Primary Employer's Business Name/Insured Federal Tax ID Number Current Policy Number DWC Use Only (Microfilm) CORRECTION/REVISION/ENDORSEMENT TO EXISTING POLICY Check one: Correction Revision > Effective Date of Change Endorsement The current policy is hereby amended (State only what is being amended) Name of Insurance Carrier: NCCI Number Name of Primary Insured: FEIN Number Address of Primary Insured: Policy Number Effective Date of Policy End Date of Policy (mm-dd-yy) (mm-dd-yy) Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: Name _______________________________________________ ADD Address _____________________________________________ > Effective Date ____________________________________________________ DELETE Federal Tax ID Number ______________________________ City _____________________ State _____ Zip ____________ Number of Employees _______________________________ Check one: Name _______________________________________________ ADD Address _____________________________________________ > Effective Date ____________________________________________________ DELETE Federal Tax ID Number ______________________________ City _________________ State _______ Zip ______________ Number of Employees _______________________________ Check one: Name ______________________________________________ ADD > DELETE Address _____________________________________________ Effective Date Federal Tax ID Number ______________________________ ____________________________________________________ City _________________ State ______ Zip ______________ Number of Employees _______________________________ DWC FORM-20A (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com