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APPEAL NO. 040891 FILED MAY 26, 2004, This appeal arises pursuant to the Texas Workers Compensation Act, TEX. LAB. CODE ANN. 401.001 et seq. (1989 Act). A contested case hearing was held on January
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Obtain the 040891rdoc form from the TDI Texas website or request it from your insurance provider.
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Fill in your personal information in the appropriate fields, including your name, address, and contact details.
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Provide details about the nature of your insurance claim or inquiry. Be specific and concise in explaining your situation.
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Sign and date the form at the designated area to verify that the information provided is true and accurate to the best of your knowledge.
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040891rdoc - tdi texas is a reporting form used by insurance companies in Texas to submit data to the Texas Department of Insurance.
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