FAQ
Supplemental report of injury

Why do I need to file this form?
The Texas Department of Insurance, Division of Workers’ Compensation (DWC) requires either the employer or the injured employee to report to the insurance carrier all return-to-work activity and post-injury change of earnings. This allows the insurance carrier to adjust the weekly amount of temporary income benefits (TIBs) paid to an injured employee to match the changes in weekly earnings after the injury.

Who is responsible for filing this form?
Either the employer or the injured employee.

Employer: The employer that the injured employee was working for at the time of the on-the-job injury must send this form to the insurance carrier and the injured employee while the injured employee is receiving TIBs and until the injured employee reaches maximum medical improvement or is no longer employed by the employer.

Injured employee: If you are no longer working for the employer where the on-the-job injury occurred, and you are receiving benefits, then you must let the workers’ compensation insurance carrier know if your wages changed or if you have received any offers of employment.
If you are not receiving benefits, you must tell the insurance carrier if the injury caused you to miss work or lose income.

How do I send this form?
Send this form to the insurance carrier by email, fax, telephone, or personal delivery. The employer must provide a copy of the form to the injured employee by email, fax, mail, or personal delivery.

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.