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Employees Request For Advance Of Benefits DWC-47 - Texas
| Employees Request For Advance Of Benefits Form. This is a Texas form and can be used in Employee Workers Compensation . |
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DWC047 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-94 Austin, TX 78744-1645 (800) 252-7031 phone · (512) 804-4378 fax Complete if known: DWC Claim # Carrier Claim # Employee's Request for Advance of Benefits Type (or print in black ink) each item on this form I. EMPLOYEE/EMPLOYEE'S ATTORNEY INFORMATION 1. Employee's Name (First, Middle, Last) 3. Employee's Mailing Address (Street or PO Box, City, State, Zip Code) 4. Employee's Telephone Number ( ) 7. Attorney/Representative's Name (if applicable) 5. Alternate Telephone Number (if available) 6. Date of Injury (mm/dd/yyyy) ( ) 8. Attorney/Representative's Address (Street or PO Box, City, State, Zip Code) 2. Employee's Social Security Number II. EMPLOYER INFORMATION (at the time of the injury) 9. Employer's Name 10. Employer's Address (Street or PO Box, City, State, Zip Code) III. INSURANCE CARRIER INFORMATION 11. Insurance Carrier's Name 13. Adjuster's Name 12. Insurance Carrier's Address (Street or PO Box, City, State, Zip Code) 14. Adjuster's Telephone Number ( ) ext. 15. Adjuster's Fax Number ( ) IV. ADVANCE REQUEST 16. Amount of advance requested 17. Amount of income benefits currently being received $ weekly monthly $ 18. Maximum weekly/monthly reduction requested to pay back advance 19. Type of income benefits being received $ TIBs IIBs SIBs LIBs 20. Length of time your doctor expects you to be off work, including the date your doctor expects you to return to work (disability period) Note: This information must be provided if you are receiving Temporary or Supplemental Income Benefits. Attach documentation from your doctor. 21. Explain the financial hardship that is the basis for requesting an advance of your income benefits. (Attach supporting documentation as necessary, i.e., copies of your bills.) V. EMPLOYEE CERTIFICATION (Read Carefully) 22. An advance will reduce the amount of future income benefits. This reduction will be determined in accordance with the amount advanced and the number of benefit payments that are likely to be made in the future. Payments will be paid in this reduced amount until the insurance carrier recovers the amount advanced. I have read the above statement and understand how an advance will affect my future income benefit payments. I also understand that there are other legal limitations regarding advance of benefits, including limitations described in the attached Frequently Asked Questions. I certify that the information I have provided is correct to the best of my knowledge. 23. Signature of Injured Employee (required) For TDI-DWC Use Only 24. Date NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC047 Rev. 03/12 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC047 Frequently Asked Questions Employee's Request for Advance of Benefits (DWC Form-047) What are some examples of the legal limitations referenced in Section V of DWC Form-047? · Only an injured employee currently receiving workers' compensation income benefits is eligible to request an advance. · A beneficiary currently receiving death benefits is not eligible to request an advance. · All advances must be based on financial hardship. · No advance will be granted to an employee whose combined post-injury earnings and income benefits equal or exceed 90% of the employee's net pre-injury wage. · The injured employee must be likely to be entitled to income benefits sufficient to cover the amount of the advance. · The total amount of benefits and advances cannot exceed the amount the employee would otherwise be entitled to under the normal payment schedule. · The amount of any one advance cannot exceed four times the maximum weekly benefit for Temporary Income Benefits at the time of injury. · No more than three advances may be granted based on the same injury. How does an advance affect my future benefits? When you receive an advance, the insurance carrier is entitled to recover the full amount of the advance from your future income benefits. The Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) determines the repayment schedule, considering the amount advanced and the number of weeks or months that benefits are likely to be paid in the future. The following examples are for illustrative purposes only. · If you are receiving Temporary Income Benefits (TIBs) or Impairment Income Benefits (IIBs), which are paid weekly, the amount of the advance will be divided by the number of weeks considered reasonable by the TDI-DWC, not to exceed the number of weeks your benefits are expected to continue. For example, if you receive an advance of $1,000 and your benefits are expected to continue for 20 more weeks, your benefits may be reduced by $50 per week ($1,000 divided by 20 weeks = $50). If you are receiving Supplemental Income Benefits (SIBs), which are paid monthly and approved quarterly, the amount of the advance will be divided by the number of months left in the approved quarter. For example, if you receive an advance of $1,000 and two months remain in the quarter, your benefits will be reduced by $500 per month ($1,000 divided by 2 months = $500). If you are receiving Lifetime Income Benefits (LIBs), which are paid weekly, the amount of the advance will be divided by the number of weeks considered reasonable by the TDI-DWC. For example, if you receive an advance of $1,000, your benefits may be reduced by $25 per week for 40 weeks ($1,000 divided by 40 weeks = $25). · · Where do I file the DWC Form-047? Submit the DWC Form-047 to the TDI-DWC by: · fax to (512)804-4378; or · mail to the Texas Department of Insurance, Division of Workers' Compensation, 7551 Metro Center Drive, Suite 100, MS-94, Austin, Texas 78744-1645. What does the TDI-DWC do? Upon receipt of the form, the TDI-DWC will review the request. You may be contacted and asked to provide additional documentation to support the request. The TDI-DWC must also determine the likelihood of sufficient income benefits to repay the advance. After reviewing request, the TDI-DWC may approve the request, reduce the amount of the advance, or deny the request. An order approving or denying the request will be sent to you, your representative, if any, and the insuranc
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