Form 052 – Fill Out and Use This PDF

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