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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 Austin, Texas 78744-1609 512-804-4000
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Begin by carefully reading the instructions provided with the form.
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Fill in your personal information, including your name, address, and contact information.
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Provide details about your injury or illness, including the date it occurred and the circumstances surrounding it.
04
Include information about any medical treatment you have received for the injury or illness.
05
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Sign and date the form, certifying that the information you have provided is accurate and complete.
Who needs tdi dwc 058?
01
Individuals who have suffered a work-related injury or illness and wish to file a claim for disability benefits.
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Employees who need to report their injury or illness to their employer and seek medical treatment.
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Employers who are required to provide workers' compensation benefits and need to keep records of reported injuries or illnesses.
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What is tdi dwc 058?
tdi dwc 058 is a form used by employers to report their Texas Department of Insurance (TDI) workers' compensation coverage.
Who is required to file tdi dwc 058?
All Texas employers who have workers' compensation insurance coverage are required to file tdi dwc 058.
How to fill out tdi dwc 058?
To fill out tdi dwc 058, employers need to provide information about their business, such as the company name, address, policy number, and contact details. They also need to report the number of employees and the total amount of payroll.
What is the purpose of tdi dwc 058?
The purpose of tdi dwc 058 is to ensure that employers provide accurate information about their workers' compensation coverage. This form helps TDI assess whether employers are complying with the state's workers' compensation requirements.
What information must be reported on tdi dwc 058?
On tdi dwc 058, employers must report their business information, policy details, employee count, and payroll amount for a specific period.
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