Get Employee Acknowledgment Of Workers ... - Texasmutual

Navigating the Employee Acknowledgment of Workers’ Compensation Network form is crucial for understanding your rights and responsibilities under your employer’s workers’ compensation insurance. This guide provides clear and concise steps to help you effectively complete the form online.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Employee Acknowledgment of Workers’ Compensation Network form and open it for editing.
2. Carefully read through the provided information regarding how to get health care under your employer’s workers’ compensation insurance. Pay particular attention to the requirements for selecting a treating doctor.
3. Indicate whether this is your Initial Employee Notification or Injury Notification by checking the appropriate box. If you are submitting an Injury Notification, enter the date of your injury in the designated format.
4. In the signature section, sign your name where indicated and enter the date of signing. This confirms your acknowledgment of the information provided.
5. Print your name clearly in the printed name section. This ensures that the document is valid and identifies you properly.
6. Fill in your address, including street address, city, state, and zip code. This provides necessary contact information for the records.
7. Enter the name of your employer as required by the form. This ensures clarity regarding your employment status.
8. Refer to the Texas Star Network® for details about network providers, and call the provided number if you need further assistance.
9. Once all fields are completed, save your changes, and download or print the form for your records. Ensure you keep a copy for your reference.
10. If requested, submit the form to Texas Mutual Insurance Company but remember to only do so if instructed.

Complete your documents online today to ensure you are adequately informed about your workers' compensation benefits.