FAQ
Employer’s report for reimbursement of voluntary payment

Where do I send this form?
Send a copy of this form to the Texas Department of Insurance, Division of Workers’ Compensation (DWC) and the insurance carrier. You can fax or mail the completed form to DWC or drop the form off at a DWC field office.

Fax: 512-804-4301

Mail: Texas Department of Insurance, Division of Workers’ Compensation
Business Process, MS BP-OPS
PO Box 12050
Austin, Texas 78711-2050

When do I send this form to DWC and the insurance carrier?
Send the form within seven days after the date of first payment. An employer should also timely file the DWC Form-001, Employer’s First report of injury or illness as Texas Labor Code Section 409.005 requires. If you fail to do this, it will waive your right to reimbursement of any voluntary payments.

When do I get paid?
The insurance carrier should reimburse the employer within seven days after receiving the request. The insurance carrier should notify DWC within seven days of reimbursing the employer the amount reimbursed and the date of the reimbursement.

What happens if the insurance carrier refuses to reimburse me?
If there is a dispute concerning reimbursement, the employer may file a subclaim in accordance with Labor Code Section 409.009.

Questions?
Call 800-252-7031, Monday through Friday, 8 a.m. to 5 p.m., Central time.
Go to www.tdi.texas.gov/wc to learn more about workers’ compensation.

Note: With few exceptions, on your request, you are entitled to:

• Be informed about the information DWC collects about you.
• Receive and review the information (Government Code Sections 552.021 and 552.023).
• Have DWC correct information that is incorrect (Government Code Section 559.004).

For more information, contact [email protected] or go to the Corrections Procedure section at www.tdi.texas.gov.