Nonsubscriber Related Forms & Notices
In our commitment to help businesses that elect to operate as nonsubscribers to do so responsibly TXANS is pleased to provide free immediate access to forms and notices that nonsubscribing businesses must utilize including state nonsubscriber related forms and notices and federal OSHA forms.
The primary state requirements stipulate the Texas nonsubscribers must:
- Report all workplace injuries when an employee is absent for a day or more of work
- Report any injury if more than one injury meets the reporting requirements during the reporting period
- Report all occupational diseases regardless of lost time
- Report all workplace fatalities
- File a report when the company opts out of workers' compensation, initially
- Notify the workers' compensation carrier of the employer’s intent to operate as a nonsubscriber
- Provide employees the appropriate written notification when the company is about to become a nonsubscriber
- Report the company’s nonsubscriber status annually via the DWC Form 5. This is required both when the company becomes a nonsubscriber and each year on the anniversary of the original “opt out”
- Identify and report all locations that operate as a nonsubscriber via the DWC Form 5s. This is required both when the company becomes a nonsubscriber and each year on the anniversary of the original “opt out”
- Provide written notice to each employee of the company’s nonsubscriber status
- Post a notice of non-coverage in several locations throughout the workplace
- Post a safety hotline notice in the workplace
Federal Filing Requirements
An annual report, called Form 5500, must be filed with the Employee Benefit Security Administration (EBSA), the DOL agency that oversees and enforces ERISA. The form 5500 asks for information about the plan, including the plan name,
plan year, plan sponsor, plan number, participants, insurance costs and financial data. The Form 5500 must be
completed and filed with the EBSA within seven (7) months after the end of the plan year. Plans with less than 100
covered participants at the beginning of a plan year are generally exempt from filing a Form 5500 if it is fully-insured, unfunded, or a combination of insured and unfunded. TXANS members may obtain a copy of the Form 5500 by contacting TXANS.
Please complete the form below and after clicking on submit you will have the ability to download the state forms and notices and more.
Please note that these forms and notices represent only a small part of a comprehensive responsible nonsubscriber
injury benefit program. TXANS members and suppliers may access the Laws and Regulations and the TXANS
Member Resource Center sections of this website or contact TXANS for other forms, posters and related laws and regulations.
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