Establishing secure connection…Loading editor…Preparing document…

Workers' Compensation Form DWC-1 Notice of Potential

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

REQUEST FOR COPIES OF CONFIDENTIAL CLAIMANT INFORMATION

TEXAS DEPARTMENT OF INSURANCE

DIVISION OF WORKERS' COMPENSATION

7551 Metro Center Drive, Suite 100, Austin, TX 78744

Please carefully read the information on both sides of this form and the accompanying instructions. Incorrectly completed forms will be returned without action. This form must be signed by a party eligible to receive the information requested. The signature must be notarized.

(Please type or print)

Submit a separate DWC Form-153 for each DWC or IAB #

I. Claim File Identification

Provide the following information to identify the requested claim file.

DWC or IAB Number

Employee's Social Security Number (last 4)

Employee's Name

Employee's Date of Injury

Address

City

State

Zip Code

II. Requestor Information

Provide the following information pertaining to the requestor.

Name

DWC/Representative Box No. (If Applicable)

Address

E-mail Address

City, State

ZIP

Telephone No.

Fax No.

III. Information Requested

Please indicate the information and services requested.

Claim File

Certified

Uncertified

Dispute Resolution Contact Data (electronic)

Complete File

Specific Document in File:

Medical Dispute Resolution File (after 1/1/91)

Certified

Uncertified

Tracking No:

Medical Dispute Resolution Contact Data (electronic)

Complete File

Specific Document in File:

Indemnity Dispute Resolution File (claims with a date of injury after 1/1/91 only)

Certified

Uncertified

DWC Docket No:

Complete File

Specific Document in File:

Video Tape (if available)

CD (if available)

Audio Tape (if available)

Tape Transcription: Hourly Rate

IV. Requestor Eligibility and Notarization

Please check one box only.

The employee or the employee's legal beneficiary

(Attach documentation)

The employee's or the legal beneficiary's representative

(Attach documentation)

The insurance carrier or insurance carrier’s legal counsel/representative

(Attach documentation)

The Texas Property and Casualty Insurance Guaranty Association

If the association has assumed the obligations of an impaired insurance company.

The employer at the time of injury

Requestor must provide injured employee's period of employment

fromto

A third party litigant in a lawsuit

Copy of petition and answer must be attached.

Requestor must provide injured employee's date of injury

The Texas Certified Self-Insurer Guaranty Association

Established under Subchapter G, Chapter 407, if it has assumed obligations of an impaired employer.

Health Care Provider who is a party to a Medical Dispute

(Section 413.031 of the Act)

I have read and understand this form and the accompanying instructions. I am entitled to receive the confidential employee information being requested as indicated above. I understand that it is a Class A misdemeanor to unlawfully receive, publish, disclose, or distribute confidential information in or derived from an employee's claim file.

Name of Requestor (Please Print)

Position/Title

Firm Name (if applicable)

Federal Tax I.D.#

Signature

Date

State of

County of

Before me on the above date personally appeared , who after first being sworn or affirmed, said that the statements contained in this request are true.

Signed

Notary Public, State of

My Commission Expires

Instructions

Request for Copies of Confidential Claimant Information Instructions (DWC Form-153)

1. DWC Form-153 must be completed in its entirety. Please print or type. Submit a separate request form for each DWC claim number. We do not accept faxed or emailed copies.

2. Section II includes a space for an e-mail address. The e-mail address is requested so that TDI may process the request expeditiously, obtain additional information to complete verification and for billing purposes.

3. A requestor must indicate in Section IV the legal basis on which he/she is eligible to receive requested confidential employee information.

4. A lay person or a legal representative may represent a claimant or a claimant beneficiary.

5. The requestor must swear or affirm to the correctness of the entitlement information before a notary public, sign the completed form before the notary, and have the notary complete the acknowledgment.

6. Copies of this form will be accepted if both sides are an exact reproduction of the original and include an original signature and notarization.

7. Indicate if a certified copy is requested.

8. Charges and billing will be as follows: charges exceeding $40 will require approval and estimates over $100 will require a deposit before documents can be provided/mailed.

9. No priority mailing is available unless the requestor provides an account number.

10. For additional assistance in completing this form call the area that maintains the file requested.

11. A cancellation of a request must be in writing.

IMPORTANT: BY EXECUTION OF DWC FORM-153, THE REQUESTOR REPRESENTS THAT HE OR SHE IS ENTITLED TO THE INFORMATION REQUESTED AND THAT HE OR SHE HAS FULL AUTHORITY TO ACT AS A REQUESTOR.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Workers' Compensation Form DWC-1 Notice of Potential Is

The Workers' Compensation Form DWC-1 Notice of Potential is a standardized California workplace injury form used to document and notify an employer and insurer of an employee's work-related injury or occupational illness. It captures claimant and employer details, injury description, dates, and initial medical treatment, creating an official record that starts the administrative process for benefits, medical care, and claims handling while preserving facts and timelines for future review.

Why completing a DWC-1 Notice of Potential matters

Filing the DWC-1 creates a written record that documents the incident, helps secure timely medical evaluation, notifies the employer and insurer, and preserves evidence needed for benefit determinations and potential appeals.

Why completing a DWC-1 Notice of Potential matters

Who typically completes or receives the DWC-1 Notice of Potential

The form is completed by injured workers and handled by employers, claims administrators, and treating providers as part of the workers' compensation intake process.

  • Injured employees notifying their employer and documenting the incident quickly.
  • Employers or HR staff who receive and forward the notice to claims administrators.
  • Treating medical providers or occupational health clinics supplying initial treatment details.

Accurate routing and copies are essential: the employer, the insurer or claims administrator, and the employee should each retain a copy for claims handling and recordkeeping.

Primary signers and stakeholders

Injured Employee

The employee who experienced the injury provides personal details, a description of the incident, dates, and their signature to establish the initial claim record and access to medical care.

Employer / Adjuster

The employer or insurer representative records employer details, confirms receipt, and uses the form to open an initial claim file and coordinate medical and administrative next steps.

Security and compliance considerations for the form

Encryption in transit: TLS 1.2/1.3
Encryption at rest: AES-256
Audit trail: Timestamped actions
HIPAA coverage: BAA required
Federal e-sign law: ESIGN / UETA compliance
Access controls: Role-based permissions

Step-by-step: completing the Workers' Compensation Form DWC-1 Notice of Potential

Follow these core steps to create a clear, useable record and speed claims handling while reducing avoidable delays.

  • 01
    1. Record claimant: Enter full legal name and contact information as on ID.
  • 02
    2. Date and location: Provide exact injury date and precise location details.
  • 03
    3. Describe the injury: Describe how injury occurred and body part(s) affected.
  • 04
    4. Sign and distribute: Sign, date, and send copies to employer and claims administrator.

Online workflow settings for DWC-1 processing

Configure a straightforward electronic workflow to collect signatures, attachments, and delivery confirmations for compliance and traceability.

Field Configuration
Authentication Email verification or SMS code
Signature type ESIGN-compliant e-signature
Attachments PDF medical reports and photos
Routing Send to employer, insurer, and claimant

How the electronic submission process typically flows

A predictable, logged routing sequence reduces follow-ups and ensures each party receives the same record.

  • Prepare form: Populate fields and attach supporting documents.
  • Assign signers: Add employee and employer or adjuster emails.
  • Authenticate signer: Confirm identity via email code or SMS.
  • Deliver and store: Send copies and retain an audit trail.

Technical requirements for e-submission and integrations

Ensure the signing platform supports secure e-signatures, audit trails, and the file types you use before collecting electronic DWC-1 notices.

  • File formats: PDF and DOCX supported
  • Common integrations: Salesforce, NetSuite, Google Workspace
  • Authentication options: Email, SMS code, or KBA

eSignature vendor comparison for DWC-1 electronic handling

Comparison of common vendor starting prices and core features relevant to secure DWC-1 collection; signNow is listed first per platform data.

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 by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Key components included on a professional DWC-1 Notice of Potential

A complete DWC-1 contains standardized sections that capture claimant facts, employer details, injury specifics, immediate treatment, witness information, and authenticated signatures.

Claimant Details

Full legal name, contact information, date of birth and job title to uniquely identify the employee for the claim file and follow-up.

Employer Information

Employer legal name, location, supervisor, and payroll or employer ID to route the notice to the correct claims unit or carrier.

Injury Description

Concise factual account of how and where the injury occurred, the sequence of events, and body part(s) affected for early case assessment.

Dates and Timing

Date and time of injury, date reported to employer, and initial treatment dates to document timelines that affect benefits and investigations.

Medical Treatment

Initial treatment provided, treating facility or provider contact, follow-up care plan, and attachments such as medical notes or diagnostic results.

Signatures and Acknowledgment

Signature blocks for the employee and employer/adjuster, dated attestations, and any witness information to authenticate the submission.

Practical tips for accurate and efficient completion

These practices reduce processing time, minimize dispute risk, and help claims administrators and medical teams act on reliable information.

Notify promptly and document contemporaneously
Report the injury to your employer as soon as it is safe to do so and complete the DWC-1 with contemporaneous details to preserve accuracy and speed medical authorization.
Attach supporting documentation
Include initial medical records, witness statements, and photos when available to reduce follow-up questions and accelerate decision-making by claims handlers.
Use consistent legal names and IDs
Match the employee name and employer identifiers to payroll and insurance records to avoid identity mismatches that can delay benefits.
Maintain secure copies and an audit trail
Keep signed copies with timestamps and delivery receipts to demonstrate timely notice and protect against later evidentiary disputes.

Common mistakes to avoid when preparing a DWC-1 Notice of Potential

  • Delaying notification or backdating information, which can complicate benefit access and investigation.
  • Leaving injury descriptions vague or incomplete, prompting clarifying contacts and slower processing.
  • Using inconsistent names or incorrect employer identifiers, causing routing or verification delays.
  • Submitting unsigned or undated forms, which may be rejected or returned for completion.

Potential consequences of incorrect or late DWC-1 submissions

Benefit delays: Late or incomplete forms can postpone medical authorization and indemnity payments.
Claim denial risk: Missing key facts increases the risk of contested benefits.
Administrative costs: Extra time and resources needed to correct or resubmit forms.
Investigative burden: Insufficient details trigger additional interviews and evidence gathering.
Recordkeeping exposure: Poor retention practices can complicate audits or appeals.
Legal disputes: Errors may increase the likelihood of litigation or formal hearings.

Timelines and what to expect after filing a DWC-1 Notice of Potential

Processing timelines vary by employer and insurer; prompt filing speeds medical authorization and claim establishment while reducing downstream friction.

Immediate reporting:

Notify employer as soon as practicable after injury to begin intake.

Employer intake:

Employer forwards the notice to the claims unit and secures medical triage.

Claims acknowledgment:

Claims administrators typically acknowledge receipt and open a file for investigation and benefits.

Medical authorization:

Initial treatment authorization or direction to a treating provider follows claims triage.

Appeals and disputes:

Disputed decisions enter a formal process with prescribed timelines that vary by jurisdiction.

How organizations use e-sign and digital workflows for sensitive intake forms

Real organizations report improved compliance and faster turnaround when they pair secure e-signatures with structured intake workflows for health and claims forms.

BIS — Dan Rotelli, CEO

The team needed strict compliance safeguards for regulated forms

  • They evaluated security and certifications
  • We felt most comfortable with airSlate SignNow given their SOC 2 certification and strict focus on ESIGN and UETA act compliance.

Fertility Centers of Illinois — John Butler, Founder

The center required secure remote signatures for patient intake

  • They needed reliable API integration with records systems
  • The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company.

Frequently asked questions about using a DWC-1 Notice of Potential electronically

Answers to common operational and legal questions about completing, signing, and storing the DWC-1 when using electronic workflows and e-signature platforms.


Need help? Contact support

Explore Templates

Property Inventory Lease Land Agreement Severance Agreement
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.