Fillable Printable Mail Or Personally Deliver This Form To:

Mail Or Personally Deliver This Form To:

DW C FORM-156 (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION

PROSPECTIVE EMPLOYMENT AUTHORIZATION AND CERTIFICATION

Please carefully read the instructions on the reverse side before submitting this form. Incorrect/incomplete forms will be returned without act ion.

SECTION I: TO BE COMPLETED BY JOB APPLICANT

1. Name of Job Applicant (Print or type) 3. Social Security Number

2. Complete Address of Job Applicant (Print or type)

4. Date Job Applicati on Submitted

I understand that the Texas Workers' Compensation Act provides for the release of certain prior work related injury information to prospective

Texas employers who carry workers' compensation insurance if the employer obtains my written authorization b

efore making a request for

that information. I also understand that if this employer is covered by the Americans With Disabilities Act, my prior work related injury claim

information may be released only if the indicated employer has properly completed and certified the information on this form. Prospective

employers filing valid requests will be provided with a report on prior work related injury claims only if an applicant has m

ade two or more

general injury claims in the preceding five years. I hereby

authorize release of information permitted by law on my work related injuries to the

prospectiv e employ er nam ed below.

Job Applicant's Signature _______________________________________________________ Date _________________________________

SWORN AND SUBSCRIBED TO BEFORE ME BY THE SAID _________________________________________ (Print Job Applicant's Name)

ON THIS _____________________________ DAY OF ______________________________________, YEAR _______________ .

Signature of Notary Public

Print Name of Notary Public

(Seal or Stamp)

My Commission expires: ________________________________________________

SECTION II: TO BE COMPLETED BY PROSPECTIVE TEXAS EMPLOYER

1. Name of Employer (Print or type)

3. Employer's Federal Tax I. D. #

4. Date Job Applicati on Received

2. Address and Phone Number of Employer (Print or type)

Phone Number

( )

5. Prepaid Account Number

I am a prospective Texas employer who has workers' compensation insurance. I am entitled to receive prior injury information concerning

this job applicant

under the Texas W orkers' Compensation Act, Texas Labor Code, Section 402.087. I am not prohibited from receiving this

information under the Americans With Disabilities Act of 1990, 42 U.S.C. §12101 et. seq. because:

(Employer Must Check One):

I am a Texas employer who is not covered by the Americans W ith Disabilities Act of 1990. (The Americans With Disabilities Act of

1990 defines "employer" as: "a person engaged in an industry affecting commerce who has 15 or more employees for each working

day in each of 20 or more calendar weeks in the current or preceding year and any agent of such person").

I am a Texas employer who is covered by the Americans With Disabilities Act of 1990, who is requesting this info

rmation prior to

hiring the above-named job applicant, but after having made a conditional offer of employment to the above-

named applicant. I am

requesting this information regarding all post-offer prospective job applicants in this job category, regardl

ess of disability.

Information concerning the Americans W ith Disabilities Act may be obtained by calling 1 (800) 949-4232; TDD 1 (713) 520-5136 or

the Texas Commission on Human Rights, (512) 437-3450.

A $2.00 fee is required of the prospective employer per request. Your remittance must be attached. The DWC FORM-

156 will be

returned without action if payment is not enclosed. Fees are subject to change. M ake checks payable to DWC.

I certify that I am an authorized representative of this employer and the statements in Section II of this document are true,

complete and correct to the best of my knowledge and belief.

Employer/Representative's Signature__________________________________________________ Date __________________

SWORN AND SUBSCRIBED TO BEFORE ME BY THE SAID (Print Employer/Re p. Name)

ON THIS _________ DAY OF ____ ___ ___ ___ ___ __ _ ____ ___ ___ __ _________ , YEAR .

Signature of Notary Public

Print Name of Notary Public

(Seal or Stamp)

My Commission Expires: ________________________________________________

Mail or personally deliver this form to:

TEXAS DEPARTMENT OF INSURANCE

DIVISION OF WORKERS' COMPENSATION

7551 Metro Center Drive, Suite 100, MS

-92B

Austin, TX 78744

THIS FORM MUST BE FILLED OUT COMPLETELY AND

MUST BE SIGNED AND DATE D BE FORE A NOTARY.

DWC FORM-156 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION

DWC FORM - 156

PROSPECTIVE EMPLOYMENT AUTHORIZATION AND CERTIFICATION INSTRUCTION SHEET

http://www.tdi.texas.gov

GENERAL:

1. PAYMENT MUST BE SUBMITTED WITH EACH REQUEST. Each DW C FORM-156 processed will req uire a $2.00

fee, which includes postag e. The f orm will be return ed witho ut actio n if pa ym ent is n ot encl osed. Fees are subjec t to

change. Make checks payable to DWC.

2. Use DWC FORM-156, PROSPECTIVE EMPLOYMENT AUTHORIZATION AND CERTIFICATION form, to obtain

confidential claim file information on persons who have submitted an application for employment. The Division will

provide the dates of injury and descriptions of two or more general injury claims filed by the applicant within the past

five years. The use of this service is not m andatory. Refer to Advisor y 99-01 for additional information. T o obtain a

copy of this advisory visit the DWC website indicated above.

3. DWC FORM-156 MUST BE COMPLETED IN ITS ENTIRETY. Please print or type. The original signed and

notarized form must be mailed or personally delivered to the address indicated at top of DWC FORM-156, not more

than 14 days after the dat e on which the applicatio n for em plo yment is submitted.

4. For additional assistance in completing DWC FORM-156, call the Reprographics Section/Pre Employment at (512)

804-4990-ex t. 391 .

5. DWC FORM-156 m ay not be FAXED a nd will be r eturned witho ut action. Conf idential i nformation will not be releas ed

by telephone.

6. In order to be eligible to receive confidential information, the Texas employer must carry Workers' Compensation

Insurance coverage. Coverage will be verified before information will be released.

SECTION I - JOB APPLICANT INFORMATION

1. The applicant must provide his/her full name, address and social security number. The date the job application was

submitted must be indicated in Section I, Box 4.

2. The applicant must sign the request form before a notary and have the notary complete the acknowledgement portion.

SECTION II - EMPLOYER INFORMATION

1. The Texas employer must provide the company name, address, phone number and Federal Tax I.D. number.

2. The Texas employer may authorize an employee of the company to request and receive the confidential information

on the employer's behalf. The authorized employee must sign the request form before a notary and have the notary

complete the acknowledgment portion. Incomplete or incorrectly attested forms will be returned to the employer

without proc ess ing.

3. Information regarding the Americans with Disabilities Act must be completed by checking ONE of the boxes.

IMPORTANT:

BY EXECUTION OF DWC FORM-156, THE TEXAS EMPLOYER REPRESENTS THAT HE OR SHE IS ENTITLED TO

THE INFORM ATION REQUESTED AND T HAT HE OR SHE H AS FULL AUT HORITY TO ACT AS A REQUESTO R. IT

IS A CLASS A MISDEMEANOR FOR UN AUTHORI ZED PERSON S TO RECEIVE CONFIDENT IAL INFO RMATION OR

TO DISCLOSE SUCH INFORMATION TO UNAUTHORIZED PARTIES. TEXAS LABOR CODE SECTIONS 402.064;

402.084; 402.087 & 402.091.