Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.

Effective Date: 
10/2013

Documents

Instructions

Updated: 10/2013

Purpose

To document the acknowledgment of liability regarding the relationship between the employer and the applicant for employment in the Consumer Directed Services (CDS) option.

Procedure

When to Prepare

The employer reviews all information contained in the document with each new applicant for employment and completes each section of the form. This form is completed for each potential employee.

Number of Copies

Original and two copies.

Transmittal

The employer keeps the original on file, gives a copy to the applicant for employment and provides a copy to the Financial Management Services Agency (FMSA).

Form Retention

The employer and the FMSA must keep this form for five years after termination of the employee's employment, or until all outstanding litigation, claims and audits are resolved.

Detailed Instructions

Liability Acknowledgement Between the Employer and the Applicant for Employment

The employer signs and dates this section to acknowledge an understanding of the information and to confirm the information was presented to the applicant for employment.

The applicant for employment signs and dates this section to acknowledge the information was presented by the employer and to confirm the applicant's understanding of the information.

Liability Notice to Applicants for Employment

Section I —

The employer checks the statement that describes the employer’s Texas Workers' Compensation subscription status.

Section II —

  1. Section II is not applicable if the first option in Section I (employer subscribes to Texas Workers' Compensation) is checked. Skip to Acknowledgment by Employer and Applicant for Employment.
  2. The employer must complete Section II if the second option in Section I (employer does not subscribe to Texas Workers' Compensation) is checked. The employer checks each statement in Section II that describes the arrangement made for an employee's work-related injuries or illnesses.

Acknowledgment by Employer and Applicant for Employment

Signature – Employer — The employer acknowledges by dated signature that he has completed this form and understands the information and that he has presented the information to the employee.

Signature – Applicant for Employment — The applicant for employment acknowledges by dated signature the information in Sections I and II.