Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 56 - STRUCTURED COMPROMISE SETTLEMENT AGREEMENTS
Section 56.10 - Form

(1) be submitted on a form approved by the board;

(2) be accompanied by a physician's signed report of the findings of a recent examination of the employee;

(3) be accompanied, in the event of serious injury to claimant's eye, by a medical report indicating that healing has occurred and whether the other eye is or may be affected;

(4) be accompanied, in the event of severe and disfiguring burns or lacerations, by a descriptive medical report of the scars. In all cases involving injury to the face, arms, or hands, a color photograph taken after maximum healing must be submitted to the board;

(5) be submitted in five parts. The original must be white, the second part pink, the third yellow, the fourth white, and the fifth white. The forms must be submitted with carbon left intact. The board will furnish the following parties with approved copies of the forms.