DWC 030 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-96 Austin, TX 78744-1645 (512) 804-4000 phone · (512) 804-4346 fax Austin Representative's Authorized Designees Fax to the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) at the number shown above I. AUSTIN REPRESENTATIVE INFORMATION 1. Austin Representative's Name (First, Middle, Last) 3. Austin Representative's Mailing Address (Street or PO Box, City State 4. Austin Representative's E-mail Address 6. Austin Representative's Telephone Number ( ) 8. Austin Representative's Federal Employer ID Number (FEIN) Zip) 2. Austin Representative's Organization Name 5. Austin Representative's Internet Address 7. Austin Representative's Fax Number ( ) 9. Austin Representative's TDI-DWC Box Number II. AUTHORIZED DESIGNEE(S) 10. Check the appropriate box to add or remove authorization for the TDI-DWC to release notices, letters, and other correspondence to the named individual(s) and/ or organization(s). Failure to produce identification may result in the TDI-DWC's refusal to release notices, letters, and other correspondence. Action Effective Date Individual's Name Organization's Name Add Add Add Add Add Add Add Add Add Remove Remove Remove Remove Remove Remove Remove Remove Remove III. AUSTIN REPRESENTATIVE AFFIRMATION The undersigned Austin representative authorizes the TDI-DWC to release notices, letters, and other correspondence to the above-named individual(s) and/or organization(s). The Austin representative affirms that the above-named individual(s) and/or organization(s) have been informed that the workers' compensation information involved in TDI-DWC communications is subject to the confidentiality requirements of Subtitle A, Title 5, Texas Labor Code (Texas Workers' Compensation Act) and that the individual or organization must store all such workers' compensation claim information in a secure environment with all appropriate security and privacy safeguards so as to prevent unauthorized access to or disclosure of the information. 11. Austin Representative's Signature 12. Austin Representative's Printed Name 13. Date of Signature For TDI-DWC Use Only NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). American LegalNet, Inc. www.FormsWorkFlow.com DWC 030 Rev. 12/11 Page 1 of 1