DWC044 Texas Department of Insurance Division of Workers' Compensation Hearings / Dispute Resolution Services 7551 Metro Center Drive, Suite 100 · MS-35 Austin, TX 78744-1645 (512) 804-4010 phone · (512) 804-4011 fax Complete, if known: DWC Claim #: Carrier Claim #: Election to Engage in Arbitration Type (or print in black ink) each item on this form I. CLAIM DISPUTE INFORMATION 1. DWC Claim Number 3. Claimant's Name 5. Field Office 2. Medical Fee Dispute Decision Number (if applicable) 4. Insurance Carrier's Name 6. Date Benefit Review Conference Ended, if applicable (mm/dd/yyyy) 7. Check ONLY one box to indicate the type of dispute for which arbitration is elected: Medical fee dispute Indemnity dispute Specify benefit issues remaining in dispute: NOTE: Arbitration may be elected only for disputes that remain unresolved after a Benefit Review Conference. 8. Is the injured employee a first responder, as defined in Texas Labor Code §504.055, who sustained a serious bodily injury*? Yes No *bodily injury that creates a substantial risk of death or that causes death, serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ II. ELECTION OF ARBITRATION By signing below, the parties to the above referenced claim pending before the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC), elect, pursuant to Texas Labor Code, Chapters 410 and 413, to engage in arbitration concerning the issues identified in Box 7. The parties understand that this arbitration election requires the consent of the parties affected by the dispute, and that once the arbitration election is filed with the TDI-DWC, the parties are no longer entitled to a TDI-DWC Contested Case Hearing, or review by the TDI-DWC Appeals Panel or the State Office of Administrative Hearings (SOAH) and that judicial review is strictly limited. Further, the parties understand that the election for arbitration is binding and irrevocable on the parties signing below for the resolution of the above referenced disputes. The decision of the arbitrator is final unless vacated by a court of competent jurisdiction, based on the provisions of §410.121 of the Texas Labor Code. The parties also acknowledge that that they are familiar with the arbitration provisions of the Texas Labor Code §410.024 and §§410.101-410.121, and the TDI-DWC Arbitration Rules in 28 Texas Administrative Code §§144.1-144.16, and agree to abide by them. Insurance Carrier 9. Insurance Carrier's Name 11. Insurance Carrier Representative's Printed Name 13. Insurance Carrier Representative's Signature 10. Phone Number 12. Alternate Phone Number 14. Date of Signature (mm/dd/yyyy) For TDI-DWC Use Only DWC044 Rev. 06/12 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC044 Check the appropriate box: Injured Employee Health Care Provider Subclaimant Pharmacy Processing Agent 15. If injured employee is checked above, is the employee assisted by the Office of Injured Employee Counsel (OIEC)? Yes No 16. Requester's Printed Name 19. Requester's Signature 21. Representative's Printed Name (if applicable) 22. Phone Number 24. Representative's Signature 23. Alternate Phone Number 25. Date of Signature (mm/dd/yyyy) 17. Phone Number 18. Alternate Phone Number 20. Date of Signature (mm/dd/yyyy) Frequently Asked Questions What is the purpose of electing arbitration? Arbitration may be used only to resolve disputed benefit issues. It is an alternative to a Contested Case Hearing and requires mutual agreement of the parties. Arbitration may be elected, in accordance with 28 TAC, Chapter 144, for any disputes arising out of claim(s) that are under the jurisdiction of the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC). Can I change my mind after electing to engage in arbitration? No, an election to engage in arbitration is binding and irrevocable on all parties. Can I appeal the arbitrator's decision? There is no right to appeal except as provided in the Texas Labor Code, Section 410.121. The final award rendered by the arbitrator cannot be appealed to the TDI-DWC's Contested Case Hearing, TDI-DWC's Appeals Panel, or to the State Office of Administrative Hearings (SOAH). What is the deadline for filing the DWC Form-044? This form must be signed by all parties and filed with the TDI-DWC not later than the 20th day after the conclusion of the Benefit Review Conference as shown in Box 6 on the form. Where do I file the DWC Form-044? Submit the completed form to the TDI-DWC by mailing it to the address shown at the top of the form or by faxing the form to (512) 804-4011. What happens after I file the DWC Form-044? The TDI-DWC will assign an arbitrator not later than 30 days after the date on which the election is filed and will notify the parties. Each party is entitled to one rejection of an assigned arbitrator. The arbitrator will schedule an arbitration proceeding to be held within 30 days of being assigned the case and shall notify the parties, the employer, and the TDI-DWC of the date and time. 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, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). For TDI-DWC Use Only Claimant's Name: DWC Claim Number: DWC044 Rev. 06/12 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com