WCI Forms
Healthcare Network Forms
WCI Forms
- DWC 1 - Employer's First Notice of Injury Form
- DWC 6 - Employer's Supplemental Report of Injury
- DWC 3 - Employer's Wage Statement
- WCI23 - Employee's Leave Election
- Form 23P - Injury Leave for Peace Officers
- Employee's First Report of Work-Related Injury of Endemic Illness - FVWC
- UT System Administration - Employee's First Report of Work-Related Injury
- Employee's Rights & Responsibilities (English)
- Derechos y Responsabilidades Para los Empleados (Español)
- Notice to Employees (English)
- Aviso a los Trabajadores (Español)
- Monthly WCI Calculation Report
WCI HEALTHCARE NETWORK FORMS
UT System Healthcare Network Acknowledgement Forms
- The University of Texas System Administration
- The University of Texas at Arlington
- The University of Texas at Austin
- The University of Texas at Dallas
- The University of Texas at El Paso
- The University of Texas Permian Basin
- The University of Texas Rio Grande Valley
- The University of Texas at San Antonio
- Stephen F. Austin State University
- The University of Texas at Tyler
- The University of Texas Southwestern Medical Center
- The University of Texas Medical Branch at Galveston
- The University of Texas Health Science Center at Houston
- The University of Texas Health Science Center at San Antonio
- The University of Texas MD Anderson Cancer Center
- Workers' Compensation HCN-Opt In
IMO Med-Select HCN Information
- HCN Employee Handbook
- HCN Notice of Network Requirements
- HCN Network FAQ
- Provider Search and Network Service Areas
WCI HEALTHCARE NETWORK FORMS – OTHER LANGUAGES
Vietnamese
Employee Handbook
Sổ Tay Nhân Viên Hệ Thống Đại Học Texas
Notice of Network Requirements
Thông Báo Các Yêu Cầu Mạng Lưới dành cho Hệ Thống Đại Học Texas
Acknowledgement Form
Mẫu Đơn Xác Nhận
The forms above are provided by The University of Texas System and Injury Management Organization, Inc. Please contact your respective University of Texas System (UT System) Workers' Compensation Insurance (WCI) Representative before completing any forms. All forms utilized by UT System Institutions contain all necessary information and questions required by TDI/DWC .
Questions
For more information regarding Workers' Compensation Insurance forms, refer to your respective UT System WCI Representative , the UT System WCI Office or TDI/DWC.
