Texas > Workers Compensation > Carrier
Insurance Carrier Notice Of Coverage-Cancellation-Non Renewal Of Coverage DWC-20 - Texas
| Insurance Carrier Notice Of Coverage-Cancellation-Non Renewal Of Coverage Form. This is a Texas form and can be used in Carrier Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 1. Insurance Carrier Name Employer/Insured Information 7. Primary Employer/Insured Name 2. Federal Tax ID No/ (FEIN) 3. NCCI No. 8. Primary Employer/insured Business Mailing Address 4. DWC Carrier (MBI No.) 5. Policy Type Standard Divided Risk Type of Transaction (check one only) New Policy Carrier 10 days Cancellation/Non Renewal Carrier 30 days Cancellation/Non Renewal Correction/Revision/Endorsement (attach DWC FORM-20A) Renewal Reinstatement 9. No. of Locations and/or entities covered. (Exclude Primary Insured) 11. Employer's Workers' Comp Class Code 10. Federal Tax ID No. 12. Estimated No. of Employees Voluntary Backdated Effective Date of Policy POLICY INFORMATION 13. Policy No. 14. Effective Date of Policy: (mm-dd-yy) From To 15. Effective Date of Cancellation/Reinstatement: (mm-dd-yy) 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: ADD DELETE Name > 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 20. Date of Notice DWC FORM-20 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
|
|||||||
