Fill and Sign the Texas Workers Form

     CARRIER'S CLAIM #                                                             decrease increase your weekly temporary income benefit payment to $       your wages. The proposed effective date of this change in your weekly payment is $       within two (2) weeks from the date of this notice which is                               Send to: Injured Employee TWCC# TWCC Field Office Handling ClaimNOTICE TO EMPLOYEE: INTENTION TO REQUEST COMMISSION PERMISSION TO ADJUST BENEFITS Instructions for Insurance Carrier: The insurance carrier must obtain approval from the Texas Workers' Compensation Commission before an injured seasonal employee's temporary income benefits are adjusted because of a seasonal change in wages. When Commission approval is requested for an adjustment, the injured employee must be informed of the intent by mailing by first class mail this notice to the employee. 1. Employee's Name (Last, First M.I.) and Telephone Number 2. Social Security Number 3. Date of Injury 4. Mailing Address (Street or P.O. Box) 5. Employer's Business Name City State ZIP Code 6. Insurance Carrier's Name *** NOTICE TO EMPLOYEE *** I the workers' compensation insurance carrier in the above NAME OF CARRIER styled claim, intends to request approval from the Texas Workers' Compensation Commission to because of a seasonal change in You must submit to the insurance carrier's adjuster at the address shown below any available wage information The information may include wage records from the Texas Employment Commission, copies of your W-2 forms, copies of bank statements, affidavits from your employer(s), payroll check stubs, or other documents showing your wages during previous years. Failure to submit the information may result in your weekly temporary income benefit being decreased based on your wage history for the most recent five (5) quarters available from the Texas Employment Commission. You have the right to request a Benefit Review Conference to resolve a dispute concerning a seasonal change in your wages. If you have any questions or need assistance, you can reach the Texas Workers' Compensation Commission at its toll-free number 1-800-252-7031 or contact the Commission field office handling your claim. 7. Adjuster's Name 8. Adjuster's Business Mailing Address (PRINTED) 9. Adjuster's Telephone Number City State ZIP Code Interim TWCC-54 (Rev. 05/93) Traducción en español al reverso.