Employers Report Of Non-Covered Employees Occupational Injury Or Disease {DWC-7}

DWC007 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-96 Austin, TX 78744-1645 (800) 372-7713 phone · (512) 804-4146 fax Employer's Report of Non-covered Employee's Occupational Injury or Disease Type or print in black ink Non-subscribing Employer Subscribing Employer - Employee Waived Workers' Compensation Insurance Coverage I. EMPLOYER INFORMATION 1. Employer Business Name 2. Reporting Period (mm/yyyy) 4. Employer Business Mailing Address (Street or PO Box, City, County, State, Zip Code) 3. Number of Injured Employees Included on This Report 5. Provide the following: NAICS NAICS Codes Employment 6. Employer Physical Address (Street, City, State, Zip Code) 7. Employer Phone Number 8. Federal Employer ID Number 9. Name of Person Completing Form 10. Phone Number of Person Completing Form 11. Title of Person Completing Form 12. Signature of Person Completing Form 13. Date of Signature (mm/dd/yyyy) II. INJURED EMPLOYEE INFORMATION / INJURY DATA 14. Employee Name (First, Middle, Last) 16. Date of Birth (mm/dd/yyyy) 19. Occupation 17. Date of Hire (mm/dd/yyyy) 20. Hourly Wage 15. Employee's SSN 18. Sex Male Female 21. Employee NAICS Code 22. Race/Ethnic Identification White Black Hispanic Other (specify) Asian or Pacific Islander American Indian or Alaskan Native For TDI-DWC Use Only DWC007 Rev. 01/13 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DWC007 23. Address Where Injury/Occupational Disease Occurred (Street, City, State, Zip Code) 24. Type of Location Where Injury/Occupational Disease Occurred Primary Business Location On-site Job Location Traveling between Job Locations 25. Date of Injury/Occupational Disease (mm/dd/yyyy) 26. Date Reported By Employee (mm/dd/yyyy) 27. Return to Work Date or Expected Date (mm/dd/yyyy) 28. Reported Cause of Injury 29. Nature of Injury/Occupational Disease 30. Equipment Involved in the Injury (if any) 31. Body Part(s) Affected 32. First Day of Absence from Work (mm/dd/yyyy) 33. Number of Days Absent from Work 1 Day or Less >1 Day ­ 7 Days 34. Occupational Disease 35. Fatality Yes No Yes No If Yes, provide date (mm/dd/yyyy) 36. Description of Incident 8 Days or More NOTE : Title 28 Texas Administrative Code, Chapter 160 requires employers to report work-related deaths, on-the-job injuries and occupational diseases in the form and manner required by TDI-DWC. The social security number may be used to identify the injured employee. NOTE : With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004) For TDI-DWC Use Only Employer's Name: Employer's FEIN: DWC007 Rev. 01/13 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 1 2 DWC007 Injury Data for Additional Injured Employee(s) (reproduce this page, if necessary) Employer Business Name Employer FEIN II. INJURED EMPLOYEE INFORMATION / INJURY DATA 14. Employee Name (First, Middle, Last) 16. Date of Birth (mm/dd/yyyy) 19. Occupation 17. Date of Hire (mm/dd/yyyy) 20. Hourly Wage Reporting Period (mm/yyyy) 15. Employee's SSN 18. Sex Male Female 21. Employee NAICS Code 22. Race/Ethnic Identification White Black Hispanic Asian or Pacific Islander American Indian or Alaskan Native Other (specify) 23. Address Where Injury/Occupational Disease Occurred (Street, City, State, Zip Code) 24. Type of Location Where Injury/Occupational Disease Occurred Primary Business Location On-site Job Location Traveling between Job Locations 25. Date of Injury/Occupational Disease (mm/dd/yyyy) 26. Date Reported By Employee (mm/dd/yyyy) 27. Return to Work Date or Expected Date (mm/dd/yyyy) 28. Reported Cause of Injury 29. Nature of Injury/Occupational Disease 30. Equipment Involved in the Injury (if any) 31. Body Part(s) Affected 32. First Day of Absence from Work (mm/dd/yyyy) 34. Occupational Disease Yes No 36. Description of Incident 33. Number of Days Absent from Work 1 Day or Less >1 Day ­ 7 Days 35. Fatality Yes No If Yes, provide date (mm/dd/yyyy) 8 Days or More For TDI- DWC Use Only DWC007 Rev. 01/13 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DWC007 Frequently Asked Questions Employer's Report of Non-covered Employee's Occupational Injury or Disease (DWC Form-007) Which employers are required to report on-the-job injuries, occupational diseases, and workrelated deaths on the DWC Form-007? The following employers are required to file the DWC Form-007: · An employer that does not have workers' compensation insurance coverage (non-subscriber) and employs five or more employees who are not exempt from workers' compensation insurance coverage must file the DWC Form-007 to report all on-the-job injuries and occupational diseases. Examples of exempt employees include certain domestic workers, and certain farm and ranch workers. An employer that has workers' compensation insurance coverage must file the DWC Form-007 to report an on-the-job injury or occupational disease for an employee who has waived workers' compensation insurance coverage in accordance with Texas Labor Code §406.034. · Failure to file the form may subject the employer to administrative penalties. What do I do if I need to report more than two injured employees? Copy page three of the form as many times as necessary for reporting additional injured employees. When do I file the DWC Form-007? The form must be filed not later than the 7th day of the month following the month in which: · · · a work-related death occurred, an employee was absent from work for more than one day* as a result of an on-the-job injury; or the employer acquired knowledge of an occupational disease. *Do not count the day of the injury or the day the injured employee returned to work when calculating the number of days absent from work. NOTE: If no such deaths, injuries, or diseases occurred during a calendar month, no report is required for that month. Are any fields on the DWC Form-007 optional? No, all applicable fields must be completed each time the DWC Form-007 is filed. How do I file the DWC Form-007? Submit the DWC Form-007 to the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) by: · · faxing the form to (512) 804-4146; or mailing the form to the address listed at the top of the form. DWC007 Rev. 01/13 Page 4 of 5 American LegalNet, Inc. www.FormsWo