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DWC022 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 MS-94 Austin, TX 78744-1645 (800) 252-7031 phone (512) 804-4378 fax Si DESE hangar con alien
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EMPLOYEE/EMPLOYEE'S ATTORNEY NAME (INCL.) (FIRST NAME) 2. EMPLOYEE/EMPLOYEE'S ATTORNEY ADDRESS (INCL.) (FIRST ADDRESS) 3. EMPLOYEE/EMPLOYEE'S ATTORNEY ADDRESS/TEMPORARY ADDRESS 4. EMPLOYEE/EMPLOYEE'S ATTORNEY ADDRESS/TEMPORARY ADDRESS — (TEMPORARY) 5. EMPLOYEE/EMPLOYEE'S ATTORNEY ADDRESS/TEMPORARY ADDRESS — (TEMPORARY) Signed with an asterisk, or notarized.
NOTE: Each attestation should be accompanied by a check or money order for 25.00 for both of the following amounts due to the INS and should be made payable to the INS. A check made payable to the INS for the amount of the Claim will also serve as an acknowledgment that the employer is entitled to claim. The amount of the Employer's Claim will either be reduced by a portion in the amount due to the INS, or deducted by the INS from its portion of the Claim.
4. EMPLOYER'S REQUEST for EX PARTE ATTESTATION of EMPLOYEE'S RESPONSIBILITIES 1. ATTESTATION of EMPLOYEE'S RESPONSIBILITIES 1. EMPLOYEE'S RESPONSIBILITIES (INCL.) 2. EMPLOYER'S RECORDED INFORMATION (INCL.) 1. DATE OF BIRTH (INCL.) 2. SEX OF EMPLOYEES (INCL.) 3. RESIDENCE AT TIME OF EMPLOYMENT (INCL.) 4. DUTIES OF EMPLOYEE IN RELATION TO THE BUSINESS (INCL.) 5. EXAMINATIONS INVOLVING PERSONAL INFORMATION (INCL.) 6. EXAMINATIONS INVOLVING PUBLICATION OF INFORMATION (INCL.) 7. EXAMINATIONS INVOLVING CONFIDENTIAL OR SECRET INFORMATION (INCL.) 8. CONFERENCE WITH ANEMONE (INCL.) 9. EXAMINATION OF CUSTOMER REPORTS, COMPLAINT AND DOCUMENTS (INCL.) 2.
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