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Form Dwc005 Employer Notice Of No Coverage Or Termination Of Coverage - Texas Department Of Insurance Division Of Workers' Compensation Page 3

The employer must also provide this notice to each employee:

at the time of hire;

when the employer elects to not have workers' compensation insurance;

within 15 days of notification to the insurance carrier that the employer is terminating coverage

unless the employer maintains continuous coverage under a new policy or becomes a certified

self-insurer; or

within 15 days of cancellation by the insurance company.

The required notice may be found on the TDI website at:

(English) and

(Spanish).

Are non-subscribers required to file other forms with the TDI-DWC?

Employers with five or more employees are required to report work-related injuries and diseases to the

TDI-DWC. Non-subscribers and covered employers whose employee(s) have waived workers’

compensation insurance coverage must report these work-related injuries and diseases using the DWC

Form-007, Employer’s Report of Non-covered Employee’s Occupational Injury or Diseases. The form

must be filed not later than the 7

day of the month following the month in which:

a work-related death occurred,

an employee was absent from work for more than one day* as a result of an on-the-job injury, or

the employer acquired knowledge of an occupational disease.

*Do not count the day of the injury or the day the injured employee returned to work when calculating

the number of days absent from work.

The DWC Form-007 can be obtained from the TDI website at:

Are any fields on the DWC Form-005 optional?

No, all applicable fields must be completed each time the DWC Form-005 is filed.

Additional information can be obtained from the TDI website at:

or by calling

1-800-372-7713.

NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC

collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have

TDI-DWC correct information that is incorrect (Government Code, §559.004).

DWC005 Rev. 01/13

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Form Dwc005 Employer Notice Of No Coverage Or Termination Of Coverage - Texas Department Of Insurance Division Of Workers' Compensation Page 3