compensation insurance coverage from [name of commercial insurance company] . In the event of work-related injury or occupational disease. This coverage is effective from [effective date of workers' compensation insurance policy] . Any injuries or occupational diseases which occur on or after that date will be handled by [name of commercial insurance company] . An employee or a person acting on the employee's behalf, must notify the employer of an injury or occupational disease not later than the 30th day after the date on which the injury occurs or the date the employee knew or should have known of an occupational disease, unless the Texas Department of Insurance, Division of Workers' Compensation (Division) determines that good cause existed for failure to provide timely notice. 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] NOTICE TO EMPLOYEES CONCERNING WORKERS' COMPENSATION IN TEXAS has workers' EMPLOYEE ASSISTANCE: The Division provides free information about how to file a workers' compensation claim. Division staff will answer any questions you may have about workers' compensation and process any requests for dispute resolution of a claim. You can obtain this assistance by contacting your local Division field office or by calling 1-800-252-7031. The Office of Injured Employee Counsel (OIEC) also provides free assistance to injured employees and will explain your rights and responsibilities under the Workers' Compensation Act. You can obtain OIEC's assistance by contacting an OIEC customer service representative in your local Division field office or by calling 1-866-EZE-OIEC (1-866393-6432). SAFETY VIOLATIONS HOTLINE: The Division has a 24 hour toll-free telephone number for Notice 6 (01/13) 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. TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION Rule 110.101(e)(1) American LegalNet, Inc. www.FormsWorkFlow.com COVERED EMPLOYER Texas Workers' Compensation Rule 110.101(e)(1) requires employers who are covered by workers' compensation through a commercial insurance company to advise their employees that they do have workers' compensation insurance coverage and to advise their employees of the Texas Department of Insurance, Division of Workers' Compensation's toll free number to obtain additional information about their workers' compensation rights. 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)(1). 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