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Attorney Application For Web Access DWC-151 - Texas

Attorney Application For Web Access Form. This is a Texas form and can be used in Other Business Workers Compensation .
 Fillable pdf Last Modified 9/30/2014
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Mail or personally deliver this form to: TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS' COMPENSATION 7551 Metro Center Drive, Suite 100 Austin, Texas 78744 ATTORNEY APPLICATION FOR WEB ACCESS 1. Name of Attorney, (First, M, Last) 2. Mailing Address 3. Firm Name 4. Telephone Number 5. Bar Card Number City State ZIP 6. Individual E-mail Address I, the undersigned attorney, do hereby certify that I am the attorney for the clients identified in these Applications for Attorney's Fees, that by submitting this application either by an original signature, stamp signature, encryption or facsimile, it shall have the same effect as an original signature, that I am responsible and liable for any information contained in this submission. I understand I am responsible and liable for any information entered in on line submissions, and that I am duly authorized and qualified in all respects. If more than one attorney performs work, then this certification applies to that part of the services provided by me personally. I understand, and agree I will receive an Access Code via e-mail which will allow me to access the DWC Web-enabled Attorney Fee Processing System (WAFPS). I understand I am responsible for all actions accomplished with my Access Code. I understand the Access Code is to be used only by me and must be kept confidential. I will not disclose it to anyone or allow anyone to use my Access Code. I agree to change my Access Code immediately should it become known by submitting a new application for WAFPS access. If I no longer need access to the WAFPS system, I will send an e-mail to WAFPS@tdi.texas.gov to delete my account. Failure to follow these policies and procedures may result in loss of access to the WAFPS system at the Division's sole discretion. Attorney Signature_______________________________________ Date _________________________________ INSTRUCTIONS The application must be submitted with the attorney's name. An application cannot be submitted in the firm's name. The attorney's original signature is required to obtain web access. Only the attorney listed on this application will be given an access code. A separate application must be filed for any attorney wishing to receive an access code. When Applications for Attorney's Fees are submitted with more than one attorney, the additional attorneys bar car numbers must be on file with the Division. Upon receipt of the application, the Division will issue an Access Code. The attorney will be advised of the Access Code via e-mail at the e-mail address provided on this application. For security purposes, each attorney submitting an application must have an individual e-mail address. Should the attorney wish to change the Access Code, another application must be submitted to the Division. For questions concerning this form, send an e-mail to WAFPS@tdi.texas.gov or call Texas Department of Insurance, Division of Workers' Compensation, Customer Services Section at 512-804-4636. DWC FORM-151 (Rev. 10/05) DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com
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