TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS’ COMPENSATION 7551 Metro Center Drive, Suite 100 Austin, Texas 78744 CLAIM # _________________________________________ Carrier’s Claim # ___________________________________ PAYMENT OF COMPENSATION OR NOTICE OF REFUSED/DISPUTED CLAIM (DWC Form-021) 1. MARK ⌧ TYPE OF BENEFIT Certify benefits will be paid as accrued Section 409.021 Temporary Income Benefits 3. Employee's Name and Mailing Address 10. Name and Mailing Address of Insurance Carrier 4. Social Security Number 11. Address of Insurance Carrier Claims Office 5. Date of Injury Impairment Income Benefits 6. County of Injury 12. Insurance Carrier Representative and Phone No. 7. Nature of Injury 13. Professional License No. 8. Employer's Name and Mailing Address 14. Insurance Carrier's First Written Notice of Injury Received on 9. Federal Tax I.D. No. Supplemental Income Benefits 15. Name and Title of Person Notifying Insurance Carrier Lifetime Income Benefits Initial Payment Annual Increase Death Benefits Correction to Previous Filing 2. Date of this Notice: COMPLETE APPROPRIATE SECTION BELOW INITIAL PAYMENT A-1 16. Date of Lost Time Began TERMINATION A-2 25. Reason for Termination REDUCTION/RESUMPTION A-3 34. Date of Resumed or Reduced 17. Date of Payment 26. Date of Last Payment 27. Rate Paid 35. Date of Payment 18. Amount of Payment $ 19. For No. of Weeks $ 20. Rate of Comp. 28. Intermittent Periods of Lost Time From Work 22. To 23. Remarks *If fatal injury name & Address of Beneficiary (ies) being paid and relationship to deceased. $ 37. No. of Weeks $ 21. From 36. Amount of Payment 38. From COMPENSATION PAID 29. From 32. Days 40. Payment Resumed or Reduced 30. To 31. Weeks 39. To Temporary Income Benefits Impairment Income Benefits 33. Total Amount Indemnity 24. Payment mailed or delivered to: Medical Impairment $ $ Supplemental Income Benefits 41. Average 42. Hourly Weekly Wage Wage Prior to Injury $ $ Following Injury $ $ Income Benefits Lump Sum $ Notice of Refused Or Disputed Claim PAYMENT REFUSED OR DISPUTED FOR THE FOLLOWING REASON(S): (SECTION 409.021, 409.022) 43. MEDICAL PAYMENT DISPUTES (Section 408.027): If an Insurance Carrier disputes the amount of payment for medical services or the entitlement to payment for medical services or the entitlement to payment for medical services, the carrier must report its position on DWC FORM-62 REPORT OF MEDICAL PAYMENT DISPUTE. A COPY OF THIS FORM WAS MAILED TO CLAIMANT CLAIMANT'S REPRESENTATIVE ____________________________ (date) Division Date Stamp Here DWC FORM-021 Rev. 10/05 American LegalNet, Inc. www.FormsWorkflow.com Page 1 DWC FORM-021 (Payment of Compensation or Notice of Refused/Disputed Claim) Not later than the 15th day after the date on which the insurance carrier receives written notice of an injury, the carrier shall: (1) begin payment of benefits, or (2) notify the DWC and the injured employee, in writing, of its refusal to pay, and of the employee's right to request a benefit review conference, and (3) how to obtain additional information from DWC. The insurance carrier is required to provide notice of initiation of payment of income benefits or denial of compensability to the injured employee and the Division. Division rule 124.2 requires notice to be made to the injured employee using a plain language notice. Rule 124.2 also requires the notice to be provided to the Division via electronic data interchange. However, DWC FORM-021 may be used to accomplish these requirements. An insurance carrier who fails to either begin compensation or file DWC FORM-21, within this 15-day period, may receive an Administrative Violation. Initiation of compensation does not prevent the carrier from investigating and subsequently denying the claim during the 60-day period following receipt of written notice of the injury. The carrier must specify the reason for refusal of compensation. DWC FORM-021 may also be used by the carrier to indicate the intent to begin benefits when compensable time begins to accrue, or medical payments are due (Sections 408.082 and 408.027). This form may be used by the carrier when transitioning from payment of one type of benefits to another. A carrier should attach a payment summary for frequent adjustments when filling in block 40. The DWC FORM-021 is considered filed when personally delivered or postmarked. Send DWC's copy to the field office handling the claim. [Section 408.082, Accrual of Rights to Income Benefits; Section 408.101, Temporary Income Benefits; Section 408.121, Impairment Income Benefits; Section 408.142, Supplemental Income Benefits; Section 408.161, Lifetime Income Benefits; Section 408.181, Death Benefits; Section 408.027, Payment of Health Care Provider; Section 409.021, Initiation of Benefits; Insurance; Carrier's Refusal; Rule 124.1, Written Notice of Injury Defined; 124.2, Insurance Carrier Reporting and Notification Requirements] DWC FORM-021 Rev. 10/05 American LegalNet, Inc. www.FormsWorkflow.com Page 2