Workers' Compensation Notice 10 - Concerning Workers' Compensation in Texas Mandatory

NOTICE TO EMPLOYEES CONCERNING WORKERS’ COMPENSATION IN TEXAS	
COVERAGE: 	Effective on [effective date of certificate] 	 	 [name of employer] 	 	
 	 provides workers’ compensation insurance coverage 
as a member of a self-insurance group under Labor Code Chapter 407A  in the event of work-related 
injury or occupational disease. Claims for injuries or occupational dise\
ases 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, unles\
s the Texas Department 
of Insurance, Division of Workers’ Compensation (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 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 occupation\
al health and safety laws. 
Employers are prohibited by law from suspending, terminating, or discrim\
inating against any employee 
because he or she in good faith reports an alleged occupational health o\
r safety violation. Contact the 
Division at 1-800-452-9595.	
Notice 10 (01/13)	 	TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION	 	Rule 110.101(e)(3)

EMPLOYER MEMBER OF A SELF-INSURANCE GROUP:	
 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)(3).