Carrier Representative Information Submission Form
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Carrier Representative Information Submission Form. This is a Texas form and can be use in Carrier Workers Compensation.
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Tags: Carrier Representative Information Submission Form, DWC-27, Texas Workers Compensation, Carrier
Texas Department Of Insurance
Division of Workers’ Compensation
Insurance Coverage Section
7551 Metro Center Dr. Ste.100 • MS-96
Austin, TX 78744-1609
(512) 804-4000 (512) 804-4346 fax www.tdi.state.tx.us
CARRIER REPRESENTATIVE INFORMATION SUBMISSION FORM
Name of Carrier/Self-Insured
FEIN#
Group Affiliation
Effective Date
Insurance Carrier’s E-mail Addresses
Claims
Underwriting
CARRIER PRIMARY MAILING ADDRESS FOR CORRESPONDENCE FROM THE DIVISION
Mailing Address
City/State/ZIP
AUSTIN REPRESENTATIVE or
EBILLING CONTACT
(i.e., Name of Carrier Representative before the Division in Austin):
Company/Contact Name
FEIN#
Mailing Address
City/State/ZIP
E-Mail Address
Telephone Number
Signature
Title
Fax
Number
Date
Web Address______________________
This form may be reproduced.
Please return this form to:
Texas Department of Insurance,
Division of Workers’ Compensation
Insurance Coverage Section; MS-96
7551 Metro Center Drive, Suite 100
Austin, TX 78744
DWC USE ONLY
Changes made by
Participant ID#
DWC Box #
Date
or fax to (512) 804-4346
DWC027 Rev. 09/07
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