Workers' Compensation Insurance

Forms
DWC 1-Employer's First Notice of Injury Form DWC 6- Employer's Supplemental Report of Injury DWC 3-Employer's Wage Statement DWC 53- Employee's Request to Change Treating Doctor, Non-Network Form 23- Request for Paid Leave	Employee's Rights & Responsibilities (English) Derechos y Responsabilidades Para los Empleados (Español) What is Workers' Compensation? Notice to Employees (English) Aviso a los Trabajadores (Español) MyMatrixx First Fill Form

Forms

The forms above are provided by the Texas Department of Insurance, Division of Workers' Compensation Insurance (TDI/DWC). Please contact your respective University of Texas System (UT System) Workers' Compensation Insurance (WCI) Representative before completing any forms. Some UT System Institutions have developed forms regarding First Notice of Injury. All forms utilized by UT System Institutions contain all necessary information and questions required by TDI/DWC.

Questions

For more information regarding Workers' Compensation Insurance forms, refer to your respective UT System WCI Representative, the UT System WCI Office or TDI/DWC.

 

 

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