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Employers Contest Of Compensability DWC-4 - Texas
| Employers Contest Of Compensability Form. This is a Texas form and can be used in Employer Workers Compensation . |
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TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION 7551 Metro Center Drive, Suite 100 Austin, Texas 78744 CLAIM # Carrier's Claim # EMPLOYER'S CONTEST OF COMPENSABILITY 1. Employee's Name (Last, First, M.I.) 4. Employer's Name (Last, First, M.I.) 5. Employer's Mailing Address (Street or P.O. Box) 2. Social Security Number 3. Date of Injury City 6. Employer's Telephone No. ( ) State Zip Code 7. Insurance Carrier In accordance with Art. 8308-5.10 of the Texas Workers' Compensation Act, the employer has the right to contest the compensability of an employee's injury if the insurance carrier accepts liability for the payment of benefits. 8. Provide any relevant facts supporting the reason(s) for contesting compensability. Division Date Stamp Here Employer's Signature _______________________________________________________ Date __________________________ Title ____________________________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com DWC FORM-4 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION DWC FORM - 4 (Employer's Contest of Compensability) An employer desiring to contest the compensability of a claim that the insurance carrier has accepted may file an Employer's Contest of Compensability with the Texas Department of Insurance, Division of Workers' Compensation (DWC). The employer may contest compensability of a claim after presenting the grounds for non-compensability to the carrier and giving the carrier the opportunity to contest compensability. The employer may file the FORM-4 no later than 50 days after the date the insurer received written notice of the injury. This will be printed as a single page form. The form is considered filed when personally delivered or postmarked. Send to the DWC field office handling the claim. [Art. 8308, Sec. 5.10. Employer Bill of Rights, Texas Workers' Compensation Act] American LegalNet, Inc. www.USCourtForms.com DWC FORM-4 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION
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