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Texas department of insurance division of workers compensation Form: What You Should Know
THE DEPARTMENT IS NOT RESPONSIBLE OR LIABLE FOR (1) ANY ACTION OR LEGAL PROCEEDINGS; (2) ANY INTERPRETATION; (3) ANY ERRORS, INACCURACIES, MISREPRESENTATIONS, OR OTHER INACCURACIES, INCLUDING WITHOUT LIMITATION, ERRORS, INACCURACIES, MISREPRESENTATIONS, OR OTHER INACCURACIES IN THE WORKERS' COMPENSATION OR (4) ANY DEFAMATION OF THE INFORMATION OBTAINED FOR SUCH REPORT. EACH OF THE REPORTS IS MADE ON AN “AS-IS” BASIS FROM INFORMATION REPORTED BY ADMINISTRATION. NO WARRANTY IS MADE, EXPRESS OR IMPLIED, THAT THE USE OF THE INFORMATIONAL REPORT (INCLUDING ANY INTERPRETATION, ANY ERRORS OR INACCURACIES, ANY CLAIMS, OR OTHER DAMAGES), INCLUDING WITHOUT LIMITATION, THE CONTINUE, THE REPORTING, THE USE OF ADMINISTRATION'S CONTINGENCIES OR OTHER INFORMATION SUPPLIED BY ADMINISTRATION, WILL BE FREE OF DEFECTS OR WILL OTHERWISE MEET YOUR REQUIREMENTS. YOU ALSO AGREE THAT UT SYSTEM SHALL NOT BE LIABLE FOR PERSONAL INJURY, RECOVERABLE COSTS, OR OTHER SPECIAL DAMAGES OF ANY KIND INCURRED UNTIL AND INCLUDING PRIOR TO YOUR AUTHORIZATION TO ASSUME THE ENTIRE COST OF COVERAGE FOR ANY WORKABLE. You authorize Austin-Travis County EMS and the Austin/McAllen VA Medical Facility to release your information to DWC and to DWC to submit such reports for you at its cost or your expense. To obtain more information, you can call the Medical Information Specialist at, or you can contact DWC directly at: or TDI-DWC-Form-03. [DWC FORM-003 .pdf] DWC FORM-103.pdf Note: DWC FORM-103 may be substituted for DWC FORM-103A and can only be used for the period of your contract from July 1, 2019, to June 30, 2021.
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