Form 052 PDF Details

In Texas, navigating the aftermath of a work-related injury involves a series of legal and procedural steps, among which completing the DWC Form-052 stands as a critical juncture for those seeking Supplemental Income Benefits (SIBs). Administered by the Texas Department of Insurance, Division of Workers’ Compensation, this form is essential for injured workers who have reached a point in their recovery where maximum medical improvement is determined, yet they continue to suffer from an impairment that hinders their earning capacity. The DWC Form-052 not only serves as an application for SIBs but also necessitates detailed documentation from the employee, including personal identification, employment and insurance carrier information, an account of work search efforts, and certification by the employee attesting to their eligibility under the stipulated conditions. This comprehensive form further outlines the process for calculating SIBs and guides both employees and insurance carriers through the application and determination stages of the benefit. With spaces designated for documenting work search activities and wages during the qualifying period, the form strikes a balance between rigorous eligibility criteria and the provision of necessary support for injured workers. Moreover, it outlines dispute resolution mechanisms for instances where entitlement to benefits is contested, laying down a clear pathway for the reconciliation of disagreements between all parties involved.

QuestionAnswer
Form NameForm 052
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesform 052, dwc tdi program, tdi application program, dwc application form

Form Preview Example

Texas Department Of Insurance

Division of Workers’ Compensation

7551 Metro Center Dr. Ste.100 • MS-603 Austin, TX 78744-1609

(800) 252-7031 (512) 804-4378 fax www.tdi.texas.gov

Please complete, if known:

DWC Number

Carrier Claim Number

Send first quarter SIBs applications to the TDI-DWC field office handling your claim. Send applications for all other quarters to the insurance carrier.

APPLICATION FOR SUPPLEMENTAL INCOME BENEFITS (DWC Form-052)

SECTION 1: EMPLOYEE INFORMATION

1.

Employee's Name (Last, First, M.I.)

2. Social Security Number

3.

Telephone Number

 

 

 

 

 

 

4.

Mailing Address (Street or P.O. Box, City, State, Zip Code)

 

 

5.

Date of Injury

 

 

 

 

 

6.

Current Treating Doctor’s Name

 

7. Current Treating Doctor’s Telephone Number

 

 

 

 

 

 

SECTION 2: EMPLOYER / INSURANCE CARRIER INFORMATION

1. Employer's Name

2. Insurance Carrier's Name

 

 

 

 

3. Adjuster's Name

4. Adjuster's Telephone Number

Extension

 

 

 

SECTION 3: SIBs QUALIFYING INFORMATION

1.

Impairment Rating

 

2.

Date of Maximum Medical Improvement

 

 

 

 

 

3.

Quarter Number

 

4.

Filing Deadline

 

 

 

 

 

5.

Dates of Quarter

Beginning:

 

Ending:

 

 

 

 

 

6.

Dates of Qualifying Period

Beginning:

 

Ending:

 

 

 

 

 

7.

County of Residence:

 

8.

Number of minimum weekly work search

 

 

 

 

efforts for your county of residence:

 

 

 

 

 

SECTION 4: WORK SEARCH ACTIVITIES FOR THE QUALIFYING PERIOD

To further document work searches, use the “Detailed Job Search / Employer Contact Log” on page 5 of this form.

Week

 

 

Check All That Apply

Notes and Type of

Number

 

 

Documentation Attached (see instructions)

 

 

 

 

 

 

 

Sample

Unable to Work

Working

Work Search Efforts

Copy of my rehab plan from ABC Therapy; copies of three job

 

applications Two jobs found with assistance from staff at Workforce

 

Vocational Rehab Program

 

Number of Work

 

 

Dev’t office, one job vacancy I found in the newspaper

 

 

 

 

 

Searches Conducted 3

 

 

 

 

 

 

1.

Unable to Work

Working

Work Search Efforts

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

Searches Conducted

 

2.

Unable to Work

Working

Work Search Efforts

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

Searches Conducted

 

3.

Unable to Work

Working

 

Work Search Efforts

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

4.

 

Unable to Work

Working

 

Work Search Efforts

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

 

 

DWC052 Rev. 04/09

 

 

 

 

 

Page 1 of 6

Week

 

 

Check All That Apply

 

 

Notes and Type of

Number

 

 

 

 

Documentation Attached (see instructions)

 

 

 

 

 

 

 

 

 

 

5.

 

 

Unable to Work

Working

 

 

 

Work Search Efforts

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

6.

 

 

Unable to Work

Working

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

 

Unable to Work

Working

 

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

8.

 

 

Unable to Work

Working

 

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

 

 

Unable to Work

Working

 

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Work

 

 

 

 

 

Vocational Rehab Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

 

 

Unable to Work

Working

 

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

 

Unable to Work

Working

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

 

 

Unable to Work

Working

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

13.

 

 

Unable to Work

Working

 

 

Work Search Efforts

 

 

 

 

 

 

 

 

 

 

 

 

Vocational Rehab Program

 

Number of Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Searches Conducted

 

 

 

SECTION 5: WAGES DURING QUALIFYING PERIOD

Week Ending

Gross Wages Earned

Week Ending

Gross Wages Earned

 

 

 

 

1.

$

8.

$

 

 

 

 

2.

$

9.

$

 

 

 

 

3.

$

10.

$

 

 

 

 

4.

$

11.

$

 

 

 

 

5.

$

12.

$

 

 

 

 

6.

$

13.

$

 

 

 

 

7.

$

 

 

 

 

 

 

SECTION 6: CERTIFICATION

I certify that:

I have not elected to have any of my impairment income benefits paid in a lump sum;

I am earning less than 80% of my average weekly wage as a result of my impairment from my compensable injury;

I have complied with the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) Work Search Requirements (Texas Labor Code § 408.1415 and Texas Administrative Code §130.101 and §130.102); and,

the information I have provided on this Application for Supplemental Income Benefits is true. I understand that if I intentionally provide false information to obtain benefits, I can be charged with an administrative or criminal penalty.

Employee’s Signature ___________________________________________ Date ________________

DWC052 Rev. 04/09

Page 2 of 6

SECTION 7: NOTICE OF ENTITLEMENT OR NON-ENTITLEMENT

Quarter Number

Beginning Date

Ending Date

TO BE COMPLETED BY TDI-DWC FOR FIRST QUARTER

AND BY INSURANCE CARRIER FOR SUBSEQUENT QUARTERS.

Employee Entitled to Supplemental Income Benefits

Monthly Payments for 3 Months $

 

 

 

 

Employee Not Entitled to Supplemental Income Benefits

 

 

 

Reason for Non-entitlement:

 

 

 

Signature of Reviewing Authority

Date

Printed Name of Reviewing Authority

 

Title

Telephone Number

INFORMATION FOR DISPUTING ENTITLEMENT OR AMOUNT OF SUPPLEMENTAL INCOME BENEFITS:

To Employee

To dispute non-entitlement to supplemental income benefits or the monthly amount to be paid in any quarter, you must have facts, such as your detailed job search/employer contact log or a current narrative report from your doctor supporting your disability, or a legal basis.

To dispute the determination by TDI-DWC or the insurance carrier, you must request a benefit review conference by contacting the TDI-DWC office handling your claim or call (800) 252-7031.

To Insurance Carrier

To dispute the first quarter, request a benefit review conference within 10 days after receiving notice from TDI-DWC.

To dispute entitlement to a subsequent quarter when payment has been made in the previous quarter, request a benefit review conference within 10 days after receiving the employee's Application for Supplemental Income Benefits.

To dispute entitlement to a subsequent quarter without prior payment in the previous quarter, send the notice of non-entitlement to the employee within 10 days of the date the form was filed with the insurance carrier. Include the reason(s) for finding non-entitlement and give instructions to the employee about how to dispute the insurance carrier's determination.

CALCULATION OF SUPPLEMENTAL INCOME BENEFITS

To Be Completed By TDI-DWC Or Insurance Carrier To Show Wages Used To Calculate Monthly Payments

1.

$

x

80%

=

$

 

(Average Weekly Wage)

 

 

 

(Transfer to Line 4A)

2.

$

+

$

=

$

 

(Earned Wages)

 

(Offered Wages)

 

(Transfer to Line 3A)

3.

$

÷

13

=

$

 

(3A - Total Wages)

 

 

 

(Transfer to Line 4B)

 

 

 

 

 

4.

$

$

=

$

 

(4A)

 

(4B)

 

(Transfer to Line 5A)

5.

6.

$

x

80%

=

$

(5A)

 

 

 

(Transfer to Line 6A)

$

x

4.34821

=

$

 

 

(6A)

)

 

 

 

(Monthly Payment*)

 

If Contribution: (%

 

 

 

 

7.

$

 

 

x

 

=

$

 

 

(Monthly Payment)

 

 

(% of Reduction)

 

(Transfer to Line 8B)

8.

$

 

 

$

=

$

 

 

(Monthly Payment)

 

 

(8B - Contribution Reduction)

 

(Reduced Monthly Payment)

*Subject to a maximum amount.

DWC052 Rev. 04/09

Page 3 of 6

APPLICATION FOR SUPPLEMENTAL INCOME BENEFITS (DWC Form-052)

To complete this application, refer to the TDI-DWC publication

“Questions and Answers about Supplemental Income Benefits.”

When do I file the application for SIBs?

The SIBs application deadlines will be different for each injured employee, depending on the dates of the qualifying period. Generally, you must submit your application for SIBs six days before the end of the qualifying period, but no later than seven days after the end date of the qualifying period. For the first quarter, this filing deadline is provided for you in Item #4 of the SIBs notification letter sent to you by the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC). For other quarters, your insurance carrier will provide you with the filing deadline in Section 3, Item # 4 of this form.

Where do I send the completed form?

For the first quarter, send the completed DWC Form-052 and supporting documentation to the TDI-DWC Field Office handling your claim. Field office contact information is available at http://www.tdi.texas.gov/wc/dwccontacts.html#offices. For all other quarters, return the form to your insurance carrier. You may file the form by first class mail, personal delivery or electronic submission (including fax or e-mail).

How many job applications and/or work search contacts must I make if I am actively seeking work?

You must make at least the minimum number of job applications and/or work search contacts consistent with those for unemployment compensation benefits. These vary by county of residence. You must contact TDI-DWC at 1-800-252-7031 or go to the website at http://www.tdi.texas.gov/wc/employee/suppben.html to find the number of minimum weekly work search requirements for the county where you live.

What documentation should I provide to show that I meet TDI-DWC’s work search requirements?

You must maintain supporting documentation, applications, letters, and notes to clearly demonstrate your active efforts to meet the TDI-DWC work search requirements for each week during the entire qualifying period. The following are examples of the various types of acceptable documentation.

To Document Work Searches - If you have not returned to work and you are able to work in any capacity, you must look for a job to match your ability to work during each week of the qualifying period. Appropriate documentation includes:

Work search log attached to DWC Form-052, Application for Supplemental Income Benefits;

Documentation about any follow-up visits to a potential employer; and/or

Copies of employment applications or resumes which document your efforts to find a job.

If you have any offers of employment which you do not accept, you must include information about the offered wages as part of this application. If you are self-employed, show your gross weekly wages as the total amount of income received from self- employment. Use the attached “Detailed Job Search / Employer Contact Log” (page 4 of this form) to document your efforts.

To Document an Inability to Work - If you are unable to work due to your compensable injury for any part or all of the qualifying period, you must submit a narrative report from a doctor which specifically explains how your compensable injury caused your inability to perform any kind of work for the specific period of time.

To Document Participation in Vocational Rehabilitation Services - If you participate in a Vocational Rehabilitation Services program, you must provide documentation to show your efforts to meet the requirements of your vocational rehabilitation plan.

To Document Employment During the SIBs Qualifying Period - You must provide documentation that you earned less than 80% of your average weekly wage as a direct result of your impairment from the compensable injury. Appropriate documentation includes payroll stubs and wage statements.

When and how will I know if I am approved for SIBs?

TDI-DWC will notify you of first quarter SIBs entitlement no later than the last day of your IIBs period. For all subsequent quarters, the insurance carrier must notify applicants of its decision of SIBs entitlement within 10 days of the receipt of an application. The notice will contain specific information regarding the reason for its determination. If you are denied SIBs, the notice will include the grounds for the determination, the beginning and ending dates of the quarter, and instructions for the parties if they want to dispute the decision.

Where do I find more information regarding SIBs?

More information about SIBs, including a listing of each Texas county’s number of minimum work searches and the TDI-DWC publication “Questions and Answers about Supplemental Income Benefits,” is available on the website at http://www.tdi.texas.gov/wc/employee/suppben.html.

NOTE: With few exceptions, you are entitled on request to be informed about the information that TDI-DWC collects about you. Under §§552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under §559.004 of the Government Code you are entitled to have TDI-DWC correct information about you that is incorrect. For more information, call the local TDI-DWC field office at 800-252-7031.

DWC052 Rev. 04/09

Page 4 of 6

Detailed Job Search / Employer Contact Log (provide detail for each job contact)

Name:

 

 

 

Number of minimum weekly work search efforts for your county of residence:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

Business Name, Address,

Contacted

 

Submitted

 

Person Contacted

Description

 

Results

(mm/dd/yyyy)

Phone and Website

 

 

 

 

 

 

 

 

 

 

 

 

of Job

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

 

 

Start date

 

 

 

 

 

 

web

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

Start date

 

 

 

 

 

 

web

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

Start date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

web

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

Start date

 

 

 

 

 

 

web

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURED EMPLOYEES MUST DOCUMENT EACH EMPLOYER CONTACT- USE ADDITIONAL PAGES AS NEEDED

DWC052 Rev. 04/09

Page 5 of 6

Detailed Job Search / Employer Contact Log (provide detail for each job contact)

Name:

 

 

 

Number of minimum weekly work search efforts for your county of residence:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

Business Name, Address,

Contacted

 

Submitted

 

Person Contacted

Description

 

Results

(mm/dd/yyyy)

Phone and Website

 

 

 

 

 

 

 

 

 

 

 

 

of Job

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

 

 

Start date

 

 

 

 

 

 

web

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

Start date

 

 

 

 

 

 

web

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

Start date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

web

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In person

 

Cover letter

 

 

 

 

 

 

 

 

 

 

Job offered

 

 

 

 

 

Application

Name

 

 

 

 

 

 

 

 

Amount of

 

 

 

 

By phone

 

 

 

 

 

 

 

 

 

 

 

Resume

 

 

 

 

 

 

 

 

 

 

wages offered

 

 

 

 

 

 

 

 

By fax

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accepted offer?

 

 

 

 

By mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

By e-mail /

 

 

 

 

Fax

 

 

 

 

 

Start date

 

 

 

 

 

 

web

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

Not hiring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURED EMPLOYEES MUST DOCUMENT EACH EMPLOYER CONTACT- USE ADDITIONAL PAGES AS NEEDED

DWC052 Rev. 04/09

Page 6 of 6

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Step number 1 for completing dwc program

2. Once your current task is complete, take the next step – fill out all of these fields - SECTION EMPLOYER INSURANCE, Insurance Carriers Name, SECTION SIBs QUALIFYING, Date of Maximum Medical, Dates of Quarter Beginning Ending, Dates of Qualifying Period, County of Residence, Number of minimum weekly work, efforts for your county of, SECTION WORK SEARCH ACTIVITIES, To further document work searches, Week, Number Sample Unable to Work, Check All That Apply, and Notes and Type of with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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Be very mindful while completing Notes and Type of and Insurance Carriers Name, since this is the section in which most users make some mistakes.

3. The next stage is hassle-free - fill out all the empty fields in Number Sample Unable to Work, Unable to Work Working Vocational, Unable to Work Working Vocational, Unable to Work Working Vocational, Unable to Work Working Vocational, Number of Work Searches Conducted, Copy of my rehab plan from ABC, and DWC Rev Page of to conclude this segment.

Unable to Work Working Vocational, Unable to Work Working Vocational, and Number Sample Unable to Work inside dwc program

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Stage no. 4 of completing dwc program

5. Since you near the last sections of this form, there are actually a couple extra points to complete. In particular, Unable to Work Working Vocational, Unable to Work Working Vocational, Work Search Efforts Number of Work, SECTION WAGES DURING QUALIFYING, Week Ending, Gross Wages Earned, Week Ending, and Gross Wages Earned should all be done.

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