NOTICE TO EMPLOYEES CONCERNING WORKERS' COMPENSATION IN TEXAS does not have workers' compensation insurance coverage. As an employee of a non-covered employer, you are not eligible to receive workers' compensation benefits under the Texas Workers' Compensation Act. However, a non-covered (non-subscribing) employer can and may provide other benefits to injured employees. You should contact your employer regarding the availability of other benefits for a work-related injury or occupational disease. In addition, you may have rights under the common law of Texas should you have an on the job injury or occupational disease. Your employer is required to provide you with coverage information, in writing, when you are hired or whenever the employer becomes, or ceases to be, covered by workers' compensation insurance. COVERAGE: [Name of employer] SAFETY VIOLATIONS HOTLINE: The Division has a 24 hour toll-free telephone number for reporting unsafe conditions in the workplace that may violate occupational health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any employee because he or she in good faith reports an alleged occupational health or safety violation. Contact the Division at 1-800-452-9595. Notice 5 (01/13) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION Rule 110.101(e)(4) American LegalNet, Inc. www.FormsWorkFlow.com Non-Covered Employer Texas Workers' Compensation Rule 110.101(e)(4) requires employers who are not covered by workers' compensation, either by election, cancelation or termination of coverage to advise their employees that they do not have workers' compensation insurance coverage. Notices in English, Spanish and any other language common to the employer's employee population must be posted and: 1. Prominently displayed in the employer's personnel office, if any; 2. Located about the workplace in such a way that each employee is likely to see the notice on a regular basis; 3. Printed with a title in at least 26 point bold type, subject in at least 18 point bold type, and text in at least 16 point normal type; and 4. Contain the exact words as prescribed in Rule 110.101(e)(4). The notice on the reverse side meets the above requirements. Failure to post or to provide notice as required in the rule is a violation of the Act and Division rules. The violator may be subject to administrative penalties. Do Not Post This Side American LegalNet, Inc. www.FormsWorkFlow.com