Dwc Form-46 Employee'S Request For Acceleration Of Impairment Income Benefits - Texas Department On Insurance
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1
2Send To: TEXAS DEPARTMENT OF INSURANCE
CLAIM # ________________________________________________
DIVISION OF WORKERS’ COMPENSATION
Field Office Handling Claim
Carrier’s Claim # _________________________________________
EMPLOYEE'S REQUEST FOR ACCELERATION OF IMPAIRMENT INCOME BENEFITS
1. Employee's Name
4. Employee's Telephone Number
2. Mailing Address (Street or P.O. Box)
5. Date of Injury
City
State
Zip Code
6. Insurance Company’s Name
3. Employee's Social Security Number (last 4 digits)
7. Employer's Name
xxx-xx-
8. Amount of Acceleration Requested (The accelerated payment cannot exceed your weekly net pre-injury wage which is based on 85% of
your average weekly wage before your injury.) $____________
9. Please explain the reasons for your hardship that is the basis for requesting acceleration of your impairment income benefits.
INJURED EMPLOYEE: PLEASE READ CAREFULLY
010. a)
This form is to be completed and filed with the Texas Department of Insurance, Division of Workers’ Compensation
only if you are receiving weekly impairment income benefits and if there is not a pending dispute of the impairment
rating.
b)
Acceleration of impairment income benefits will increase the amount of your weekly checks but will reduce the number
of weeks you will receive impairment income benefits.
c)
If you are entitled to supplemental income benefits and you receive accelerated payment of impairment income
benefits, the payment period for supplemental income benefits will not begin until after the end of the original number of
weekly impairment income benefits. This means that you will not receive any weekly benefits between your last
accelerated payment of impairment income benefits and the beginning of supplemental income benefits.
I have read the above and understand how acceleration will affect my weekly payments. I certify that the information I have
provided is correct to the best of my knowledge.
Signature of Injured Employee
Date ____________________
DIVISION ORDER
Acceleration Approved
The insurance company shall initiate accelerated payments no later than 7 days after receiving
notice of the Division's approval. (See reverse side for calculation of payments.)
Number of accelerated payments
Amount of accelerated payments $
Acceleration Denied
Reason for denial:
Authorized DWC Employee's Signature
Title
Telephone Number
Date
DWC FORM-46 (Rev. 10/05) Page 1
DIVISION OF WORKERS’ COMPENSATION
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