Programs | May 31, 2023
Workers' Comp Claims & Notices
Ready to report a claim? Below is information on medical treatment for injured workers, how to report new claims and required forms for existing claims.
Online and Email Claims Reporting
For Members who would like online access, or access has expired to report injuries and other claim forms online, please contact Helana Barmore to obtain or reset your security credentials.
Injured Worker Medical Network
Injured workers of participating counties are required to treat for their on-the-job injuries with providers who are part of the Political Subdivision Workers' Compensation Alliance. This website address is www.pswca.org. Treating doctors and specialists are searchable on this web site. For more information concerning whether or not your county participates in the Alliance, please contact your county workers' compensation coordinator or your claims examiner at 800 752 6301.
Employer's First Report of Injury or Illness (DWC-1)File DWC-1 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 (DWC-3)File DWC-3 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 (DWC-6)File DWC-6 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 (DWC-2)File DWC-2 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.
Medication First Fill AuthorizationDownload a 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' Compensation in Texas (Notice 6)Download a 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 (Notice 9)Download a 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 Rights and ResponsibilitiesDownload a Hard Copy
Injured Employee Rights and ResponsibilitiesDownload a 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.
Notice Regarding First Responder Liaison to Assist in Workers’ Compensation ClaimsDownload a Hard Copy
This notice must be posted where first responders frequent. It provides information on the Office of Injured Employee Counsel liaison specifically designated to assist, educate and advocate on behalf of all first responders.