Forms

The TDI requires all reports to be submitted on their most current forms.  Please check back regularly to verify that you are using the most current forms available.  These forms require Microsoft Word and can be printed and mailed or e-mailed. Alternatively, you can click the Fill Online button and submit your document electronically.

E-mail all forms to Lisa Folsom at claims@detsif.com .

 Online Forms

*You can still access the  downloadable Word Doc files by clicking the link on form name.

Click Here to Download DWC-1 Employer’s First Report of Injury

Click Here to Download DWC-3 Employer’s Wage Statement

Click Here to Download DWC-3-SD Employer’s Wage Statement for School Districts

Click Here to Download DWC-6  Supplemental Report of Injury

Click Here to Download DWC-48 Request for Travel Reimbursement (PDF only)

Click Here to Download DWC-53  Request to Change Treating Doctor

Click Here to Download DET-111  Voluntary Use of Paid Leave

Click Here to Download Refusal of Medical Treatment

Click Here to Download Internal Accident Investigation Report

      Click Here to Download On-Site Supervisor’s Accident Investigation Report

      Click Here to Download Witness Statement

      Click Here to Download Witness Statement (Spanish)

      Click Here to Download Employee Statement of Injury

      Click Here to Download Employee State of Injury (Spanish)

Click Here to Download GASB Statement

Instructions:

1.  Download and save the forms to your computer.

2.  Fill out the repetitious information and save the form again.

3. Filling out a form is a simple “type and tab” process.  After
completing a form, print and sign a copy for your files.  You may
also save the form to your computer.

4.  E-mail the form to claims@detsif.com or FAX the form to
(409) 384-7953.  To e-mail do a “file, send to, mail recipient
(as   attachment)”.

5.  We acknowledge receipt of all e-mailed forms by return
e-mail.  If you do not get a response from us you can assume that
the form was not received.