Carriers Request For Seasonal Employee Wage Information From Texas Employment Commission Records
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Carriers Request For Seasonal Employee Wage Information From Texas Employment Commission Records Form. This is a Texas form and can be use in Employee Workers Compensation.
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Tags: Carriers Request For Seasonal Employee Wage Information From Texas Employment Commission Records, DWC-56, Texas Workers Compensation, Employee
PREPAYMENT ACCOUN T #:
CLAIM # ______________________________________________
Carrier's Claim # ________________________________________
CARRIER'S REQUEST FOR SEASONAL EMPLOYEE WAGE INFORMATION
FROM TEXAS EMPLOYMENT COMMISSION RECORDS (DWC Form-056)
A $15.00 fee must be paid for this request for seasonal employee wage information from the Texas Workforce
Commission. No action will be taken on the request without payment. Send the request with payment to:
Field Services, MS-600, Texas Department of Insurance, Division of Workers' Compensation, 7551 Metro Center
Drive, Suite 100, Austin, Texas 78744.
1. Employee's Name (Last, First M.I.) and Telephone Number
(
State
On
3. Date of Injury
xxx-xx-
)
4. Mailing Address (Street or P.O. Box)
City
2. Social Security Number
5. Employer's Business Name
ZIP Code
6. Insurance Carrier's Name
the insurance carrier shown above filed notice with the injured seasonal employee of its
DATE
intention to request the Texas Department of Insurance, Division of Workers' Compensation's approval to adjust
the employee's average weekly wage and temporary income benefit payment because of a seasonal change in the
employee's wages. The seasonal employee did not provide wage information to the carrier within two (2) weeks
from the date of notice according to a thorough search of the carrier's records.
The insurance carrier requests the Texas Department of Insurance, Division of Workers' Compensation to contact
Texas Workforce Commission for the seasonal employee's wage history for the most recent five (5) quarters
available.
ADJUSTER CERTIFICATION
I certify the wage information requested will be used solely to determine whether an injured seasonal employee's
average weekly wage and temporary income benefit payment should be adjusted.
Adjuster's Name
(PRINTED)
Adjuster's Business Mailing Address (Street or P. O. Box)
Adjuster's Signature
City
State
ZIP Code
DIVISION USE ONLY
Date Information Requested from TWC
DWC FORM-56 EES-1 Rev. 10/05
Date Information Provided to Carrier's Designated Austin Representative
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