Fill and Sign the Dwc Form 041 Employees Claim for Compensation for a

DWC051 Rev. 02/17 Page 1 of 2 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. Date of Injury (mm/dd/yyyy) 4. Mailing Address (Street or P. O. Box, City, State, Zip Code) 5. Employer's Business Name 6. 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 wag e. The Texa s Department of Insurance, Division of Workers' Compensation (TDI-DW C) 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-DW C 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 resu lt of your impairment, and if you in good faith have tried to obtain employment in line with your ability to w ork. 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 T HE INJURY. Medical benefits related to this injury will not be affected if you recei ve 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] 7. Maximum Medical Improvement Date as Determined by a Doctor (mm/dd/yyyy) 8. Impairment Rating % Rating Doctor's Name Did you or insurance carrier dispute the rating? Yes No Weekly Impairment Income Benefit Amount $ 9. Date Returned to Work (mm/dd/yyyy) Present Rate of Pay $ Hourly W eekly Monthly Other Have you returned to work for at least 3 months? Yes No 10. I hav e 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 11. Da te Received From Employee (mm/dd/yyyy) 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 ACCEPTED, PAYMENT ENCLOSED Lump Sum Amount Paid $ Date Paid (mm/dd/yyyy) For Period From (mm/dd/yyyy) To (mm/dd/yyyy) Carrier Representative's Printed Name __________________________________________ Signature _______________________________________________________ Date _____________________ DWC051 Rev. 02/17 Page 2 of 2 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 mont hs earning at least 80% of the employee's average weekly wage. How to A pply The employee may apply to receive a lump sum (commute) by filing an Employee's Election for Comm uted (Lump Sum) Impa irment 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-DW C 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 t he 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-DW C to set a benefit review conference to resolve the issue. Eligibility for f urther 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 S tatutes Texas Workers' Compensation Act: http://www.tdi.t exas.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 loca l TDI-DWC Field Office at 800 -252 -7031. NOTE : With few exceptions, upon your request, you are entitled to be informed about the inform ation TDI-DWC collects about you; get and review the information (Government Code, §§552.021 and 552.023); and have T DI-DWC correct information that is incorrect (Government Code, §559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure section at www.tdi.texas.gov .