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Workers' Compensation Forms

Supervisor's Report of Injury

1. Download form to computer

2. Fill out form in Adobe

3. Print Form

4. Supervisor signature is required

5. Supervisor send form to &

For questions please call Katherine Beamer at 512-245-3616

Claims Procedure Checklists

WC Policies & Procedure : Claims Procedure Checklist (PDF, 183 KB)

Authorization for Release of Information

SORM16_InfoRelease[2] : Inormation Release Form (PDF, 46 KB)

Employee's Report of Injury

SORM-29_EmployeesReportOfInjury[2] : Employee Report of Injury (PDF, 500 KB)

Request for Travel Reimbursement

dwc048_trvlreim (PDF, 168 KB)

Witness Statement

SORM74_WitnessStatement[2] : Witness Statement English (PDF, 686 KB)
SORM74_WitnessStatement[3] : Witness Statement Spanish (PDF, 198 KB)

Employees Election Regarding Utilization of Sick and Annual Leave

SORM-80_SickAnnualleave[2] : Sick & Annual Leave Usage Election English (PDF, 182 KB)
SORM-80_SickAnnualleave [3] : Sick & Annual Leave Usage Election Spanish (PDF, 246 KB)

Medical Reimbursement Request Form

SORM-81A (PDF, 372 KB)

SORM/CareWorks Network Acknowledgement Form