DWC FORM-001 (Employer's First Report of Injury or Illness) The employer is required to file an Employer's First Report of Injury or Illness [DWC FORM-001 Rev. 10/05] with the injured worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease. The Employer's First Report of Injury or Illness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimant's employment and circumstances surrounding the injury or illness are also requested. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. [Workers' Compensation Rule 120.2] DWC FORM-001 Rev. 10/05 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS (DWC FORM-001) Type (or print in black ink) each item on this form. Failure to complete each item may delay the processing of the injury claim. Section 409.005, Texas Workers' Compensation Act, requires an Employer's First Report of Injury or Illness (DWC FORM-001 Rev. 10/05 to be filed with the Workers' Compensation Insurance Carrier not later than the eighth day after the receipt of notice of occupational disease, or the employee's first day of absence from work due to injury or death. A copy of this report must be sent to the employee or the employee's representative. For purposes of this section, a report is filed when personally delivered, or postmarked. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. If a report has not been received by the carrier, the employer has the burden of proving that the report was filed within the required time frame. The employer has the burden of proving that good cause existed if the employer failed to file the report on time. An employer who fails to file the report without good cause may be assessed an administrative penalty. An employer who fails to file the report without good cause waives the right to reimbursement of voluntary benefits even if no administrative penalty is assessed. Once the employer has completed all information pertaining to the injury the employer should maintain the copy of this report to serve as the Employer's Record of Injury required by Section 409.006. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. The Division’s Health and Safety will use data from this report for the Job Safety Information System established in Section 411.032 of the Texas Workers' Compensation Act. This report may not be considered admission or evidence against the employer or the insurance carrier in any proceeding before the Division or a court in which facts set out in the report are contradicted by the employer or insurance carrier. "SPECIAL INSTRUCTIONS FOR CERTAIN ITEMS" Items 2,7,8: Section 402.082, Texas Workers' Compensation Act requires the Division to maintain information as to the race, ethnicity and sex on every compensable injury. This information will be maintained for non-discriminatory statistical use. Item 4: If no home phone, please provide a phone number where the employee can be reached. Items 5,15,17, 26,29,30: Enter data in month, day, year format. Example: 08-13-54. Item 18: List nature of accident or exposure, e.g., fall from scaffold, contact with radiation, etc. If occupational disease, so state. Item 19: List specific body part, e.g., chin, right leg, forehead, left upper arm, etc. If more than one body part is affected, list each part. Item 20: Describe in detail (1) the events leading up to the injury/illness, (2) the actual injury, e.g., cut left forearm, broken right foot, etc., and (3) the reason(s) why accident/injury occurred. Use an additional sheet of paper if necessary. Item 22: State the exact work-site location of the injury, e.g., construction site, office area, storage area, etc. Item 24: List object, substance, or exposure that directly inflicted the injury or illness, e.g., floor, hammer, chemicals, etc. Items 32,33: Enter date in month-year format. Example: 02-56. Item 37: Enter the number of days or hours that make up a full work week for your employees. Item 45: Enter the 6-digit North American Industry Classification System (NAICS) Code of the employer. The primary code is the code which appears in block 5 of Form C-3, "Employer's Quarterly Report" to the Texas Workforce Commission. Item 46: For companies with a single NAICS code, the specific code is the same as the primary code. For companies with multiple NAICS codes, enter the code that identifies the specific business, activity, or work-site location the employee was working in at the time of the injury. This may or may not be the same as the primary code. DWC FORM-001 Rev. 10/05 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers’ Compensation, Unless the Division specifically requests a direct filling. CLAIM # ______________________________________ CARRIER'S CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 1. Name (Last, First, M.I.) 2. Sex M - 3. Social Security Number - - 4. Home Phone ( 6. Does the Employee Speak English? YES 7. Race 5. Date of Birth (m-d-y) ) 17. Date Lost Time Began (m-d-y) - 16. Time of Injury 15. Date of Injury (m-d-y) F - : - 18. Nature of Injury* am pm 19. Part of Body Injured or Exposed* - If No, Specify Language 20. How and Why Injury/Illness Occurred* NO 8. Ethnicity White Black Native American Asian 9. Mailing Address Hispanic Other Street or P.O. Box City 22. Worksite Location of Injury (stairs, dock, etc.)* 21. Was employee doing his YES regular job? NO 23. Address Where Injury or Exposure Occurred Name of business if incident occurred on a business site State Zip Code County 10. Marital Status Street or P.O. Box County City Married Widowed Separated Single 11. Number of Dependent Children 12. Spouse's Name State Zip Code Divorced 24. Cause of Injury(fall, tool, machine, etc.)* 13. Doctor's Name 25. List Witnesses 14. Doctor's Mailing Address (Street or P.O.Box) 26. Return to work date/or expected (m-d-y) City State Zip Code YES - 30. Date of Hire (m-d-y) 31. Was employee hired or recruited in Texas? YES 34. Employee Payroll Classification Code 36. Rate of Pay at this Job Hourly $ $ Hours 42. Business Mailing Address and Telephone Number Street or P.O. Box State 44. Federal Tax Identification Number NO - Months - 33. Length of Service in Occupation Months Years ______ Years ______ 35. Occupation of Injured Worker 38. Last Paycheck was: Days $ for 39. Is employee an Owner, Partner, or Corporate Officer? Hours or Days YES NO 41. Name of Business 40. Name and Title of Person Completing Form City 29. Date Reported (m-d-y) - 32. Length of Service in Current Position NO 37. Full Work Week is: Weekly 28. Supervisor's Name 27. Did employee die? Telephone ( ) Zip Code 43. Business Location (If different from mailing address) Number and Street City 45. Primary North American Industry Classification System Code:(6 digit) 48. Workers' Compensation Insurance Company State 46. Specific NAICS Code (6 digit) Zip Code 47. Texas Comptroller Taxpayer No. 49. Policy Number 50. Did you request accident prevention services in past 12 months? YES NO If yes, did you receive them? YES NO 51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING) X DWC FORM-1 (Rev. 10/05) Page 3 Date ________________________________________ DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com