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Carriers Request For Seasonal Employee Wage Information From Texas Employment Commission Records DWC-56 - Texas
| Carriers Request For Seasonal Employee Wage Information From Texas Employment Commission Records Form. This is a Texas form and can be used in Employee Workers Compensation . |
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PREPAYMENT ACCOUN T #: CLAIM # ______________________________________________ Carrier's Claim # ________________________________________ CARRIER'S REQUEST FOR SEASONAL EMPLOYEE WAGE INFORMATION FROM TEXAS EMPLOYMENT COMMISSION RECORDS A $15.00 fee must be paid for this request for seasonal employee wage information from the Texas Employment Commission. No action will be taken on the request without payment. Send the request with payment to: Employee/Employer Field Services, Workers' Compensation Information Services Center, MS-602, Texas Department of Insurance, Division of Workers' Compensation, 7551 Metro Center Drive, Suite 100, Austin, Texas 78744. 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 On DATE the insurance carrier shown above filed notice with the injured seasonal employee of its intention to request the Texas Department of Insurance, Division of Workers' Compensation's approval to adjust the employee's average weekly wage and temporary income benefit payment because of a seasonal change in the employee's wages. The seasonal employee did not provide wage information to the carrier within two (2) weeks from the date of notice according to a thorough search of the carrier's records. The insurance carrier requests the Texas Department of Insurance, Division of Workers' Compensation to contact Texas Employment Commission for the seasonal employee's wage history for the most recent five (5) quarters available. ADJUSTER CERTIFICATION I certify the wage information requested will be used solely to determine whether an injured seasonal employee's average weekly wage and temporary income benefit payment should be adjusted. Adjuster's Name (PRINTED) Adjuster's Signature Adjuster's Business Mailing Address (Street or P. O. Box) City State ZIP Code DIVISION USE ONLY Date Information Requested from TEC Date Information Provided to Carrier's Designated Austin Representative DWC FORM-56 EES-1 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com
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