Texas Department Of Insurance Division of Workers' Compensation Records Processing 7551 Metro Center Dr. Ste.100 x MS-93 Austin, TX 78744-1609 (800) 252-7031 (512) 804-4378 fax www.tdi.texas.gov DWC Claim# Carrier Claim# Send the completed form to the TDI-DWC field office handling the claim. EMPLOYER'S CONTEST OF COMPENSABILITY (DWC Form-004) The employer has the right to contest the compensability of an employee's injury if the insurance carrier accepts liability for the payment of benefits. The employer may contest compensability of a claim after presenting the grounds for non-compensability to the carrier and giving the carrier the opportunity to contest compensability. [Texas Workers' Compensation Act �409.011] 1. Employee's Name (Last, First, M.I.) 2. Social Security Number (last four digits) xxx-xx4. Employer's Name (Last, First, M.I.) 3. Date of Injury (mm/dd/yyyy) 5. Employer's Mailing Address (Street or P.O. Box, City, State, Zip) 6. Employer's Telephone No. 7. Insurance Carrier 8. Provide any relevant facts supporting the reason(s) for contesting compensability. TDI-DWC Date Stamp Here Employer's Signature _______________________________________________ Date ______________________ Title ________________________________________________________________________________ If you have questions about this form, contact staff at your local TDI-DWC Field Office at 800-252-7031. NOTE: With few exceptions, you are entitled on request to be informed about the information that TDI-DWC collects about you. Under ��552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under �559.004 of the Government Code you are entitled to have TDI-DWC correct information about you that is incorrect. For more information, call the local TDI-DWC field office at 800-252-7031. DWC004 Rev. 11/08 American LegalNet, Inc. www.FormsWorkFlow.com Page 1