Form Dwc051 PDF Details

Navigating the intricacies of receiving impairment income benefits (IIBs) after a workplace injury in Texas can be complex, but the DWC051 form serves as a crucial tool for injured employees seeking to assert their rights under the Texas Workers' Compensation Act. Specifically designed to facilitate the process of electing commuted (lump sum) impairment income benefits, this form is essential for those who have made a significant recovery and returned to work, earning at least 80% of their average weekly wage. The Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC), mandates the submission of this form to both the insurance carrier and a TDI-DWC field office, ensuring that the employee's choice to receive a lump sum payment is processed efficiently. The form includes sections for personal information, details about employment and injury, and an option for the employee to confirm they have read and understood their election. Additionally, it outlines the procedure for appealing a denied request through the benefit review conference system, stressing the importance of timely communication and the implications of accepting a lump sum on future benefits. As such, it encapsulates a key intersection between employee rights and the procedural framework established by the Texas Workers' Compensation Act, serving as a vital document for navigating post-injury financial recovery.

QuestionAnswer
Form NameForm Dwc051
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesForm-051, tdi, DWC051, tdi dwc051

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Texas Department Of Insurance

Division of Workers’ Compensation

Records฀Processing฀ 7551฀Metro฀Center฀Dr.฀฀Ste.100฀฀MS-93฀ Austin,฀TX฀78744-1609฀ (800)฀252-7031฀฀(512)฀804-4378฀fax฀฀฀฀฀www.tdi.texas.gov

DWC Claim#฀฀฀฀ ฀ ฀ ฀ ฀ ฀

Carrier Claim#฀฀฀฀ ฀ ฀ ฀ ฀

Send฀the฀completed฀original฀form฀to฀the฀insurance฀carrier.฀฀ Send฀a฀copy฀to฀TDI-DWC฀field฀office฀handling฀the฀claim.฀

EMPLOYEE'S ELECTION FOR COMMUTED (LUMP SUM) IMPAIRMENT INCOME BENEFITS (DWC Form-051)

1.฀฀Employee's Name

2.

Telephone Number฀฀

3.฀฀Social Security Number

4.฀฀Date of Injury(mm/dd/yyyy)

฀ ฀

฀ ฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀

(last฀4฀digits) xxx-xx

฀ ฀ ฀ ฀ ฀ ฀

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

฀ ฀ ฀ ฀ ฀ ฀

฀6.฀฀Employer's Business Name

7.฀฀Insurance Carrier's Name

Notice to Employee:฀฀Section฀408.128฀of฀the฀Texas฀Workers'฀Compensation฀Act฀allows฀you฀to฀elect฀to฀receive฀your฀impairment฀income฀benefits฀in฀a฀lump฀ sum฀if฀you฀have฀returned฀to฀work฀for฀at฀least฀three฀months,฀earning฀at฀least฀80%฀of฀your฀average฀weekly฀wage.฀

The฀Texas฀Department฀of฀Insurance,฀Division฀of฀Workers'฀Compensation฀(TDI-DWC)฀field office handling your claim฀will฀assist฀you฀with฀information฀to฀ complete฀this฀form,฀if฀needed.฀฀If฀the฀insurance฀carrier฀denies฀your฀request,฀you฀may฀request฀TDI-DWC฀to฀set฀a฀benefit฀review฀conference฀by฀calling฀800- 252-7031.฀฀

WARNING: Supplemental Income Benefits may be available to you at the end of the impairment period if you have an impairment rating of 15% or more, are earning less than 80% of your average weekly wage as a direct result of your impairment, and if you in good faith have tried to obtain employment in line with your ability to work. IF YOU RECEIVE A LUMP SUM PAYMENT OF YOUR IMPAIRMENT INCOME BENEFITS, YOU WILL NOT BE ABLE TO RECEIVE SUPPLEMENTAL INCOME BENEFITS OR ANY ADDITIONAL INCOME BENEFITS FOR THE INJURY. Medical benefits related to this injury will not be affected if you receive a lump sum.

[Section 408.128, Commutation of Impairment Income Benefits, Section 408.041- 408.0446, Average Weekly Wage, Section 408.142, Supplemental Income Benefits, Texas Workers' Compensation Act; Rule 147.10]

8.฀Maximum Medical Improvement Date as Determined by a Doctor฀฀(mm/dd/yyyy)฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀

9.฀Impairment Rating฀ ฀฀฀฀฀฀฀ ฀ ฀ ฀ ฀%฀฀฀฀฀฀฀฀฀Rating Doctor's Name฀ ฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀฀฀฀

Did you or insurance carrier dispute the rating?฀฀฀Yes฀฀฀฀No฀฀฀฀฀฀฀

฀฀฀฀Weekly Impairment Income Benefit Amount฀$฀฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀

10.฀Date Returned to Work(mm/dd/yyyy)฀฀ ฀ ฀฀฀฀฀฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀

 

 

 

฀฀฀฀Present Rate of Pay ฀$฀฀ ฀ ฀ ฀฀฀฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀฀฀฀฀฀

฀Hourly฀฀฀฀฀฀

฀Weekly฀฀฀฀฀฀

฀Monthly฀฀฀฀฀฀

฀Other฀฀฀฀฀

฀฀฀฀Have you returned to work for at least 3 months?฀฀฀฀฀ ฀Yes฀฀฀฀฀฀฀฀฀฀ ฀No฀฀฀

 

 

11.฀I have read and understood this form, or it has been explained to me.

 

 

฀฀฀฀฀฀Employee's Signature฀___________________________________฀฀฀฀Date(mm/dd/yyyy)฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀฀฀฀฀฀฀฀ ฀

TO BE COMPLETED ONLY BY THE INSURANCE CARRIER

12.฀Date Received From Employee(mm/dd/yyyy)

฀ ฀ ฀ ฀ ฀ ฀

ACCEPTED, PAYMENT ENCLOSED฀฀฀฀฀฀฀

DENIED - DOES NOT MEET REQUIREMENTS SET BY LAW

฀Employee฀not฀earning฀at฀least฀80%฀of฀preinjury฀฀average฀weekly฀wage฀

฀Employee฀not฀employed฀for฀at฀least฀3฀months฀฀ ฀Impairment฀rating฀being฀disputed฀

Lump Sum Amount Paid฀$฀฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀ ฀฀฀฀฀Date Paid(mm/dd/yyyy)฀ ฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀฀฀฀

For PeriodFrom฀฀(mm/dd/yyyy)฀฀฀ ฀ ฀฀฀฀฀฀฀฀฀฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀฀฀฀฀฀฀To฀฀(mm/dd/yyyy)฀฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀

Carrier Representative's Printed Name฀฀__________________________________________฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀

Signature฀฀_______________________________________________________฀฀฀฀฀฀฀฀฀฀฀฀฀฀Date฀_____________________฀

DWC051฀Rev฀11/08฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Page฀1฀

Employee's Election for Commuted (Lump Sum)

Impairment Income Benefits (DWC FORM-051)

Who may use this form to elect lump sum impairment income benefits (IIBs)?

An฀ injured฀ employee฀ may฀ elect฀ to฀ receive฀ the฀ remainder฀ of฀ impairment฀ income฀ benefits฀ to฀ which฀ the฀ employee฀is฀entitled฀in฀a฀lump฀sum฀if฀the฀employee฀has฀returned฀to฀work฀for฀at฀least฀three฀months฀earning฀ at฀least฀80%฀of฀the฀employee's฀average฀weekly฀wage.฀฀฀

How to Apply The฀employee฀may฀apply฀to฀receive฀a฀lump฀sum฀(commute)฀by฀filing฀an฀Employee's฀Election฀for฀Commuted฀ (Lump฀ Sum)฀ Impairment฀ Income฀ Benefits฀ (DWC฀ FORM-051)฀ with฀ the฀ workers'฀ compensation฀ insurance฀ carrier.฀ ฀ The฀ employee฀ must฀ also฀ send฀ a฀ copy฀ of฀ the฀ completed฀ form฀ to฀ the฀ Texas฀ Department฀ of฀ Insurance,฀Division฀of฀Workers'฀Compensation฀(TDI-DWC).฀฀The฀form฀may฀be฀obtained฀by฀contacting฀your฀ local฀ field฀ office฀ at฀ 800-252-7031฀ or฀ downloading฀ it฀ from฀ the฀ website฀ at฀ http://www.tdi.texas.gov/forms/form20employee.html.฀

Notice of Approval or Denial From Carrier The฀insurance฀carrier฀must฀send฀a฀notice฀of฀approval฀or฀denial฀to฀both฀TDI-DWC฀and฀the฀injured฀employee฀ no฀ later฀ than฀ 14฀ days฀ after฀ receipt฀ of฀ the฀ request.฀ ฀ A฀ notice฀ of฀ approval฀ must฀ include฀ payment฀ of฀ the฀ impairment฀ income฀ benefits฀ in฀ a฀ lump฀ sum.฀ ฀ A฀ notice฀ of฀ denial฀ must฀ include฀ the฀ insurance฀ carrier's฀ reason(s)฀for฀denial.฀

If฀the฀injured฀employee฀does฀not฀receive฀notice฀of฀approval฀or฀denial฀timely฀from฀the฀insurance฀carrier,฀the฀ injured฀employee฀may฀contact฀the฀local฀TDI-DWC฀field฀office.฀฀If฀the฀insurance฀carrier฀denies฀the฀request,฀ the฀injured฀employee฀may฀request฀TDI-DWC฀to฀set฀a฀benefit฀review฀conference฀to฀resolve฀the฀issue.฀

Eligibility for Further Income Benefits if Approved If฀the฀injured฀employee฀receives฀a฀lump฀sum฀payment฀of฀impairment฀income฀benefits,฀the฀employee฀will฀not฀ be฀eligible฀to฀receive฀supplemental฀income฀benefits฀or฀any฀other฀income฀benefits฀for฀the฀injury.฀฀Medical

benefits related to this injury will not be affected by receiving the lump sum IIBs.

Applicable Statutes

Texas฀Workers'฀Compensation฀Act:฀฀http://www.tdi.texas.gov/wc/act/index.html

Section฀408.128,฀Commutation฀of฀Impairment฀Income฀Benefits฀

Section฀408.041-408.0446,฀Average฀Weekly฀Wage฀

Section฀408.142,฀Supplemental฀Income฀Benefits฀

Questions?

If฀you฀have฀questions฀about฀this฀form,฀contact฀staff฀at฀your฀local฀TDI-DWC฀Field฀Office฀at฀800-252-7031.฀

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.฀

DWC051฀Rev.฀11/08฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Instructions฀฀

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2. When the previous section is completed, you have to add the required specifics in Section Commutation of Impairment, Maximum Medical Improvement Date, Impairment Rating Rating, Did you or insurance carrier, Yes, Weekly Impairment Income Benefit, Date Returned to Workmmddyyyy, Present Rate of Pay, Hourly, Weekly, Monthly, Other, Have you returned to work for at, Yes, and I have read and understood this so you're able to go further.

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