Written Request For Interlocutory Order {DWC-58}

Texas Department of Insurance Division of Workers' Compensation CLAIM Number: _____________________________________ Carrier Claim Number: ________________________________ Chief Clerk of Proceedings 7551 Metro Center Drive, Suite 100, MS-35 z Austin, Texas 78744-1609 512-804-4000 z 512-804-4071 fax z www.tdi.texas.gov WRITTEN REQUEST FOR INTERLOCUTORY ORDER (DWC Form-058) 1. Party Requesting an Interlocutory Order: Injured Worker Insurance Carrier: 4. Date of Injury (mm/dd/yyyy) 2. Injured Worker's Name (Last, First M I) Beneficiary Sub-Claimant 3. Social Security Number (last 4 digits) Date of BRC: (mm/dd/yyyy) 5. Insurance Carrier's Name 6. Employer's Business Name 7. Type of request: Temporary Income Benefits Death or Burial Benefits Pay Impairment Income Benefits Lifetime Income Benefits Suspend Supplemental Income Benefits Medical Benefits 8. Average Weekly Wage 9. Duration/Amount of Benefits Requested 10. Explanation/Justification to Support Request (documents supporting this request may be attached to this form). 11. Requestor Information Requestor's Signature Requestor's Typed or Printed Name Requestor's Mailing Address Hand delivered to other parties at the Benefit Review Conference. Mailed / Delivered / Faxed (circle one) to other parties on _____________________ (date). Date of Request (mm/dd/yyyy) Phone Number Fax Number DWC058 Rev. 09/07 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 Form DWC058 Instructions (Written Request for Interlocutory Order) Who may use this form? An injured employee, beneficiary, subclaimant or insurance carrier may use this form to make a written request for the payment or suspension of benefits. Where to submit this form? The DWC058 should be filed with the benefit review officer presiding over the benefit review conference (BRC). Supporting documents addressed in Section 10 are not necessary if already included in the BRC exchange. Opportunity to respond: The opposing parties will be given the opportunity to respond to any requests for interlocutory order. DWC Action: The presiding officer has up to three days after receipt of a request for an interlocutory order to act. If the order is issued, a copy will be provided to all parties to the dispute. Parties may contact the Division with any questions regarding this form. You may find contact information at http://www.tdi.texas.gov/wc/dwccontacts.html or call 1-800-252-7031. NOTE: With few exceptions, you are entitled on request to be informed about the information that Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) collects about you. Under §552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under §559.004 of the Government Code you are entitled to have TDI-DWC correct information about you that is incorrect. For more information, call the local Division of Workers' Compensation field office at 512-804-4437. DWC058 Rev. 09/07 Instructions American LegalNet, Inc. www.FormsWorkFlow.com