Send form to DWC and a copy to insurance carrier Texas Department of Insurance Division of Workers’ Compensation 7551 Metro Center Drive, Suite 100 Austin, Texas 78744 CLAIM # ____________________________ Carrier Claim # _______________________ NOTICE OF REPRESENTATION OR WITHDRAWAL OF REPRESENTATION GENERAL CLAIM AND REPRESENTATIVE IDENTIFICATION INFORMATION Section I. Injured Employee Information 1a. Last Name 1b. First Name 2. Date of Birth (mm/dd/yyyy) 3. Social Security Number 1c. Middle Name 4a. Phone Area Code 4b. Phone Number 4c. Phone Extension 6b. City 6a. Street Address 6c. State 1d. Name Suffix 5. Date of Injury (mm/dd/yyyy) 6d. Zip Code Section II. Beneficiary Information (if represented person is a beneficiary) 7a. Last Name 7b. First Name 8. Date of Birth (mm/dd/yyyy) 9. Social Security No. (last 4) 7c. Middle Name 10a. Phone Area 10b. Phone Number Code 10c. Phone Extension 12b. City 12a. Street Address 12c. State 7d. Name Suffix 11. Relation of Injured Employee 12d. Zip Code Section III. Representative Information 13b. First Name 13a. Last Name 13c. Middle Name 14b. City 14a. Street Address 14c. State 13d. Name Suffix 14d. Zip Code 15. Email Address 16. Firm Name 17. Representative’s State Bar # 18. Date of License (mm/dd/yyyy) 19a. Phone Area Code 19b. Phone Number 19c. Phone Extension 20. Fax Number NOTICE OF REPRESENTATION NOTE: Both the claimant and the representative must sign and date the Notice of Representation below before the relationship becomes Effective. Send this form to DWC at the address shown above and a copy to the insurance carrier. I certify that I am representing the interests of the above named claimant’s workers’ compensation claim for the above date of injury under the Following circumstances: (PLEASE CHECK THE APPROPRIATE BOX) My representation began on: ____________________. I am not aware of any other person or attorney representing this injured employee at this time. My representation began on: ____________________. I am aware that _______________________________________________________ was previously representing this claimant. I hereby certify I have verified that the previous representative has withdrawn representation for the above referenced claimant. By signing below, I affirm that I qualify as a representative either as an attorney, or, if other than an attorney, I affirm that I qualify as a non-attorney representative under the Texas Workers’ Compensation Act and the Workers’ Compensation Rules, and that as a non-attorney representative, no fee or remuneration shall be received by me either directly or indirectly from a claimant. By signing below the claimant acknowledges the person indicated above will represent the claimant for the above date of injury. Claimant’s Signature Date Signed Representative’s Signature Date Signed NOTICE OF WITHDRAWAL OF REPRESENTATION NOTE: Either the representative or the claimant may terminate this representation relationship at any time, however, Rule 152.1(e) states,” A Client who discharges an attorney does not, by this action, defeat the attorney’s right to claim a fee.” The party terminating the relationship must sign below and provide a copy to the other party, the insurance carrier, and the DWC field office handling the claim. By my signature below, I am terminating this representation relationship effective the date indicated below. I will provide a copy of this Representation withdrawal notice to the other party, the insurance carrier, and the DWC filed office handling the claim. Claimant’s Signature DWC FORM-150 (Rev. 10/05) Page 1 Date Signed Withdrawing Representative’s Signature Date Signed DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR FILING NOTICE OF REPRESENTATION OR WITHDRAWAL OF REPRESENTATION The Texas Department of Insurance, Division of Workers’ Compensation has provided this form to allow customers to use standardized form for reporting their representation of injured employee or beneficiaries or to notify DWC regarding the withdrawal of such representation. Mail this form to DWC at: Texas Department of Insurance, Division of Workers’ Compensation 7551 Metro Center Drive, Suite 100 Austin, Texas 78744 A copy of this form must also be send to the insurance carrier. Special Instructions for Certain Requested Information Block 15 The representative should provides an email address if they have one. Block 16 If, as a representative, you are associated with a specific firm or organization, please provide that organization’s name. Block 17 Complete this block only if you are an attorney who is licensed by the State Bar of Texas. DWC FORM-150 (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com