FORMS

DETSIF 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.

Important

Claims Submission Guidance

Email all forms to:

Makenzie Reeves, ACE — mreeves@athensadmin.com
Judith Dye, Supervisor — jdye@athensadmin.com
Renee Garcia, Business Manager — rgarcia@detsif.com
DETSIF Claims — claims@detsif.com

Please email claims to all 4 email addresses.

Member Profile Information Update

After Hours

Prescription Card Access

If this is after hours and you need a prescription filled, please use one of the cards below.

Prescription Card (English)Prescription Card (Spanish)

Claim Forms

You can still access the downloadable Word Doc files by clicking the link on the form name. Download, complete, and return the forms as needed.

Claim Form

DWC-1 Employer’s First Report of Injury

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DWC-3 Employer’s Wage Statement

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DWC-3-SD Employer’s Wage Statement for School Districts

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DWC-3 Employee’s Multiple Employer Wage Statement

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DWC-6 Supplemental Report of Injury

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DWC-48 Request for Travel Reimbursement (PDF only)

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DWC-53 Request to Change Treating Doctor

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

DET-111 Voluntary Use of Paid Leave

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

Refusal of Medical Treatment

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

Internal Accident Investigation Report

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

On-Site Supervisor’s Accident Investigation Report

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

Witness Statement

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

Witness Statement (Spanish)

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

Employee Statement of Injury

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

Employee State of Injury (Spanish)

Download the current form and keep a completed version on file for claims processing and documentation.

Claim Form

GASB Statement

Download the current form and keep a completed version on file for claims processing and documentation.

Instructions

How to Complete and Return Forms

Download and save the forms to your computer.
Fill out the repetitious information and save as template.
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.
Email completed forms to claims@detsif.com or fax to (409)384-7953. Please also send to mreeves@athensadmin.com and jdye@athensadmin.com.
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.

Quick Notes

Form Reminders

Always use the most current TDI forms available.

These forms generally require Microsoft Word.

Completed claims should go to DETSIF Claims and the Athens contacts listed above.

If you do not receive a reply confirming receipt, assume the form was not received and follow up.

Annual Payroll Request Forms

Click the link that applies to your entity type. DETSIF requires this at least annually, however quarterly would be preferred.

Appraisal District

Health District

Housing Authority

River Authority

Please include all payroll: fulltime, part time, overtime and substitutes.

Need More DETSIF Information?

Use the member profile update page when your information changes, keep the prescription cards available for after-hours needs, and review the DETSIF flyer for a broader overview of the fund and its services.

Member Profile Update