Forms and Publications

Texas

These forms are included in your claim packet from Summit, if applicable to your situation.

Statement of Injured
This form allows you to give us detailed information about your injury and how it happened. Please complete and return it to us quickly so that we may continue processing your claim.

Medical Release(Authorization to Disclose Health Information)
Please sign, date and return this form to our office. Be sure to have your signature witnessed. Also, please enclose a list of all doctors you have seen since your injury, including the physician’s address, appointment dates and any follow-up visits you have scheduled.

Mileage Reimbursement(Request for Travel Reimbursement DWC048)
You can be reimbursed on a roundtrip basis for mileage to and from a medical provider, if you travel more than 30 miles one-way to the medical provider, and there is no other medical provider reasonably available within 30 miles of where you live. Mileage reimbursement forms should be returned to your claims adjustor promptly. Be as accurate as possible when reporting your mileage. Remember, intentionally inflating or falsifying mileage information to obtain an increased mileage reimbursement benefit is workers’ comp fraud, and can jeopardize your workers’ comp benefits. You must use this form to submit the reimbursement request to Summit within one year of the date you incurred the expenses.

Employers First Report of Injury or Illness(Notice of Injury DWC Form-001)
This form is used to report a work-related injury or illness to Summit. The copy in your injured worker packet includes the information given to Summit when your injury was reported to us. Please keep that copy for your records.

Notice of Injured Employee Rights and Responsibilities
In your claim packet, you will receive a written copy of the Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (Notice of Rights and Responsibilities) adopted by the Public Counsel of the Office of Injured Employee Counsel (Public Counsel). This document will inform you about your rights, benefits and responsibilities under Texas law.

Beneficiary Claim for Death Benefits
To make a claim for death benefits, a beneficiary should complete a Beneficiary Claim for Death Benefits form (DWC042) and file it with the Texas Department of Insurance, Division of Workers’ Compensation, and provide us with a copy. This form contains instructions as to how it should be completed, and how to file it.