Form 2025

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The document is a form (DWC Form-041) from the Texas Department of Insurance, Division of Workers' Compensation, used for filing a claim for workers' compensation due to work-related injuries or occupational diseases. It outlines the necessary information required from the injured employee, including personal details, injury specifics, employer information, and doctor details. The form must be submitted within one year of the injury or awareness of the work-related condition. It also provides instructions for completing the form and contact information for assistance.

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Click ‘Get Form’ to open it in the editor.
Begin with the 'Injured Employee Information' section. Fill in your full name, date of birth, and social security number. Ensure your address and contact details are accurate.
Indicate your race/ethnicity and marital status. Specify if you have an attorney representing you and whether you have returned to work, including the date if applicable.
Move to the 'Injury Information' section. Report whether it's an injury or occupational disease, providing details such as the date of injury and where it occurred.
Complete the 'Employer Information' section with your employer's name and contact details at the time of injury.
Finally, fill out the 'Doctor Information' section with your treating doctor's details. Don't forget to sign and date the form before submission.

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Versions	Form popularity	Fillable & printable
2007	4.9 Satisfied (55 Votes)

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