Report your injury to your employer within 30 days

Texas does not require employers to carry workers' comp — check if your employer is a subscriber

If your employer is a non-subscriber, you may sue directly for damages

Workers' Compensationmoderate

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Form Details

Total fields: 36
Auto-fillable: 22 (61%)
Time without BeneFill: 25 minutes
Time with BeneFill: 7 minutes
Time saved: 18 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

TDI Online (recommended)

https://www.tdi.texas.gov/wc/employee/index.html

File your Employee's Claim for Compensation online.

📬

Mail to Texas DWC

Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 Austin, TX 78744-1645

📠

Fax to DWC

Fax: 512-804-4401

Filing Deadline

Within 1 year of the injury date or within 1 year of when you knew the condition was work-related.

Required Attachments

📎 Completed DWC-041 Employee's Claim for Compensation form
📎 Medical records documenting the injury and treatment

Processing Time

The insurance carrier has 15 days to begin paying benefits or deny the claim after receiving notice.

What Happens Next

DWC will review the claim and notify you and the carrier. If the carrier denies, you can request a Benefit Review Conference.

Tips for This Form

✓ Report your injury to your employer within 30 days
✓ Texas does not require employers to carry workers' comp — check if your employer is a subscriber
✓ If your employer is a non-subscriber, you may sue directly for damages
✓ More info: https://www.tdi.texas.gov/wc/employee/index.html

More Workers' Compensation Forms

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

Employer's First Report of Injury (Longshore)

LS-202 · U.S. Department of Labor (OWCP)

Employer's First Report of Injury or Occupational Illness under the Longshore and Harbor Workers' Compensation Act. Must be filed within 10 days of injury.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Texas Department of Insurance, Division of Workers' Compensation or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.