DWC005 Rev. 02/18Page of Texas Department of InsuranceDivision of Workers' Compensation - Insurance Coverage (MS-96)7551 Metro Center Drive, Suite 100, Austin, Texas 78744-1645 (800) 252-7031 | F: (512) 804-4146 | TDI.texas.gov | @TexasTDIDWC005Employer Notice of No Coverage or Termination of Coverage La versi363n en espa361ol est341 disponible en http://www.tdi.texas.gov/forms/dwc/dwc005snocov.pdf II. STATEMENT OF NO COVERAGEI. EFFECTIVE DATES (The effective dates cannot exceed a one-year period)IV. PRIMARY EMPLOYER INFORMATION 3. Employer Business Name4. Federal Employer ID Number5. Employer Business Mailing Address (Street or PO Box, City State Zip) 6. Employer Business Type 7. Six-Digit NAICS Code NOTE: You must provide name, Federal Employer ID number and address of each Texas business location, subsidiary, or separate entity of the primary employer covered by this report. 1. SELECT ONE The employer named below DOES NOT HAVE workers' compensation insurance coverage, pursuant to the Texas Workers' Compensation Act, Texas Labor Code, Section 406.004. The employer named below HAS TERMINATED workers' compensation insurance coverage, pursuant to the Texas Workers' Compensation Act, Texas Labor Code, Section 406.007. (Provide the following information.)OR Policy terminated effective240(mm/dd/yyyy): Policy number: Insurance 240company: Insurer informed of termination on (mm/dd/yyyy): Employees were (or will be) notified on (mm/dd/yyyy): III. STATEMENT OF REPORTABLE INJURIES OR DISEASES2. Did you have any death, injury that resulted in the injured employee's absence from work for more than one day, or knowledge of an occupational disease since your last Employer Notice of No Coverage or Termination of Coverage? Yes NoIf your response is 223Yes224, you may be required to file a DWC Form-007, Non-covered Employer's Report of Occupational Injury or Illness. (See the Frequently Asked Questions section of this form.) The election selected below is effective from(mm/dd/yyyy). (mm/dd/yyyy) to Row Name Federal Employer ID Number Address Street or PO Box CityStateZip CodeV. PERSON PROVIDING INFORMATION 8. Name9. Telephone Number (area code, number, extension) For TDI-DWC Use Only 10. Title 11. E-mail Address 12. Signature 13. Date of Signature (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com DWC005 Rev. 02/18Page of DWC005Frequently Asked Questions Employer Notice of No Coverage or Termination of CoverageWho must file the DWC Form-005? You must file the DWC Form-005 if you: 267 do not have workers' compensation insurance, or 267 you have terminated your workers' compensation insurance coverage However, if your only employees are exempt from coverage under the Texas Workers' Compensation Act (for example, certain domestic workers, and certain farm and ranch workers) you do not have to file. Failure to file the form when required may subject the employer to administrative penalties.How do I file the DWC Form-005? Employers can submit the DWC Form-005 to the TDI-DWC by:267 filing electronically on the TDI website at: https://txcomp.tdi.state.tx.us/TXCOMPWeb/common/home.jsp : 267 faxing the form to (512) 804-4146; or 267 mailing the form to the address listed at the top of the form. When do I file the DWC Form-005? You must file a separate DWC Form-005 each time one of the following conditions exists:267 Annually between February 1st and April 30th of each calendar year; 267 Within 30 Days of hiring your first employee, unless this due date falls between February 1st and April 30th and you submit the form within this time period; 267 Within 10 Days of receiving a request (to file the DWC Form-005) from DWC; 267 Within 10 Days after notifying your workers' compensation insurance carrier that you are terminating coverage unless you purchase a new policy or become a certified self-insurer; How do I determine my filing start date? Use May 1, unless:1. You have never filed a DWC Form-005, then the start date is the first day you did not have coverage (see either #2 or #3 to determine the specific date). 2. You terminated workers' compensation insurance coverage, then the start date is the first date you did not have coverage. 3. You hired your first employee, then the start date is the first day the employee started working. How do I determine my filing period end date? Use April 30, unless: 267 You purchased, or plan to purchase a workers' compensation insurance policy, then the End Date is the last date you did not, or will not, have coverage. What is a NAICS code? NAICS (pronounced "nakes") is the six-digit North American Industry Classification System code that identifies the classification of your business. You may be able to locate the code in either:1. Block 5 of your Unemployment Quarterly Report (Form C-3) from the Texas Workforce Commission; and/or; 2. If you have multiple NAICS codes, they may appear in the left margin of the Multiple Worksite Report - BLS 3020 from the U.S. Bureau of Labor Statistics; or 3. For more help with NAICS codes, visit the NAICS web page at: www.naics.com Select "Find Your NAICS Code" from the top menu and use the "NAICS Keyword Search" to enter one or more words that generally describe your business. For example, if you are in the restaurant business, enter "restaurant" and get a complete listing of NAICS codes for the restaurant industry. American LegalNet, Inc. www.FormsWorkFlow.com DWC005 Rev. 02/18Page of DWC005Are any fields on the DWC Form-005 optional? All applicable fields must be completed each time the DWC Form-005 is filed. Section I 267 The effective dates are always required. Section II 267 When reporting cancellation or termination of workers' compensation insurance in Statement of No Coverage, the policy and insurer information, and the notification dates must be provided. Section III 267 A selection from Statement of Reportable Injuries or Diseases is always required. Section IV 267 All primary employer fields (boxes 3 through 7) are required. 267 Additional business location information is required when applicable. Section V 267 The signature field is not required when filing online. How/when must a non-subscriber notify employees that workers' compensation coverage is not provided? You must post the Notice to Employees Concerning Workers' Compensation in Texas in the workplace in English, Spanish and any other language common to the employer's employee population in the print type specified by DWC rules whenever you: 1. elect to not have workers' compensation insurance; 2. cancel or terminate workers' compensation insurance; 3. withdraw from certified self-insurance; or 4. have workers' compensation coverage cancelled by the insurance company. You must also provide this notice to each employee: 1. at the time of hire; 2. when the employer elects to not have workers' compensation insurance; 3. within 15 days of notification to the insurance carrier that the employer is terminating coverage unless the employer maintains continuous coverage under a new policy or becomes a certified self-insurer; or 4. within 15 days of cancellation by the insurance company. The required notice may be found on the TDI website at: http://www.tdi.texas.gov/forms/dwc/notice5.pdf (English) and http://www.tdi.texas.gov/forms/dwc/notice5s.pdf (Spanish)NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, 247247552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, 247559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure section at www.tdi.texas.gov .Are non-covered employers required to file other forms with TDI-DWC? You must report work-related injuries and diseases using the DWC Form-007, Employer's Report of Non-covered Employee's Occupational Injury or Diseases if: 1. You have five or more employees and do not have workers' compensation insurance; or 2. you have employee(s) that have waived workers' compensation insurance coverage, whether or not you have workers' compensation insurance. You mus