Texas Department Of Insurance Request For Record Check
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1
2Send to: TEXAS DEPARTMENT OF INSURANCE
DIVISION OF WORKERS' COMPENSATION
REQUEST FOR RECORD CHECK
7551 Metro Center Drive, Suite100, MS-92B
Austin, TX 78744
INSTRUCTIONS: Please carefully read the instructions before completing this form. INCORRECT/INCOMPLETE FORMS
WILL BE RETURNED TO REQUESTOR WITHOUT ACTION. PAYMENT MUST ACCOMPANY REQUEST FORM.
I. CLAIMANT IDENTITY. Provide the following information to identify the injured employee
Injured Employee's Name
Injured Employee's Social Security Number
II. REQUESTOR INFORMATION. Record check information will be sent to the requestor's address shown below.
Requestor
Title
Firm Name
DWC/Adjuster Box Number (if applicable)
Mailing Address
DWC Account Number (if applicable)
City, State
ZIP
Telephone Number
Authorized Legal
Representative
(
)
Statement on File
III. FEES.
Record Checks are $15.00 each.
Check box if Certification is requested. ($1 Additional Fee)
IV. REQUESTOR ELIGIBILITY AND NOTARIZATION. The Texas Workers' Compensation Act, Texas Labor Code, Title 5,
Section 402.084, limits the release of confidential information in or derived from an employee's claim file to the categories of
parties listed below. Please indicate the category of eligibility, which qualifies you to receive the information requested. Sign
and complete the notarization prior to sending the request to DWC. Eligibility will be verified. Please check one box only.
The workers’ compensation insurance carrier. Requestor
The employee or the employee's legal beneficiary
must provide injured employee's date of injury:
The employee's or the legal beneficiary's representative
mo./dy./yr.
The Texas Property and Casualty Insurance Guaranty
(attach letter of representation)
Association, if that association has assumed the
The employer at the time of injury. Requestor must
obligations of an impaired insurance company
provide injured employee's period of employment:
A third party litigant in a lawsuit, in which the cause of
to
mo./yr .
mo./yr.
action arises from the incident that gave rise to the
injury
The Texas Certified Self-Insurer Guaranty Association
(COPY OF PETITION AND ANSWER MUST BE ATTACHED).
Requestor must provide injured employee's date of injury:
established under Subchapter G, Chapter 407, if that
association has assumed the obligations of an impaired
mo./yr.
employer
I have read and understood this form and the accompanying instructions. I am entitled to receive the confidential employee
information being requested as indicated above. I understand it is a Class A misdemeanor to unlawfully receive, publish,
disclose, or distribute confidential claim information in or derived from an employee's claim file. {Texas Labor Code, Sections
402.064; 402.084; 402.086; 402.091}
Date
Signature of Requestor
_
State of
*
*
County of
*
Before me on the above date personally appeared, ______________________________________________________________________ ,
w ho after first being sworn, said the statements contained in this request are true.
Signed _______________________________________________________________________
Notary Public, State of
_
My Commission Expires _______________
DWC FORM-155 (Rev. 10/05) Page 1
DIVISION OF WORKERS’ COMPENSATION
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