DWC096 Rev. 11/2018 Page 1 of 3 SIF Reimbursement Request Form 226 Refund of Death Benefits I. REQUEST 1. Reimbursement Amount Requested 2. R equest Date 3 . Contact N ame 4 . Contact P hone N umber 5 . Contact E mail A ddress II. CLAIM INFORMATION 6. Injured Employee222s Name (First, Middle, Last) 7. DWC Claim Number 8 . Employee's D ate of I njury 9. Employee222s Date of Death III. PAYEE (Insurance carrier) 10 . Name of P ayee 1 1 . Payee F ederal T ax ID N o. 1 2 . Address of P ayee (Street or P.O. Box, City, State, ZIP Code) IV. TELL US ABOUT THE REASON FOR SEEKING THIS REIMBURSEMENT 13 . Describe the request, including a description of the f inal award or judgement that a legal beneficiary is entitled to the death benefits. For DWC Use Only American LegalNet, Inc. www.FormsWorkFlow.com DWC096 Rev. 11/2018 Page 2 of 3 IV. TELL US ABOUT THE TOTAL AMOUNT OF REIMBURSEMENT REQUESTED 1 4 . Amount of Death Benefits Paid to the SIF 1 5 . Date Carrier Paid Death Benefits to the SIF 1 6 . Calculation of R efund R equested VI. REQUIRED ATTACHMENTS: Include the following documents with each request. Claim for workers222 compensation death benefits (DWC Form-042 or DWC Form-042S). All orders or other documentation identifying legal beneficiaries and entitlement to death benefits. A detailed payment record that includes the following: date of payment; amount of payment; purpose of payment; benefit period; and payee. W-9 for the insurance carrier. Unless otherwise requested, please limit submission to the above items. To expedite review of this request, please fax to (512) 804-4759 or use electronic file transfer. For DWC Use Only American LegalNet, Inc. www.FormsWorkFlow.com DWC096 Rev. 11/2018 Page 3 of 3 Frequently Asked Questions Who can file DWC Form-096? Insurance carriers and their authorized representatives should use this form to expedite the insurance carrier222s request for reimbursement from the Subsequent Injury Fund (SIF). Can I use this form to submit a request for reimbursement of any overpayments? Use the form appropriate to the cause of the overpayment. DWC Form-096 should be used when the insurance carrier made payment of death benefits to the SIF and it is later determined by a final award of the commissioner or the final judgement of a court of competent jurisdiction that a legal beneficiary is entitled to the death benefits. What statutes and rules apply to this type of reimbursement? Texas Labor Code 247403.007(d) and 28 Texas Administrative Code 247116.11(a)(2) and (d). What response do you expect on question 13? Which final award or judgement determined that a legal beneficiary is entitled to the death benefits? Here is a sample response: 01/12/2018 Travis County Court decision: John Doe is the legal beneficiary. John Doe is the spouse of the deceased. What response do you expect on question 16? Clarify how much of the death benefit previously paid to the SIF should be refunded and how you calculated the amount. Examples: On 01/01/2017, we paid 364 weeks of death benefits to the SIF at a rate of $500.00 per week discounted for a total of $166,395.00. A dependent beneficiary has been identified and death benefits are no longer owed to the SIF. We request a full refund. OR On 01/01/2017, we paid 364 weeks of death benefits to the SIF at a rate of $500.00 per week discounted for a total of $166,395.00. The parent of the deceased is entitled to 104 weeks of death benefits. After consideration of this beneficiary, only 260 weeks of death benefits are owed to the SIF discounted for a total of $114,510.00. We request reimbursement of $51,885.00 ($166,395.00 226 $114,510.00). How do I submit this request by electronic file transfer? If you already have an account with DWC, you may use the same electronic file transfer account. If you need an account, please contact our office. American LegalNet, Inc. www.FormsWorkFlow.com