Texas Department Of Insurance Request For Record Check Page 2
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1
2DWC FORM - 155
REQUEST FOR RECORD CHECK INSTRUCTIONS
1
Use this DWC FORM-155 to request a history on a Texas workers' compensation claim. A record check provides the
.
following data: the Industrial Accident Board (IAB) or Texas Department of Insurance, Division of Workers'
Compensation (DWC) number; the date of injury; the employer at the time of injury; the nature of the injury; and the
disposition of the claim (old law) or whether the claim is Income/Indemnity or Reportable (new law). NOTE: Injuries
prior to 1/1/91 are IAB/old law. Injuries on or after 1/1/91 are DWC/new law.
2.
THIS DWC FORM-155 MUST BE COMPLETED IN ITS ENTIRETY. Please print or type. Send a separate DWC FORM-
155 request form for each claimant for which you are requesting a record check. The original DWC FORM-155 must be
submitted to the Division.
3.
PAYMENT MUST ACCOMPANY THIS REQUEST FORM. THE REQUEST WILL BE RETURNED IF PAYMENT IS
NOT ENCLOSED. FEES ARE SUBJECT TO CHANGE.
A.
All record checks are $15.00 each.
B.
Certifications are $1.00 additional fee each. If a certified record check is requested, the record check response
will have a letter of certification attached which is signed or stamped and sealed by the Custodian of Records,
or his delegate, attesting to the authenticity of the attached document. See Section III.
4.
The requestor MUST indicate the legal basis on which he or she is eligible to receive confidential claimant information.
Check only one category in Section IV that reflects your eligibility to receive confidential information.
A.
An eligible insurance carrier must have handled a workers' compensation claim for the injured worker.
B.
An out of state insurance carrier or employer, or their legal representative, may be eligible to receive record
check information. Documentation of a worker’s compensation claim against that employer or the insurance
carrier paying that claim must be provided to determine eligibility (also see number 5 below).
C.
Dates of employment or date of injury must be indicated if applicable.
5.
A party eligible to receive record check information may authorize a legal representative to request and receive the
information on their behalf. If legal representative is requestor, box must be checked for verification purposes. Refer to
DWC Advisory 95-01 for requirements and additional information. To obtain a copy of this advisory visit the DWC
website indicated above. To establish eligibility to receive confidential information, the legal representative of a party
must provide documentation of representation, e.g. letter of representation from client, copy of the contract between the
client and the representative or Original Answer.
6.
The requestor MUST swear to the correctness of the entitlement information before a notary public, sign the completed
form before the notary, and have the notary complete the sworn acknowledgment. The original signed and notarized
form should be mailed or personally delivered to the address indicated at top of DWC FORM-155. Incorrectly attested
forms will be returned to the requestor without action.
7.
Cancellation of a request for a record check may be made by calling the Reprographics Section/Record Checks at (512)
804-4990 ext. 319. No refunds will be made after the request has been processed.
8.
For additional assistance in completing this DWC FORM-155, or to make an inquiry regarding the status of your
request, call the Reprographics Section/Record Checks at (512) 804-4990 ext. 319.
9.
FAX requests and/or altered forms will not be accepted.
10.
To obtain copies of confidential claim files complete and file Request For Copies Of Confidential Claimant
Information DWC FORM-153. To obtain a pre-employment check on persons who have been given a tentative offer
of employment, complete and file Prospective Employment Authorization and Certification DWC FORM-156.
11.
Governmental Agencies/Political Subdivisions or regulatory bodies requesting confidential claimant information in a
capacity other than as an employer, should not complete this form. Please contact DWC General Counsel at (512) 804-
4275 for information concerning determination of eligibility to receive record check information.
IMPORTANT: BY EXECUTION OF DWC FORM-155, THE REQUESTOR REPRESENTS THAT HE OR SHE IS ENTITLED
TO THE INFORMATION REQUESTED AND THAT HE OR SHE HAS FULL AUTHORITY TO ACT AS A REQUESTOR. IT IS
A CLASS A MISDEMEANOR FOR UNAUTHORIZED PERSONS TO RECEIVE CONFIDENTIAL CLAIM FILE INFORMATION
OR TO DISCLOSE SUCH INFORMATION TO UNAUTHORIZED PARTIES. TEXAS LABOR CODE §§ 402.064; 402.084;
402.086 & 402.091.
DWC FORM-155 (Rev. 10/05) Page 2
DIVISION OF WORKERS’ COMPENSATION
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