DWC 027 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 x MS-96 Austin, TX 78744-1645 (512) 804-4000 phone x (512) 804-4346 fax Designation of Insurance Carrier's Austin Representative Fax to the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) at the number shown above I. INSURANCE CARRIER INFORMATION 1. Insurance Carrier's Name 3. Insurance Carrier's Primary Mailing Address (Street or PO Box, City State 4. Insurance Carrier's Federal Employer ID Number (FEIN) 2. Insurance Carrier's Group Affiliation (if applicable) Zip) 5. Insurance Carrier's TXCOMP Customer ID Number (if known) II. AUSTIN REPRESENTATIVE INFORMATION 6. Austin Representative's Name (First, Middle, Last) 8. Austin Representative's Mailing Address (Street or PO Box, City State Zip) 7. Austin Representative's Organization Name 9. Austin Representative's E-mail Address 10. Austin Representative's Telephone Number ( ) 12. Austin Representative's Federal Employer ID Number (FEIN) 11. Austin Representative's Fax Number ( ) 13. Austin Representative's TDI-DWC Box Number (if known) IV. INSURANCE CARRIER AFFIRMATION By signing below, I am attesting that I am authorized by the insurance carrier listed above to act on its behalf. The undersigned insurance carrier designates the above named person as its Austin representative and authorizes this person to act as its agent for receiving notices, letters, and other correspondence from the TDI-DWC. By signing below, the insurance carrier acknowledges that it is responsible for the acts or omissions of its designated representative and the representative's designee(s), if any, as listed on the DWC Form-030. The insurance carrier affirms that any contract or agreement with the Austin representative includes provisions that the workers' compensation information involved in TDI-DWC communications remains subject to the confidentiality requirements of Subtitle A, Title 5, Texas Labor Code (Texas Workers' Compensation Act) and that the Austin representative and its designee(s), if any, shall 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. 14. Signature of Insurance Carrier's Austin Representative Coordinator For TDI-DWC Use Only 15. Coordinator's Printed Name 16. Date of Signature 17. Coordinator's Telephone Number ( ) 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). DWC 027 Rev. 12/11 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 DWC 027 Frequently Asked Questions Designation of Insurance Carrier's Austin Representative (DWC Form-027) Does every insurance carrier have to submit the DWC Form-027? Yes. The provisions of 28 Texas Administrative Code (TAC) §156.1 provide no exemptions to these notification requirements. These requirements apply to all insurance carriers as defined by Texas Labor Code §401.011(27), including an insurance company, a certified self-insurer for workers' compensation, a certified self-insurance group, and a governmental entity that self-insures, either individually or collectively. When does this form need to be filed? Insurance carriers should file this form before they begin to provide workers' compensation insurance coverage in Texas and whenever there is a change to the information on previously submitted forms. Failure to submit the DWC Form-027 may result in correspondence delays and an administrative violation. When does a change in Austin representative become effective? A person designated under this rule continues as the Austin representative for the insurance carrier until 30 days after the TDI-DWC receives notice that the insurance carrier designates another Austin representative. Where do I get the insurance carrier's TXCOMP Customer ID Number? The insurance carrier's TXCOMP Customer ID Number can be found using the "Locate Insurance Carrier" function on the TXCOMP automated system located at https://txcomp.tdi.state.tx.us/TXCOMPWeb/common/home.jsp. This function allows the user to search for the insurance carrier using its name or Federal Employer Identification Number (FEIN). Where do I get the Austin representative's FEIN? The insurance carrier should request this information from its intended Austin representative during the contract negotiation process. Questions? If you have questions about this form or need more information about the requirements related to the designation of an Austin representative, contact the TDI-DWC Insurance Coverage section by telephone at 1-800-372-7713 and select option 6 or by e-mail at coverage.verification@tdi.texas.gov. DWC 027 Rev. 12/11 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2