TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS COMPENSATION 7551 METRO CENTER DRIVE, SUITE 100 AUSTIN, TEXAS 78744 DWC Use Only (Microfilm#) INSURANCE CARRIER NOTICE OF COVERAGE/CANCELLATION/NON-RENEWAL OF COVERAGE Insurance Carrier Information Employer/Insured Information 1. Insurance Carrier Name 7. Primary Employer/Insured Name 2. Federal Tax ID No/ (FEIN) 3. NCCI No. 4. DWC Carrier (MBI No.) 5. Policy Type Standard 8. Primary Employer/insured Business Mailing Address Divided Risk Type of Transaction (check one only) New Policy Carrier 10 days Cancellation/Non Renewal Correction/Revision/Endorsement (attach DWC FORM-20A) Renewal Reinstatement Voluntary Backdated Effective Date of Policy 9. No. of Locations and/or entities covered. (Exclude Primary Insured) 10. Federal Tax ID No. 11. Employer’s Workers’ Comp Class Code Carrier 30 days Cancellation/Non Renewal 12. Estimated No. of Employees POLICY INFORMATION 13. Policy No. 14. Effective Date of Policy: (mm-dd-yy) From 15. Effective Date of Cancellation/Reinstatement: (mm-dd-yy) To 16. Date Carrier Notified Employer of Cancellation 17. Employer/insured DBA Name DIVIDED RISK INFORMATION 18. Job site policy project or other specific operation name which this policy covers and site location/address Check one: Name ADD DELETE > Effective Date Address Federal Tax ID Number ______________________________________________________ Number of Employees City Sate Zip ______________________________________________________ For additional locations ** use DWC FORM-205 ** 19. Signature of Insurance Carrier Representative DWC FORM-20 (Rev. 10/05) Page 1 20. Date of Notice DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.USCourtForms.com