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Non-Subscriber Forms

Non-Subscribers are required to file certain forms at certain times and post notices. Please click on the specific links below to view the form or notice and to read the related instructions for filing the specific form or notice. Please note that these forms should be completed, signed, dated and sent certified mail, return receipt requested, to the address indicated on the form. Keep copies for the file!

If you have any questions please call a staff member for assistance or visit the TDI website at:
http://www.tdi.state.tx.us/forms/form20employer.html

 


 
Texas Employer Notice of No Coverage or Termination of Coverage

Non-Subscribers are required to file the Form DWC005 each year (annually) during the period between February 1 and April 30th. The Texas Department of Insurance (TDI) would like to properly identify and measure Texas Non-Subscriber Employers; if you do not make this annual filing of Form DWC005, between February 1 and April 30 each year, you will expose your Company to administrative penalties up to $25,000 per day after each April 30. Generally, if you are a brand-new Non-Subscriber, you must file the DWC005 with the Texas Department of Insurance either (1) within 30 days of hiring your first employee, or else (2) within 10 days after notifying your existing workers' compensation carrier that you are terminating workers' comp. insurance coverage. For more information please click on this link: www.tdi.texas.gov/pubs/factsheets/noncoveremp.pdf

DWC 005 (Formally Known as TWCC 5)

Texas Notice to Employees Concerning Workers' Compensation in Texas

Non-Subscribing employers must maintain the Notice 5 in areas of the workplace that allow all employees to see it on a regular basis, including the personnel office (if the company maintains a personnel office). The Notice 5 must be posted in English, Spanish, and any other language that is common to the workplace.

Notice 5 (English)

Notice 5 (Spanish)

Texas Report of Occupational Illnesses or Injuries

Non-Subscribing employers with five or more employees are required to report certain workplace injuries to the TDI. Injuries that result in more than one day away from the employees regular work schedule, all occupational diseases (regardless of lost time), and all fatalities occurring within any given calendar month must be reported on or before the seventh day of the month following the injury or illness. To report qualifying injuries, non-subscribing employers should utilize the DWC Form 7 and the Supplemental Form 7 (if additional space is needed).

DWC Form 007 (Supplemental)

OSHA Forms for Reporting/Recording Work-Related Illnesses and Injuries

Employers who are not exempt from the Occupational Health and Safety Administration's (OSHA) record keeping requirements must prepare and maintain records of work-related injuries and illnesses. This forms package contains forms for injuries and illnesses occurring in 2004.

OSHA FORMS

CSN 08/2006

 


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Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.
 


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