Fill and Sign the Notice of Fatal Injury or Occupational Disease and Claim for Form

DWC041 Rev. 03/07 Page 1 of 1 DWC Claim# Carrier Claim# Texas Department Of Insurance 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.texas.gov Å Send the completed form to this address. Employee's Claim for Compensati on for a Work-Related Injury or Occupational Disease (DWC Form-041) Claim for workers’ compensation must be filed by the injur ed 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 kn ew 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 Do you speak English? Yes No If no, specify language Marital status Married Widowed Separated Single Divorced 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 Instructions Information about Employee's Claim fo r 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 employ er 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 o If you have returned to your regular job and you are performing the same duties as you were before your injury, check the “Regular” box. o If 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 t he work you do, and may include injuries to your body that are the result of repetitive activities y ou 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 treati ng 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’ co mpensation 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 §559.00 4 of the Texas Government Code you are entitled to have the Division correct information the Division cr eates about you or your workers’ compensa tion claim that is incorrect. For more information, call the Division’s Op en Records section at 512-804-4437.