Twcc-5, Employer Notice Of No Coverage Or Termination Of Coverage
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1Send TWCC-5 by certified mail or personal delivery to:
EMPLOYER NOTICE OF
TEXAS WORKERS' COMPENSATION COMMISSION
NO COVERAGE OR
4000 South IH-35, Southfield Building
Austin, Texas 78704
TERMINATION OF COVERAGE
INSTRUCTIONS
WHO MUST FILE: All employers (including former sole proprietors who have formed corporations which have only one employee) must file
a form TWCC-5 with the Texas Workers' Compensation Commission unless the employer:
a.
has workers' compensation insurance;
c.
is a self-insured political subdivision; or
b.
is a certified self-insurer;
d.
only employs employees who are exempt from coverage under the
Texas Workers' Compensation Act.
WHEN TO FILE: See reverse side of form.
NO COVERAGE OR TERMINATION OF COVERAGE
1. Check one of the following:
ELECTS NOT
The below named employer
to obtain workers' compensation insurance coverage, pursuant to the Texas Workers'
Compensation Act, Texas Labor Code, Section 406.004.
TERMINATED
The below named employer has
workers' compensation insurance coverage, effective date ________________
of Policy Number
and has notified the ____________________________________ Insurance
Company on (date)
, pursuant to the Texas Workers' Compensation Act, Texas Labor Code, Section 406.007.
Notice has been (will be) provided to employees on the following date:
.
EMPLOYER INFORMATION
(PLEASE TYPE OR PRINT:)
2. Employer Business Name
3. Federal Tax ID Number
4. Employer Business Mailing Address
5. Description of Business Operations. Identify type and nature of business.
6. Name, Federal Tax ID Number and Address of each Business Location covered by this report, if different from the above. To identify
additional locations, submit a form TWCC 205.
Name
Address
Federal Tax ID Number
City
State
Zip
Name
Address
City
State
Zip
Federal Tax ID Number
COMMISSION DATE STAMP HERE:
PERSON PROVIDING THIS INFORMATION
7. Name
8. Title
9. Signature
10. Date
TWCC-5 (3/94)
Rule 110.1
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