COVERAGE: Effective on [effective date of certicate] [name of employer]
has been certied by the Texas Department of Insurance,
Division of Workers’ Compensation (Division) as a self-insured employer providing workers’
compensation insurance in the event of work-related injury or occupational disease. Claims for
injuries or occupational diseases which occur on or after that date will be handled by [name of third
party administrator] . An employee or a person
acting on the employee's behalf, must notify the employer of an injury or occupational disease not
later than the 30th day after the date on which the injury occurs or the date the employee knew or
should have known of an occupational disease, unless the Division determines that good cause
existed for failure to provide timely notice. Your employer is required to provide you with coverage
information, in writing, when you are hired or whenever the employer becomes, or ceases to be,
covered by workers’ compensation insurance.
EMPLOYEE ASSISTANCE: The Division provides free information about how to le a workers’
compensation claim. Division staff will answer any questions you may have about workers’
compensation and process any requests for dispute resolution of a claim. You can obtain this
assistance by contacting your local Division eld ofce or by calling 1-800-252-7031. The Ofce
of Injured Employee Counsel (OIEC) also provides free assistance to injured employees and will
explain your rights and responsibilities under the Workers’ Compensation Act. You can obtain OIEC’s
assistance by contacting an OIEC customer service representative in your local Division eld ofce or
by calling 1-866-EZE-OIEC (1-866-393-6432).
SAFETY VIOLATIONS HOTLINE: The Division has a 24 hour toll-free telephone number
for reporting unsafe conditions in the workplace that may violate occupational health and safety
laws. Employers are prohibited by law from suspending, terminating, or discriminating against any
employee because he or she in good faith reports an alleged occupational health or safety violation.
Contact the Division at 1-800-452-9595.
NOTICE TO EMPLOYEES CONCERNING
WORKERS’ COMPENSATION IN TEXAS
Notice 7 (01/13) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.101(e)(2)