Form Twcc-1 - Texas Department Of Insurance 2016-2024

Form Twcc-1 - Texas Department Of Insurance: What You Should Know

This has to be done at the Division of Workers' Compensation Form TWCC-1 Rev. 10/05 If the driver is a personal representative of your estate, you may need to file a copy of this form with the Texas office of the Office of Injured Employee Counsel. Send this form to your local Workers' Compensation Insurance Carrier. Your name: Address: City, Zip Code, Province, and State of residence: Employer's First Report of Injury or Illness [DWC FORM-001 Rev. 10/05] Page 2. DIVISION OF WORKERS' COMPENSATION. 2. In this form, you will be asked if you wish to report your accident on your Personal Injury Report (AIR). DIVISION OF WORKERS' COMPENSATION FORM-0008 Send this form to the Division of Workers' Compensation Division of Workers' Compensation. 2. If you have a Personal Injury Report submitted to the Texas Department of Insurance through a carrier with whom you have an employment relationship, the Division of Workers' Compensation will not accept  DWC FORM-0009 because the statement you are submitting is not a report. The Division of Worker's Compensation will accept any report for workers' compensation purposes. A Personal Injury Report should only be submitted if you (or anyone present during your accident) had a work-related injury that caused your work at the time of the accident, DWC FORM-0009 (Rev. 10/05) Page 3. DIVISION OF WORKERS' COMPENSATION. 3. You must enter the following for the name of the injured worker: Name of the injured worker:  Address of injured worker's business: A business address is required in this case Address of injured worker's home: City and State of residence: Driver's name and hometown (if different from worker) A work address is required if you did not use a personal address If you are the executor, administrator, or personal representative of an estate, send the form to the Office of Injured Employee Counsel.

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