered
What is the Texas DWC041 form?
The Texas DWC041 form, also known as the Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease, is a document that employees must complete to file a claim for workers' compensation benefits. This form must be submitted either by the injured employee or by someone acting on their behalf within one year of the injury or when the employee became aware that the injury or disease might be work-related.
Who should fill out the DWC041 form?
The form should be filled out by the injured employee themselves or by a representative acting on their behalf. This may include a family member, legal representative, or another individual authorized to assist with the claim process. Accurate and complete information is crucial for the claim to be processed efficiently.
What information is required on the DWC041 form?
The DWC041 form requires detailed information about the injured employee, including their personal details, work status, and specifics about the injury or occupational disease. This includes the date and time of the injury, the location where it occurred, and any witnesses present. Additionally, information about the employer at the time of injury and the treating doctor must also be provided.
What happens after I submit the DWC041 form?
Upon receiving your completed DWC041 form, the Division of Workers’ Compensation will create a claim and assign a DWC claim number. They will send you information regarding workers' compensation in Texas, as well as notify your employer and their insurance carrier about your claim. This process ensures that all parties are informed and can proceed with the necessary steps.
What if I miss the one-year filing deadline?
If you miss the one-year deadline to file your claim, it may still be possible to proceed if you can demonstrate good cause for the delay. Additionally, if your employer or their insurance carrier does not contest your claim, you may still be able to receive benefits. It is advisable to consult with a legal representative to explore your options in such cases.
Can I get help with filling out the DWC041 form?
Yes, assistance is available for completing the DWC041 form. You can contact your local Division Field Office at 1-800-252-7031 for guidance. They can provide answers to any questions you may have about the form or the workers' compensation process in Texas.
What should I do if I need to correct information on my claim?
If you find that any information on your claim is incorrect, you have the right to request a correction. Under Texas Government Code provisions, you can contact the Division’s Open Records section at 512-804-4437 to address inaccuracies in your claim information. Ensuring that your records are correct is essential for a smooth claims process.
Common mistakes
-
Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure that every section is completed, including personal details and injury specifics.
-
Incorrect Dates: Providing wrong dates, such as the date of injury or the date the injury was reported, can complicate your claim. Double-check all dates for accuracy.
-
Missing Signatures: Not signing the form can result in rejection. Always ensure that the injured employee or their representative has signed the form before submission.
-
Omitting Employer Information: Failing to include accurate employer details can hinder the processing of your claim. Verify that the employer's name and address are correct.
-
Neglecting to Specify Work Status: Not indicating whether you have returned to work and your current work status can lead to confusion. Clearly state your work status at the time of filing.
Documents used along the form
The Texas DWC041 form is a crucial document for employees seeking compensation for work-related injuries or occupational diseases. Alongside this form, several other documents are commonly used to support the claims process. Understanding these documents can help streamline the filing process and ensure that all necessary information is provided.
- DWC Form-042: This form is used to report a claim for additional benefits after the initial DWC041 form has been submitted. It allows the injured employee to request further compensation if their condition worsens or if additional medical treatment is needed.
- DWC Form-053: This document is a Request for Designation of a Treating Doctor. It is used when an injured employee wants to change their treating doctor, which may be necessary if the current doctor is not meeting the employee's needs.
- DWC Form-001: The Employee's Notice of Injury or Occupational Disease is submitted to notify the employer of the injury. This form is often filed alongside the DWC041 to ensure the employer is aware of the claim.
- DWC Form-046: This form is used to report a dispute regarding the claim. If there are disagreements about the benefits or the nature of the injury, this document initiates the dispute resolution process.
- DWC Form-007: This is the Employee's Claim for Benefits form, which can be used to appeal decisions made by the insurance carrier regarding the claim. It is essential for employees who believe their benefits have been unfairly denied.
- Medical Records: These documents provide detailed information about the injury or illness, including diagnosis and treatment. They are vital for substantiating the claim and demonstrating the impact of the injury on the employee's life.
- Employer's Report of Injury: This report, completed by the employer, outlines the circumstances surrounding the injury. It is critical for verifying the details provided by the employee and ensuring that all parties have a clear understanding of the incident.
- Witness Statements: Statements from individuals who witnessed the injury can provide additional context and support the employee's claim. These statements can clarify the events leading up to the injury and help establish liability.
Using these documents in conjunction with the Texas DWC041 form can enhance the clarity and effectiveness of a workers' compensation claim. Ensuring that all necessary paperwork is completed accurately and submitted promptly can significantly impact the outcome of the claim process.
Similar forms
The Texas DWC041 form is essential for filing a workers' compensation claim in Texas. Several other documents serve similar purposes in different contexts or jurisdictions. Here are four documents that share similarities with the Texas DWC041 form:
- California DWC 1 Form: This form is used in California for reporting work-related injuries or illnesses. Like the DWC041, it must be completed by the injured employee or their representative and submitted within a specified time frame. Both forms gather similar information about the injured party, the nature of the injury, and employer details.
- New York C-3 Form: In New York, the C-3 form is utilized to report a work-related injury. It requires the injured worker to provide personal information, details of the injury, and employer information. Similar to the DWC041, the C-3 must be filed promptly to ensure eligibility for benefits.
- Florida DWC-1 Form: The Florida DWC-1 form is another document that serves a similar purpose. It is used to notify the state of an employee's work-related injury or illness. Both forms require information about the employee, the injury, and the employer, emphasizing timely submission to secure workers' compensation benefits.
- Illinois Form 45: In Illinois, Form 45 is used to report workplace injuries. It collects comparable information regarding the injured employee, the incident, and the employer. Just like the Texas DWC041, this form must be filed within a specific time period to maintain the right to benefits.
Each of these forms is designed to facilitate the claims process for workers' compensation, ensuring that injured employees receive the necessary support and benefits in a timely manner.
Dos and Don'ts
When filling out the Texas DWC041 form, it is essential to approach the process with care and attention to detail. Below are some important dos and don'ts to keep in mind.
- Do complete all sections of the form fully. Each box must be filled out to ensure that your claim is processed without delays.
- Do provide accurate information regarding your injury, including the date, time, and circumstances surrounding the incident.
- Do include your employer's information as it was at the time of your injury. This helps to establish the context of your claim.
- Do sign and date the form before submitting it. An unsigned form may lead to complications or rejection.
- Don't leave any boxes blank unless instructed. Missing information can result in processing delays.
- Don't provide false information. Honesty is crucial, as inaccuracies can jeopardize your claim and lead to legal issues.
By adhering to these guidelines, you can help ensure that your claim for workers' compensation is submitted correctly and efficiently. If you have questions while filling out the form, do not hesitate to contact your local Division Field Office for assistance.
Misconceptions
There are several misconceptions about the Texas DWC041 form that can lead to confusion for injured employees. Here are eight common misunderstandings, along with explanations to clarify them.
- Misconception 1: The DWC041 form must be filed immediately after an injury.
- Misconception 2: Only the injured employee can fill out the form.
- Misconception 3: The form is optional if the injury seems minor.
- Misconception 4: The DWC041 form guarantees approval of the claim.
- Misconception 5: You cannot file a claim if you return to work.
- Misconception 6: The form only requires basic information.
- Misconception 7: You can file the form at any time without consequences.
- Misconception 8: You do not need to keep a copy of the submitted form.
While it's important to file a claim promptly, the form can be submitted within one year from the date of the injury or when the employee realized the injury was work-related.
In fact, a person acting on behalf of the injured employee can also complete the DWC041 form, making it easier for those who may be unable to do so themselves.
Regardless of the perceived severity of the injury, filing the DWC041 form is essential to ensure that the employee's rights to compensation are protected.
Submitting the form does not guarantee that the claim will be approved. The Division of Workers’ Compensation will review the claim and determine eligibility based on the information provided.
Returning to work does not negate the right to file a claim. Employees can still submit the DWC041 form even if they have resumed their duties.
The DWC041 form requires detailed information about the injury, the employer, and the treating doctor. Completing all sections thoroughly is crucial for a successful claim.
Filing the form after the one-year deadline can result in the loss of the right to compensation. Timeliness is essential in the claims process.
It’s wise to keep a copy of the completed DWC041 form for personal records. This can be helpful for future reference or if any issues arise with the claim.
Key takeaways
Filling out the Texas DWC041 form is a crucial step in initiating a workers' compensation claim. Here are some key takeaways to keep in mind:
- Timeliness is Essential: You must file the claim within one year of the injury or from when you realized the injury was work-related.
- Complete All Sections: Ensure that every box on the form is filled out completely. Incomplete forms can delay the processing of your claim.
- Accurate Information Matters: Provide precise details about your injury, including the date, time, and how it occurred. This information is vital for establishing your claim.
- Employer and Doctor Details: Include accurate information about your employer and treating doctor. This helps in the swift processing of your claim.
- Understand Your Rights: You have the right to access and review the information the Division collects about your claim. If any information is incorrect, you can request a correction.
- Seek Help if Needed: If you have questions or need assistance while completing the form, don’t hesitate to contact your local Division Field Office.
Being thorough and prompt in your submission can significantly impact the outcome of your workers' compensation claim.