Dwc Form 84 PDF Details

Dwc form 84 is a document that is used to report the death of an individual to Social Security. The form must be completed and returned to Social Security within ten days of the individual's death. The information on the form will help ensure that Social Security payments are stopped for the deceased person, and that any benefits owed to the individual are paid correctly. It is important to note that Dwc form 84 should not be used to report a living person who has passed away. For more information on how to report a death, please visit Social Security's website.

QuestionAnswer
Form NameDwc Form 84
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesadvisable, tx dwc 84, nullifies, dwc

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TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION (DWC)

7551 Metro Center Drive, Suite 100

Austin, Texas 78744

DO NOT SEND THIS AGREEMENT TO DWC

EXCEPTION TO APPLICATION OF JOINT AGREEMENT TO AFFIRM INDEPENDENT

RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS

NOTICE OF DECLARATION

The undersigned Hiring Contractor and the undersigned Independent Contractor declare that the Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers (as recorded on DWC FORM-83) does not apply to the subsequent hiring agreement between the Hiring Contractor and Independent Contractor. Nothing in this declaration otherwise nullifies the Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers as it applies to other hiring agreements made during the term of the joint agreement.

DATE OF JOINT AGREEMENT TO AFFIRM INDEPENDENT RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS

LOCATION OF SPECIFIC JOB SITES NOT AFFECTED BY JOINT AGREEMENT:

DATE OF SUBSEQUENT HIRING AGREEMENT TO WHICH THIS FORM APPLIES

NAME OF HIRING CONTRACTOR

NAME OF INDEPENDENT CONTRACTOR

Texas Labor Code, Texas Workers’ Compensation Act, Section 406.145.

Hiring Contractor’s Affirmation

If the Hiring Contractor’s workers’ compensation carrier changes

during the effective period of coverage, it is advisable for the Hiring Contractor to file this form with the new insurance carrier.

Federal Tax I.D. Number

Signature of Hiring Contractor

Date

 

Address (Street)

 

 

 

 

Printed Name of Hiring Contractor

 

 

Address (City, State, Zip)

Independent Contractor’s Affirmation

Signature of Independent Contractor

Date

Printed Name of Independent Contractor

Federal Tax I.D. Number

Address (Street)

Address (City, State, Zip)

The Hiring Contractor must retain the original. A legible copy of this agreement must be filed with the hiring contractor’s workers’ compensation insurance carrier within 10 days of the date of execution. An agreement is not considered filed if it is illegible or incomplete. The Independent Contractor should also retain a copy of the agreement.

DWC FORM-84 REV. 01/21

DIVISION OF WORKERS’ COMPENSATION

How to Edit Dwc Form 84 Online for Free

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How you can complete texas form84 step 1

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texas form84 writing process explained (step 2)

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