laborlaw
05-24-2005, 12:42 PM
COVERAGE: (_______________________________) has elected not
Name of Employer
to obtain workers’ compensation insurance coverage. As an employee of a non-covered employer, you are not
eligible to receive workers’ compensation benefits under the Texas Workers’ Compensation Act. However, a
noncovered employer can and may provide other
benefits to injured employees. You should contact your employer regarding the availability of other benefits or compensation for a work-related injury or illness. In
addition, you may have rights under the common law of Texas should you suffer an on the job injury or illness. 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.
Notice 5 (Rev. 07/00) TEXAS WORKERS' COMPENSATION COMMISSION Rule 110.101
COVERAGE: (_______________________________) has workers'
(Name of Employer)
compensation insurance coverage from
(_______________________________) to protect you in the event
(name of commercial insurance company)
of work-related injury or illness. This coverage is effective from (_______________________________). Any injuries or illnesses
(effective date of policy)
which occur on or after that date will be handled by
(_______________________________). An employee or a person acting
(name of commercial insurance company)
on the employee's behalf must notify the employer of an injury or illness 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 illness, unless the Commission 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.
Notice 6 (Rev. 07/00) TEXAS WORKERS' COMPENSATION COMMISSION Rule 110.101
EMPLOYEE ASSISTANCE: The Commission
provides free information about how to file a workers' compensation claim. Commission staff will explain your rights and responsibilities under the Workers' Compensation Act and assist in resolving disputes about a claim.
SAFETY HOTLINE: The Commission has established 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 of Workers' Health and Safety
Name of Employer
to obtain workers’ compensation insurance coverage. As an employee of a non-covered employer, you are not
eligible to receive workers’ compensation benefits under the Texas Workers’ Compensation Act. However, a
noncovered employer can and may provide other
benefits to injured employees. You should contact your employer regarding the availability of other benefits or compensation for a work-related injury or illness. In
addition, you may have rights under the common law of Texas should you suffer an on the job injury or illness. 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.
Notice 5 (Rev. 07/00) TEXAS WORKERS' COMPENSATION COMMISSION Rule 110.101
COVERAGE: (_______________________________) has workers'
(Name of Employer)
compensation insurance coverage from
(_______________________________) to protect you in the event
(name of commercial insurance company)
of work-related injury or illness. This coverage is effective from (_______________________________). Any injuries or illnesses
(effective date of policy)
which occur on or after that date will be handled by
(_______________________________). An employee or a person acting
(name of commercial insurance company)
on the employee's behalf must notify the employer of an injury or illness 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 illness, unless the Commission 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.
Notice 6 (Rev. 07/00) TEXAS WORKERS' COMPENSATION COMMISSION Rule 110.101
EMPLOYEE ASSISTANCE: The Commission
provides free information about how to file a workers' compensation claim. Commission staff will explain your rights and responsibilities under the Workers' Compensation Act and assist in resolving disputes about a claim.
SAFETY HOTLINE: The Commission has established 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 of Workers' Health and Safety
