Dwc Form 5 – Fill Out and Use This PDF

WHO MUST FILE: All employers (including former sole proprietors who have formed corporations which have only one employee) must file a DWC FORM-5 with the Texas Department of Insurance, Division of Workers' Compensation unless the employer:

a.	has workers' compensation insurance;	c. is a self-insured political subdivision; or
b.	is a certified self-insurer;	d. only employs employees who are exempt from coverage under the
		Texas Workers' Compensation Act.

WHEN TO FILE: See reverse side of form.

NO COVERAGE OR TERMINATION OF COVERAGE

1. Check one of the following:

The below named employer ELECTS NOT to obtain workers' compensation insurance coverage, pursuant to the Texas Workers' Compensation Act, Texas Labor Code, Section 406.004.

The below named employer has TERMINATED workers' compensation insurance coverage, effective date ________________

of Policy Number				and has notified the ____________________________________ Insurance
Company on (date)			, pursuant to the Texas Workers' Compensation Act, Texas Labor Code, Section 406.007.
Notice has been (will be) provided to employees on the following date:					.
EMPLOYER INFORMATION (PLEASE TYPE OR PRINT:)
2. Employer Business Name							3. Federal Tax ID Number

4.Employer Business Mailing Address

5.Description of Business Operations. Identify type and nature of business.

6.Name, Federal Tax ID Number and Address of each Business Location covered by this report, if different from the above. To identify additional locations, submit a DWC FORM 205.

Name

Address

City

State

Zip

Federal Tax ID Number

Name

Address

Federal Tax ID Number

City

State

Zip

PERSON PROVIDING THIS INFORMATION

DIVISION DATE STAMP HERE:

7. Name

8. Title

9. Signature

10. Date

DWC FORM-5 (Rev. 10/05) Page 1

DIVISION OF WORKERS’ COMPENSATION

INSTRUCTIONS FOR

EMPLOYER NOTICE OF NO COVERAGE OR TERMINATION OF COVERAGE

The following employers are required to file a DWC FORM-5 with the Texas Department of Insurance, Division of Workers' Compensation:

1.Employers who elect not to be covered by workers' compensation insurance must file a DWC FORM-5 by the earlier of:

a.30 days after hiring an employee who is subject to coverage under the Texas Workers' Compensation Act; or

b.30 days after receipt of a Division request for filing of a DWC FORM-5;

2.Employers principally located outside Texas must file a DWC FORM-5 within 10 days after receipt of a Division request for information regarding coverage status; or

3.Employers who cancel their workers' compensation insurance must file a DWC FORM-5 within 10 days after notifying their insurance carrier of cancellation unless the employer:

a.purchases a new policy; or

b.becomes a certified self-insurer.

If an employer chooses to cancel their insurance, coverage must be extended until the "effective date" of withdrawal (i.e., the later of 30 days after filing the DWC FORM-5 with the Division OR the policy cancellation date), during which time the employer is obligated to pay accrued premiums. The employer is not required to extend coverage beyond the end of the policy period.

ANNUAL FILING: Employers must file a new DWC FORM-5 annually on the anniversary date of the original filing.

APPLICATIONS/EXEMPTIONS: An employer who is: (1) covered by workers' compensation insurance; (2) a certified self- insurer; (3) a self-insured political subdivision; or (4) whose only employees are exempt from coverage under the Texas Workers' Compensation Act (e.g. domestic workers, certain farm and ranch workers) is not required to file a DWC FORM-5.

POSTING AND NOTICE REQUIREMENTS

An employer must post the following notice in the workplace in English, Spanish and other language common to the workplace in the print type specified by Workers’ Compensation Rules whenever the employer: (1) elects not to be covered by workers' compensation insurance; (2) cancels or terminates workers' compensation insurance; (3) withdraws from self-insurance; or (4) whose workers' compensation coverage is cancelled by the insurance company. This notice must also be provided to each mployee:

a.at the time of hiring;

b.when an employer elects not to be covered by workers' compensation insurance;

c.within 15 days of when an employer notifies the insurance carrier that the employer is dropping coverage without maintaining continuous coverage under a new policy; or

d.within 15 days of when an employer's workers' compensation policy is canceled by the insurance company.

NOTICE TO EMPLOYEES CONCERNING WORKERS' COMPENSATION IN TEXAS

COVERAGE: (_______________________________) has elected not to obtain workers’ compensation insurance coverage.

Name of Employer

As an employee of a non-covered employer, you are not eligible to receive workers’ compensation benefits under the Texas Workers’ Compensation Act. However, a non-covered employer can and may provide other benefits to injured employees. You should contact your employer regarding the availability of other benefits or compensation for a work-related injury or illness. In addition, you may have rights under the common law of Texas should you suffer an on the job injury or illness. Your employer is required to provide you with coverage information, in writing, when you are hired or whenever the employer becomes, or ceases to be, covered by workers' compensation insurance.

SAFETY HOTLINE: The Division has established a 24 hour toll-free telephone number for reporting unsafe conditions in the workplace that may violate occupational health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any employee because he or she in good faith reports an alleged occupational health or safety violation. Contact the Workers' Health & Safety at 1-800-452-9595.

Failure to file a DWC FORM-5 or to post or provide the required notices may subject the employer to administrative penalties.

DWC FORM-5 (Rev. 10/05) Page 2

DIVISION OF WORKERS’ COMPENSATION