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Employers Report For Reimbursement Of Voluntary Payment DWC-2 - Texas
| Employers Report For Reimbursement Of Voluntary Payment 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 REPORT FOR REIMBURSEMENT OF VOLUNTARY PAYMENT 1. Employer's Name 13. Employee's Name (Last,First, M.I.) 2. Employer's Mailing Address (Street or P.O. Box) 14. Employee's Mailing Address (Street or P.O. Box) City State Zip Code City State Zip Code 3. Federal Tax I.D. No. 15. Employee's Social Security Number 4. Date of Injury 5. Date of this Notice 16. Name of Insurance Carrier 6. Date Lost Time Began 7. Date of Initial Payment 17. Address of Insurance Carrier (Street or P.O. Box) 8. Amount of Payment $ 9. Number of Weeks Paid City State Zip Code $ 10. From 11. To 18. Address of Insurance Carrier Claims Office (Str. or P.O. Box) 12. This Payment: Initiates Compensation Supplements Injured Employee's Income Covers Medical Expenses Incurred City State Zip Code 19. Insurance Carrier Representative The employer should notify Texas Department of Insurance, Division of Workers' Compensation and the insurance carrier within 14 days after the date of initial payment. An employer who fails to timely file the report of injury or occupational disease as required by Art. 8308-5.05, of the Texas Workers' ompensation Act waives the right to reimbursement of any voluntary payments and may be assessed an administrative penalty, not to exceed $500.00. If there is a dispute concerning reimbursement of any employer's payments of compensation or medical benefits, the employer may file a subclaim in accordance with Art. 8308.5.08, of the Texas Workers' Compensation Act. The insurance carrier should reimburse the employer within 30 days after receiving the request and should notify the Texas Department of Insurance, Division of Workers' Compensation within 10 days of payment of the amount and date of the reimbursement. DWC FORM-2 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com DWC FORM - 2 (Employer's Report for Reimbursement of Voluntary Payment) The employer is required to file an Employer's Report for Reimbursement of Voluntary Payment [Interim DWC FORM - 2 (10/05)] with the DWC and the insurance carrier. The employer waives the right to reimbursement if it fails to notify the Division by filing DWC FORM - 1 (Employer's First Report of Injury or Illness), or did not do so in a timely manner. The Employer's Report for Reimbursement of Voluntary Payment enables an employer who voluntarily begins payment to an injured worker to recoup from the insurance carrier once a determination of compensability has been made. The insurance carrier, once the claim is found to be compensable, should reimburse the employer within 30 days after receiving the request. Initiation of payment to the worker in no way implies admission of compensability, and the worker must be notified that any payments made by the employer will later be deducted from compensation paid by the insurance carrier. Employers who voluntarily begin payment to an injured worker may not recover from the insured if the claim is determined not compensable. This form will be printed as a 3-part form with the original to the carrier, the second copy to DWC and the third copy for employer's record. The report is considered filed when personally delivered or postmarked. Send DWC's copy to the field office handling the claim. [Art. 8308-4.06. Certain Employer Payments Reimbursable; Art. 8308-5.05. Employer Report of Injury; Administrative Violation; Art. 8308-5.08. Subclaims, Texas Workers' Compensation Act] American LegalNet, Inc. www.USCourtForms.com DWC FORM -2 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION
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