Claim Submission Process

Texas

state-TX

Step 1	Click on the form and complete it in its entirety. NOTE: Blank fields may delay our ability to service your claim.
Step 2	Print or save the form to your hard drive. Please click on the First Report of Injury form found in the Forms, Documents, and Information section of this screen.
Step 3	To submit a claim: Email (preferred method): This e-mail address is being protected from spambots. You need JavaScript enabled to view it Toll Free Fax #: 877-782-3292 Toll Free Phone #: 877-782-3291 Standard Mail: SUA Insurance Company P.O. Box 06110 Chicago, IL 60606-6110

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Forms, Documents and Information

For your convenience, please find the following forms, instructions and resources:

SUA Texas Claims Kit

Texas Workers’ Compensation Employers First Report of Injury or Illness – DWC Form-1 (rev. 10/05)
This form is required to be completed by the employer immediately following an employee injury or accident.

To Request Workers' Compensation Posting Notices and Template Stickers click here.

Claim Questions

Inquiries should be directed to 877-782-3291.

Texas Healthcare Network Information

Network Presentation - Employer Roles & Responsibilities

Presentation providing the state requirements to the employer on their roles and responsibilities for the implementation of the TX HCN

English

Network Presentation - Employee Roles & Responsibilities

Presentation providing the state requirements to the employee on their roles and responsibilities for the implementation of the TX HCN

English Spanish

Network Presentation - Employer Roles & Responsibilities (Self running presentation with voiceover)

Presentation providing the state requirements to the employer on their roles and responsibilities for the implementation of the TX HCN

English

Network Presentation - Employee Roles & Responsibilities (Self running presentation with voiceover)

Presentation providing the state requirements to the employee on their roles and responsibilities for the implementation of the TX HCN

English Spanish

Introduction to Coventry WC implementation

Initial educational material for employer and employee on the implementation of the TX HCN as well as the requirements for all participating parties

English Spanish

Employee Notification Implementation

Required implementation notification paperwork distributed to employees at the time of network implementation

English Spanish

Time of Injury Employee

Required TX HCN notification paperwork distributed to employees at the time of injury

English Spanish

Frequently Asked Questions Employer

Educational material providing information to employers on frequently asked questions about their roles and responsibilities for participation in the network

English

Frequently Asked Questions Employee

Educational material providing information to employees on frequently asked questions about their roles and responsibilities for participation in the network

English Spanish

Certified Counties and Map

Required posting materials on the certified counties and corresponding map

English

Acknowledgement Form

State required employee acknowledgment form for participation in the TX HCN

English Spanish

Employer Information

Educational material for employer on their responsibilities for the network

English

Roles & Responsibilities of Employer

Outline of the roles and responsibilities of the employer in the implementation of the TX HCN

English

Roles & Responsibilities of Employee

Outline of the roles and responsibilities of the employee in the implementation of the TX HCN

English

Worksite Poster Employee Notification

State required posting for the implementation of the TX HCN

English Spanish

Grievance Form

Explanation of the grievance process for the injured employee with the appropriate forms for completion and state contacts

English Spanish

Tracking Log

State required documentation of the participating employees, with the notification date and signature date

English

Pre-Authorization Sheet

List of all required pre-authorization procedures and services while participating in the TX HCN as well as resource number to contact for any additional questions

English

Texas HCN Service Map

State required service area map to identify what counties have met the state requirements for provider participation; required to be posted at worksite

English

www.coventrywcs.com
Tool for Provider Search-Provider Nomination

http://www.tdi.state.tx.us/
Texas Department of Insurance Resources for
employer and employees