Who must file this notice?

Typically the employer or a legal representative files the notice with the insurer and state workers’ compensation office; family members or counsel may submit beneficiary claims. Follow the state agency’s form and submission rules to ensure proper routing.

Can the notice be signed electronically?

Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. §7001) and state UETA laws, unless a state-specific exception applies. Use a secure platform that captures an auditable trail and, for PHI, a BAA if required.

What attachments are required?

Attach medical reports, coroner or autopsy reports, incident reports, and proof of relationship for claimants. Missing attachments commonly cause requests for supplemental information and delay claim determinations.

How do I correct an error after submission?

Contact the insurer and state claims office immediately and submit an amended notice with a clear explanation. Keep proof of communications and retain both the original and corrected records for audit trails.

What privacy safeguards are needed?

Limit access to PHI, use encrypted transmission and storage, and ensure any vendor handling PHI signs a BAA; follow HIPAA privacy and security obligations to avoid penalties.

Who to contact if a claim is denied?

Review the denial reason, collect missing documentation, and contact the insurer’s claims adjuster or a workers’ compensation attorney to discuss appeals deadlines and evidentiary steps.

Electronic Signature
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Notice of Fatal Injury or Occupational Disease Claim

Notice of Fatal Injury or Occupational Disease Claim

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease (DWC Form-041)

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

Send the completed form to this address.

DWC Claim#

Carrier Claim#

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

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

injury 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?

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

Instructions

This form is based on the Texas Department of Insurance, Division of Workers’ Compensation DWC Form-041 instructions shown on page 2 of the PDF. Please complete all fields accurately.

What the Notice of Fatal Injury or Occupational Disease Claim Is

The Notice of Fatal Injury or Occupational Disease Claim is a formal record used to report a work-related fatality or a death attributed to an occupational disease to the employer, insurer, and relevant state workers' compensation authority. It documents the decedent's identity, date and cause of death, employer and workplace information, claimant relationship, and supporting medical or coroner reports. The notice initiates claim handling, benefits review, and statutory investigations such as OSHA inquiries or state workers' compensation investigations and creates an administrative record for benefit entitlement and legal compliance.

Why this Notice Matters for Compliance and Benefits

Filing a clear, complete notice preserves the deceased worker’s beneficiaries’ rights to death benefits, starts claims processing, and triggers any required employer or regulator actions. Accurate submission reduces delay in benefit payments and lowers the risk of administrative penalties or disputes.

Who completes and receives this notice

Typical filers and recipients vary by role but include employers, insurers, legal representatives, and next of kin; state agencies also receive official copies.

Employers and HR departments responsible for reporting and recordkeeping to insurers and state agencies.
Workers' compensation insurers and claims examiners who open and adjudicate death claims.
Attorneys, union representatives, or family members who pursue benefits or file appeals.

Maintain contact information for all recipients and document delivery dates to support claim timelines and any regulatory inquiries.

Step-by-step: preparing and filing the notice

Follow these four practical steps to assemble the notice and submit it to the employer, insurer, and the correct state agency.

01

Gather records: Collect ID, medical, coroner, and incident reports.
02

Complete form: Fill each field accurately using MM/DD/YYYY.
03

Attach evidence: Include all supporting documents and label them.
04

Submit to parties: Send to insurer, employer, and state claims unit.

Where to send the Notice and how routing typically works

The notice travels through employer, insurer, and regulator channels; use this routing guide to ensure all required recipients receive timely copies.

State claims office: File the official notice with your state workers' compensation agency.
Employer records: Place a dated copy in the employer’s incident and payroll files.
Insurer notification: Deliver to the employer’s workers’ comp insurer for claim opening.
OSHA reporting: Notify OSHA if the incident meets federal reporting thresholds.

Setting up a digital workflow for online completion

Configure these core fields and notifications when creating an online form to preserve auditability and ensure complete submissions.

Field	Configuration
Signature	Required \| Signer must enter full name and date
Authentication	Email + SMS code or ID check for sensitive filings
Attachments	Allow PDF, JPG; require mandatory evidence upload
Notifications	Send receipts to filer and insurer automatically

Technical considerations for digital filing and eSubmission

Use a platform that supports secure uploads, an auditable signature trail, and the file formats your regulator accepts.

Accepted formats: PDF, DOCX, JPG
Authentication options: Email link, SMS, KBA
Integrations: Common integrations: HRIS and claims systems

Ensure the system retains timestamps and an audit trail and can export the record in standard PDF/A or original formats for regulator review.

Timelines and statutory reporting requirements to track

Some reporting duties are time-critical; missing deadlines can trigger fines or impede benefit payments. Track both federal and state timelines.

OSHA fatality report:

Fatalities must be reported to OSHA within 8 hours (29 CFR 1904.39).

Insurer notice:

Notify the insurer as soon as practicable; many states expect prompt notice.

State claim filing:

File with the state workers’ compensation office per state deadlines.

Beneficiary claims:

Family should file benefit claims promptly to avoid statute of limitations issues.

Record retention:

Retain original records according to federal and state retention rules.

Consequences of inaccurate or late notices

Benefit delays: Payments may be postponed

Denial risk: Claim eligibility can be disputed

Regulatory fines: OSHA or state penalties possible

Legal exposure: Civil suits or wrongful death claims

Tax implications: Withholding and reporting complications

Record disputes: Problems proving timely notice

Common mistakes to avoid when preparing the notice

Incomplete identification details: missing middle name, suffix, or incorrect DOB can delay verification and benefits processing by insurers.
Failure to attach medical or coroner reports: omission often triggers requests for supplemental documents and lengthens adjudication timelines significantly.
Using informal language or vague cause descriptions: state examiners need clinical cause-of-death terms and a clear link to occupational exposure or incident.
Not documenting delivery: failing to keep submission receipts or delivery confirmations undermines proof of timely filing in disputes.

Security and privacy considerations for handling notices

Encryption: TLS 1.2/1.3 in transit

Data at rest: AES-256 encrypted storage

Audit trail: Timestamped signer actions

HIPAA: BAA required for PHI

Access controls: Role-based permissions

Certifications: SOC 2 Type II and ISO 27001

eSignature vendor pricing and capability snapshot for filing notices

Basic pricing and feature availability for common eSignature providers. signNow is listed first per comparison protocol; plan details vary by vendor and tier.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about filing and eSigning the notice

Answers to common questions about who files, what to attach, electronic signing, and next steps when corrections are needed.

Need help? Contact support

Who must file this notice?
Typically the employer or a legal representative files the notice with the insurer and state workers’ compensation office; family members or counsel may submit beneficiary claims. Follow the state agency’s form and submission rules to ensure proper routing.
Can the notice be signed electronically?
Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. §7001) and state UETA laws, unless a state-specific exception applies. Use a secure platform that captures an auditable trail and, for PHI, a BAA if required.
What attachments are required?
Attach medical reports, coroner or autopsy reports, incident reports, and proof of relationship for claimants. Missing attachments commonly cause requests for supplemental information and delay claim determinations.
How do I correct an error after submission?
Contact the insurer and state claims office immediately and submit an amended notice with a clear explanation. Keep proof of communications and retain both the original and corrected records for audit trails.
What privacy safeguards are needed?
Limit access to PHI, use encrypted transmission and storage, and ensure any vendor handling PHI signs a BAA; follow HIPAA privacy and security obligations to avoid penalties.
Who to contact if a claim is denied?
Review the denial reason, collect missing documentation, and contact the insurer’s claims adjuster or a workers’ compensation attorney to discuss appeals deadlines and evidentiary steps.

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