Form Dwc005 Employer Notice Of No Coverage Or Termination Of Coverage - Texas Department Of Insurance Division Of Workers' Compensation
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3DWC005
Texas Department of Insurance
DWC005
Division of Workers’ Compensation
Texas Department of Insurance
7551 Metro Center Drive, Suite 100 MS-96
Division of Workers’ Compensation
Austin, TX 78744-1645
7551 Metro Center Drive, Suite 100 MS-96
(800) 372-7713 phone (512) 804-4146 fax
Austin, TX 78744-1645
(800) 372-7713 phone (512) 804-4146 fax
Employer Notice of No Coverage or Termination of Coverage
Employer Notice of No Coverage or Termination of Coverage
Online submission available through Employer Online Filings at:
https://txcomp.tdi.state.tx.us/TXCOMPWeb/common/home.jsp
Online submission available through Employer Online Filings at:
https://txcomp.tdi.state.tx.us/TXCOMPWeb/common/home.jsp
I. REQUIRED STATEMENTS
I. REQUIRED STATEMENTS
1. Statement of No Coverage
1. Statement of No Coverage
The employer named below DOES NOT HAVE workers' compensation insurance coverage, pursuant to the
The employer named below DOES NOT HAVE workers' compensation insurance coverage, pursuant to the
Texas Workers' Compensation Act, Texas Labor Code, Section 406.004.
Texas Workers' Compensation Act, Texas Labor Code, Section 406.004.
The employer named below HAS TERMINATED workers' compensation insurance coverage, pursuant to the
The employer named below HAS TERMINATED workers' compensation insurance coverage, pursuant to the
Texas Workers' Compensation Act, Texas Labor Code, Section 406.007.
Texas Workers' Compensation Act, Texas Labor Code, Section 406.007.
Policy terminated effective
:
(mm/dd/yyyy)
Policy terminated effective
:
(mm/dd/yyyy)
Policy number:
Policy number:
Insurance company name:
Insurance company name:
Insurer informed of termination on
:
(mm/dd/yyyy)
Insurer informed of termination on
:
(mm/dd/yyyy)
Employees were (will be) notified on
:
(mm/dd/yyyy)
Employees were (will be) notified on
:
(mm/dd/yyyy)
The election selected above is effective from
to
. The effective
(mm/dd/yyyy)
(mm/dd/yyyy)
The election selected above is effective from
to
. The effective
(mm/dd/yyyy)
(mm/dd/yyyy)
dates cannot exceed a one-year period.
dates cannot exceed a one-year period.
2. Statement of Reportable Injuries or Diseases
2. Statement of Reportable Injuries or Diseases
Did you have any death, injury that resulted in the injured employee’s absence from work for more than one day,
Did you have any death, injury that resulted in the injured employee’s absence from work for more than one day,
or knowledge of an occupational disease since your last Employer Notice of No Coverage or Termination of
or knowledge of an occupational disease since your last Employer Notice of No Coverage or Termination of
Coverage?
Coverage?
Yes
No
If your response is “Yes”, you may be required to file a DWC Form-007, Employer’s Report of
Yes
No
If your response is “Yes”, you may be required to file a DWC Form-007, Employer’s Report of
Non-covered Employee’s Occupational Injury or Disease.
Non-covered Employee’s Occupational Injury or Disease.
(See the Frequently Asked Questions section of this form.)
(See the Frequently Asked Questions section of this form.)
II. PRIMARY EMPLOYER INFORMATION
II. PRIMARY EMPLOYER INFORMATION
3. Employer Business Name
4. Federal Employer ID Number
3. Employer Business Name
4. Federal Employer ID Number
5. Employer Business Mailing Address
(Street or PO Box, City, County, State, Zip Code)
5. Employer Business Mailing Address
(Street or PO Box, City, County, State, Zip Code)
6. Employer Business Type
7. Six-Digit NAICS Codes
6. Employer Business Type
7. Six-Digit NAICS Codes
NOTE: You must provide name, Federal Employer ID number and address of each Texas business location, subsidiary, or
NOTE: You must provide name, Federal Employer ID number and address of each Texas business location, subsidiary, or
separate entity of the primary employer covered by this report. To identify additional locations, submit a DWC Form-205,
separate entity of the primary employer covered by this report. To identify additional locations, submit a DWC Form-205,
Locations of Employer’s Business(es).
Locations of Employer’s Business(es).
III. PERSON PROVIDING INFORMATION
III. PERSON PROVIDING INFORMATION
8. Printed Name
9. Phone Number
8. Printed Name
9. Phone Number
10. Title
11. E-mail Address
10. Title
11. E-mail Address
12. Signature
13. Date of Signature
(mm/dd/yyyy)
12. Signature
13. Date of Signature
(mm/dd/yyyy)
For TDI-DWC Use Only
For TDI-DWC Use Only
DWC005 Rev. 01/13
Page 1 of 3
TX Insert 1 of 6
DWC005 Rev. 01/13
Page 1 of 3
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