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Carriers Request For Reduction Of Income Benefits Due To Contribution DWC-33 - Texas
| Carriers Request For Reduction Of Income Benefits Due To Contribution Form. This is a Texas form and can be used in Carrier Workers Compensation . |
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TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS' COMPENSATION Send to the Division Field Office Handling the Claim CLAIM # ______________________________________________ Carrier's Claim # ________________________________________ CARRIER'S REQUEST FOR REDUCTION OF INCOME BENEFITS DUE TO CONTRIBUTION Pursuant to Texas Workers' Compensation Act, Texas Labor Code, Section 408.084, at the request of the insurance carrier, the Division may order that impairment income benefits and supplemental income benefits be reduced in a proportion equal to the proportion of a documented impairment that resulted from earlier compensable injuries. The Division shall consider the cumulative impact of the compensable injuries on the employee's overall impairment in determining a reduction under this section. The insurance carrier has the sole responsibility of providing the documentation to support its request. Box 1 through 11 to be completed by insurance carrier. 1. Employee's Name 3. Mailing Address (Street or P.O. Box) 2. Employee's Social Security Number 4. Date of Injury City State ZIP 5. Employee's Telephone Number 6. Employer's Business Name 7. Insurance Carrier's Name 8. The insurance carrier requests a Division Order to reduce the employee's impairment income benefits and supplemental income benefits by % for the effects of contribution from prior compensable injury(ies). Date of Injury Body Part(s) Involved Impairment Rating (if applicable) 9. Prior compensable injury or injuries (Note: Medical records documenting impairment must be attached to this request): CLAIM No. (if applicable) 10. Impairment rating from current compensable injury % Body Part(s) Involved 11. Insurance Adjuster's Signature Printed Name Telephone Number ( )_____________________ Date _______________________________________ DIVISION ORDER APPROVED The insurance carrier is ordered to reduce impairment income benefits and supplemental income % for the effects of contribution. benefits (if any) by DENIED - For the following reason(s) Medical reports not attached (request may be resubmitted with documentation) Medical records do not support impairment from prior compensable injury Prior compensable injury's impairment was related to different body part or area No evidence of a prior compensable injury Cumulative impact of compensable injuries does not warrant reduction Authorized DWC Employee's Signature Telephone Number ( ) _________________ Printed Name and Title ______________________________________________________ Date __________________________________ If the insurance carrier or the employee disagrees with the Division Order, he/she has the right to request a Benefit Review Conference. DWC FORM-33 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com DWC FORM - 33 (Carrier's Request for Reduction of Income Benefits Due to Contribution) When a carrier requests to reduce an employee's income benefits because of the effects of contribution from prior compensable injuries, the carrier should use DWC FORM-33, Carrier's Request for Reduction of Income Benefits Due to Contribution, and submit it to the Division field office handling the claim. Medical records documenting impairment related to the earlier compensable injury or injuries must be attached to DWC FORM-33. The Division will, after reviewing the documentation, approve or deny the request. If approved, the order will state the percentage by which impairment income benefits and supplemental income benefits, if any, can be reduced. If denied, the order will state the reason(s). A copy of the order will be sent to the carrier, the injured employee and the employee's representative, if any. If the insurance carrier or the employee disagrees with the order, either party may request a Benefit Review Conference. The insurance carrier and the employee's representative, if any, are required to use DWC FORM-45, Request for a Benefit Review Conference. An unrepresented employee may request a conference by contacting the Division in any manner. [Texas Workers' Compensation Act, Texas Labor Code, Section 408.084, Contributing Injury] DWC FORM-33 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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