Texas > Workers Compensation > Employee
Request To Adjust Average Weekly Wage For Seasonal Employee DWC-55 - Texas
| Request To Adjust Average Weekly Wage For Seasonal Employee Form. This is a Texas form and can be used in Employee Workers Compensation . |
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Send to: Injured Employee DWC Field Office Handling Claim CLAIM # ______________________________________________ CARRIER'S CLAIM # ___________________________________ REQUEST TO ADJUST AVERAGE WEEKLY WAGE FOR SEASONAL EMPLOYEE Instructions for Insurance Carrier: The insurance carrier's records show that the employee in the claim shown below has failed to furnish the wage information requested on ___________. _________________________________ now requests the DATE CARRIER Division's approval to adjust the injured seasonal employee's average weekly wage from $ beginning _______________ and ending on DATE DATE TYPE OF EVIDENCE to $ . Attach ___________________________________________ showing the employee's earnings during the same period in previous years. A copy of this request must be provided to the injured worker at the same time it is submitted to the Division's field office handling the claim. Date mailed to Division and Employee: ___________________________________________________ 1. Employee's Name (Last, First M.I.) and Telephone Number ( 4. Mailing Address (Street or P.O. Box) ) 5. Employer's Business Name 2. Social Security Number 3. Date of Injury City State ZIP Code 6. Insurance Carrier's Name hhh NOTICE TO EMPLOYEE hhh A representative of the Division will attempt to contact you upon the Division's receipt of the insurance carrier's Request to Adjust Average Weekly Wage for Seasonal Employee to explain the purpose of this request and to determine whether you agree with the request to adjust your average weekly wage and your weekly temporary income benefit payment. Within the next 2 weeks you may request a Benefit Review Conference if you do not agree with the request for adjustment. Your dispute will be set for a Benefit Review Conference within 20 days of your request. You can give additional wage information for consideration. However, if you do not request a Benefit Review Conference within this period, the Division will approve the request for adjustment based on the wage information available. If you have any questions or need help, call the Texas Department of Insurance, Division of Workers' Compensation at 1-800-252-7031 or contact the Division field office handling your claim. FOR DIVISION USE The insurance carrier's Request to Adjust Average Weekly Wage for Seasonal Employee in the above styled claim is: APPROVED. Employee failed to request a Benefit Review Conference within the required 2-week period set forth above. The average weekly wage is adjusted to $ payment is adjusted to $ __________________. , beginning , and the temporary income benefit weekly and ending NOT APPROVED. Reason: _________________________________________________________________________ DWC Disability Determination Officer (SIGNATURE) Division Field Office Phone Number ( ) State ZIP Code Division Field Office Address City DWC FORM-55 (Rev. 10/05) Page 1 DIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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