Workers' Compensation Notice 7 - Concerning Workers' Compensation in Texas Mandatory

COVERAGE:	 Effective on [effective date of certificate] 	  	 [name of employer] 	  	
 	  has been certified 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 occupation\
al 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 o\
r 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 determ\
ines 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 bec\
omes, or ceases to be, 
covered by workers’ compensation insurance.	
EMPLOYEE ASSISTANCE:	 The Division provides free information about how to file 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 field office or by calling 1-800-252-7031.  The Office 
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 field office 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 occupa\
tional health and safety 
laws. Employers are prohibited by law from suspending, terminating, or d\
iscriminating 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)

CERTIFIED SELF-INSURED EMPLOYER:	
 Prominently displayed in the employer’s personnel office, if any;
2.
 Located about the workplace in such a way that each employee is likely t\
o see the notice on a 
regular basis;
3.
 Printed with a title in at least 26 point bold type, subject in at least 18 point bold type, and text in  
at least 16 point normal type; and
4.
 Contain the exact words as prescribed in Rule 110.101(e)(2).