Texas Form Dwc041 PDF Details

Embarking on the journey of understanding workers’ compensation claims in Texas introduces various forms and procedures, among which the DWC041 form stands pivotal. Designed by the Texas Department of Insurance, Division of Workers’ Compensation, this form serves as an initial claim instrument for employees seeking compensation due to work-related injuries or occupational diseases. It requires comprehensive details including personal information, injury specifics, employment, and medical provider data. Crucially, the form mandates filing within a specific timeframe – generally, within one year from the injury date or from when the employee discerns the work-related nature of their disease, unless justified exceptions apply. Submission of this accurately completed form initiates the claim process, triggering the Division to assign a claim number and inform relevant parties. Moreover, it embodies provisions for those with reduced English proficiency and outlines rights to information access and correction as per Texas government statutes, ensuring transparency and inclusivity. Such nuances accentuate the DWC041's role not merely as a document, but as a gateway to potential benefits and a lynchpin in navigating the workers’ compensation landscape in Texas.

QuestionAnswer
Form NameTexas Form Dwc041
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesyyyy, DWC, Texas, Form-041

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T e x a s De pa rt m e nt Of I nsura nc e

Division of Workers’ Compensation

Records Processing

7551 Metro Center Dr. Ste.100 • MS-94 Austin, TX 78744-1609

(800) 252-7031 (512) 804-4378 fax www.tdi.state.tx.us

DWC Claim#

Carrier Claim#

äSend the completed form to this address.

Employee's Claim for Compensation for a Work-Related Injury

or Occupational Disease (DWC Form-041)

Claim for workers’ compensation must be filed by the injured employee or by a person acting on the injured employee’s behalf within one year of the date of injury or within one year from the date the injured employee knew or should have known the injury or disease may be work-related.

I. INJURED EMPLOYEE INFORMATION

 

Name (First, Middle, Last )

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

Date of birth (mm / dd / yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (street, city/town, state, zip code, county, country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

E-Mail address

 

 

 

 

 

 

 

 

 

Sex

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race / Ethnicity

White, not of Hispanic Origin

Black, not of Hispanic Origin

Hispanic

Asian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

If no, specify language

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you speak English?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

 

Widowed

 

 

 

 

Separated

 

 

Single

Divorced

 

 

 

 

 

 

 

 

Marital status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have an attorney or other representation?

Yes

No

If yes, name of representative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you returned to work?

Yes

 

 

No

 

If returned to work, date returned (mm/dd/yyyy)

 

Work status

Regular

Restricted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupation at time of injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of hire (mm / dd / yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hired or recruited in Texas

 

Yes

No

 

 

Pre-tax wages (at the time of injury)

$

 

 

hourly

weekly

monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. INJURY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am reporting an

injury or

occupational disease

 

 

Date of injury (mm / dd / yyyy)

 

 

 

Time of injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First work day missed (mm / dd / yyyy)

 

 

 

 

 

 

 

 

 

Date injury was reported to the employer (mm / dd / yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Where did the injury occur? County

 

 

 

 

 

 

 

 

State

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If accident occurred outside of Texas, on what date did you leave Texas? (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witness(es) to the injury (list by name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe cause of injury or occupational disease, including how it is work related

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Body part(s) affected by the injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If injury is the result of an occupational disease:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. On what date was the employee last exposed to the cause of the occupational disease? (mm / dd / yyyy)

 

 

 

 

 

2. When did you first know occupational disease was work related? (mm / dd / yyyy)

 

 

 

 

 

 

 

 

 

 

 

III. EMPLOYER INFORMATION (at the time of injury)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer name

 

 

 

 

 

 

 

 

 

 

 

 

Employer address (street, city/town, state, zip code, county, country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer phone number

 

 

 

 

 

 

 

 

 

 

Supervisor name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV. DOCTOR INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of treating doctor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (street, city/town, state, zip code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of workers’ compensation health care network, if any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of injured employee or person filling out this form on behalf of injured employee

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed name of injured employee or person filling out form on behalf of injured employee

 

 

 

 

 

 

 

 

 

 

 

DWC041 Rev. 03/07

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Information about Employee's Claim for Compensation for a Work-Related

Injury or Occupational Disease (DWC Form-041)

A claim for Workers' Compensation benefits must be filed with the Division of Workers’ Compensation (Division) by the injured employee (you), or by a person acting on the injured employee's (your) behalf within one year of the injury or within one year from the date you knew or should have known the injury or disease may be work related; UNLESS good cause exists for the failure to timely file a claim, or the employer or the employer's insurance carrier does not contest the claim.

Upon receipt of your completed DWC Form-041, or other notice of your injury, the Division will create a claim and establish a DWC claim number for you, and the Division will mail information regarding workers’ compensation in Texas to you. The Division will also notify your employer and the employer’s workers’ compensation insurance carrier.

SPECIAL INSTRUCTIONS AND INFORMATION FOR COMPLETING THE DWC Form-041

General Instructions

•Complete all boxes in the DWC Form-041.

•If you have questions about completing this form, please call your local Division Field Office at 1-800-252-7031.

Injured Employee Information

•Work Status information

oIf you have returned to your regular job and you are performing the same duties as you were before your injury,

check the “Regular” box.

oIf you have been released to work with restrictions by a doctor, check “Restricted.”

Injury Information

•An injury is damage to your body that was caused by a single incident, accident, or event.

•An occupational disease is an illness or injury related to or caused by the work you do, and may include injuries to your body that are the result of repetitive activities you performed on the job over a period of time.

Employer Information

•Provide information about your employer at the time you were injured.

Doctor Information

•If you already have a workers’ compensation treating doctor, provide the name and address of the doctor.

•If you are covered under a workers’ compensation healthcare network, provide the name of the network.

Contacting Texas Department of Insurance, Division of Workers’ Compensation

If you have questions about filling out this form or workers’ compensation in Texas, please call your local Division Field Office at 1-800-252-7031.

NOTE: With few exceptions, you are entitled, on request, to be informed about the information that the Division collects or maintains about you and your workers’ compensation claim. Under §552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under §559.004 of the Texas Government Code you are entitled to have the Division correct information the Division creates about you or your workers’ compensation claim that is incorrect. For more information, call the Division’s Open Records section at 512-804-4437.

DWC041 Rev. 03/07

Instructions

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