FAQ
Accident prevention services worksheet

Who must file this form?
Insurance companies undergoing inspections by the Texas Department of Insurance, Division of Workers’ Compensation (DWC) required by 28 Texas Administrative Code Section 166.5 (Inspections of Adequacy of Accident Prevention Facilities and Services) must file the DWC Form-105. Insurance companies are responsible for timely and accurately filing the DWC Form-105.

When do I file the DWC Form-105?
An insurance company must file a completed DWC Form-105 for each policy that DWC selects at least 10 days before the scheduled date of the inspection.

Are any fields on the DWC Form-105 optional?
You must complete all fields each time you file the DWC Form-105. A DWC Form-105 is considered filed with DWC only when it accurately contains all the required data elements.

Where do I send this form?

Email: [email protected]

Mail: Texas Department of Insurance,
Division of Workers’ Compensation
Workplace Safety, Mail Code HS-WS
PO Box 12050
Austin, TX 78711-2050

Questions?
Call 1-800-252-7031, Monday to 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 refer to the Corrections Procedure section at www.tdi.texas.gov/commissioner/legal/lccorprc.html.