Correction-Revision-Endorsement To Existing Policy {DWC-20A}

Primary Employer's Business Name/Insured Federal Tax ID Number Current Policy Number DWC Use Only (Microfilm) CORRECTION/REVISION/ENDORSEMENT TO EXISTING POLICY Check one: Correction Revision Endorsement > Effective Date of Change The current policy is hereby amended (State only what is being amended) Name of Insurance Carrier: Name of Primary Insured: Address of Primary Insured: NCCI Number FEIN Number Policy Number Effective Date of Policy (mm-dd-yy) End Date of Policy (mm-dd-yy) (mm-dd-yy) Date Carrier Notified Employer to Cancel Effective Date of Cancellation (mm-dd-yy) Date of Reinstatement (mm-dd-yy) LOCATIONS Check one: ADD > DELETE Federal Tax ID Number ______________________________ Number of Employees _______________________________ City _____________________ State _____ Zip ____________ Effective Date Name _______________________________________________ Address _____________________________________________ ____________________________________________________ Check one: ADD > DELETE Federal Tax ID Number ______________________________ Number of Employees _______________________________ Effective Date Name _______________________________________________ Address _____________________________________________ ____________________________________________________ City _________________ State _______ Zip ______________ Check one: ADD > DELETE Effective Date Name ______________________________________________ Address _____________________________________________ ____________________________________________________ Federal Tax ID Number ______________________________ Number of Employees _______________________________ City _________________ State ______ Zip ______________ DWC FORM-20A (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com