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TAC Risk Management Pool

Workers' Compensation Claims Forms and Notices


CLAIMS FORMS

​Please note: You must obtain credentials to use any of these Workers' Compensation forms by or calling (512) 427-2415.
Employer’s First Report of Injury or Illness
File Online File Hard Copy
Use this form to report a work-related injury or occupational illness. You must file this form with the Pool and injured worker within eight calendar days of receiving notice from the injured worker. This form must accompany the Injured Employee Rights and Responsibilities Notice when it is sent to the injured worker.

Employer’s Wage Statement
File Online File Hard Copy
Use this form to report wages for an injured employee when he or she has reached eight days of disability (inability to earn pre-injury wages due to the compensable injury). You must report 13 weeks of gross wages before the date of injury as well as discontinued fringe benefit amounts, such as health insurance. ​

Supplemental Report of Injury
File Online File Hard Copy
File this form with the Pool if within three days,  the injured worker returns to work or loses additional time after initially returning to work, within 10 days if the employee resigns, is terminated, or is earning post-injury wages, such as modified duty or salary continuation. This form must also be sent to the injured worker.

Employer’s Report for Reimbursement of Voluntary Payment​
File Online File Hard Copy
Use this form to seek reimbursement from the Pool for salary continuation paid to law enforcement officers. The Pool will reimburse what it would have paid in Temporary Income Benefits to the injured worker as required by the Texas Labor Code.


NOTICES


Medication First Fill Au​thorization
File Online File Hard Copy
The Pool contracts with myMatrixx for pharmacy benefit management services. Please ensure your injured workers receive this form to get prescriptions filled.

Notice to Employees Concerning Workers’ Co​mpensation in Texas
File Online File Hard Copy
This notice must be posted where employees frequent to notify them of your coverage provider (TAC RMP) and the effective dates of your coverage. 

Notice Regarding Certain Work-Related Communicable Diseases
File Online File Hard Copy
This notice must be posted where first responders frequent. All first responders as defined on the notice are required to test for communicable diseases within 10 days.

Employer’s Notice of Ombudsman Program
File Online File Hard Copy
​This notice must be posted where all employees frequent. It is a notice which outlines claims and hearings assistance available within the Office of Injured Employee Counsel for injured workers. 

Employer Rights and Responsibilities
File Online File Hard Copy
This notice outlines your rights and responsibilities as an employer in the workers’ compensation system.

Injured Employee Rights and Responsibilities
File Online File Hard Copy
This notice must go to the injured worker. It must accompany the Employers’ First Report of Injury or Illness and Medication First Fill Authorization.

Workers’ Compensation Claims Contact Information

York Risk Services Group (specific claims inquiries): (800) 752-6301

Fax (512) 346-9321​​​​​
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