Get the free DWC Form-027, Carrier Representative Information Submission Form - tdi texas

DWC 027 Texas Department of Insurance Division of Workers Compensation 7551 Metro Center Drive, Suite 100 MS-96 Austin, TX 78744-1645 (512) 804-4000 phone (512) 804-4346 fax Designation of Insurance

How to fill out dwc form-027 carrier representative

1. To fill out the DWC Form-027 Carrier Representative, you need to start by providing the necessary information. This includes your name, title, address, city, state, ZIP code, phone number, and email address. Make sure to fill out each field accurately.
2. Next, you will need to provide the name and title of the person completing the form. This person should be authorized and knowledgeable about the workers' compensation insurance policy of the carrier.
3. The form requires you to specify the date the form is being completed, as well as the name of the insurance carrier.
4. In the following section, you will need to enter the employer information. This includes the name, address, city, state, ZIP code, phone number, and email address of the employer. Ensure you enter the employer's information exactly as it appears on their workers' compensation insurance policy.
5. The form will then prompt you to provide the employee's information. This includes their name, social security number, date of birth, gender, occupation, hire date, and the date of injury. Make sure to accurately fill out these details to avoid any discrepancies.
6. Next, you will need to provide the claim information. This includes the date the insurance carrier received the claim, the claim number, the injury code(s), and the body part(s) affected. Make sure to use the appropriate codes and accurately specify the affected body parts.
7. The form will ask you to provide information about the medical treatment requested or provided. This includes the name and address of the treating physician, the diagnosis codes, and the treatment details. Ensure you provide all the necessary information accurately.
8. Finally, you will need to sign and date the form. The carrier representative filling out the form should sign their name and enter the date of completion.

Who needs DWC Form-027 Carrier Representative?

1. DWC Form-027 Carrier Representative is required for insurance carriers that need to provide accurate and complete information about the workers' compensation insurance policy and any related claim. This allows the Division of Workers' Compensation to effectively monitor carriers and ensure appropriate benefits are provided to injured workers.
2. Employers who are covered by workers' compensation insurance and have claims filed against them will require the DWC Form-027 Carrier Representative. It helps establish communication between the insurance carrier, employer, and the Division of Workers' Compensation, ensuring that the necessary information is provided and processed correctly.
3. Additionally, injured employees and their legal representatives may also need to be aware of the DWC Form-027 Carrier Representative. It allows them to identify the carrier representative responsible for handling their claim and assists in maintaining effective communication throughout the claims process.

For pdfFiller’s FAQs

What is dwc form-027 carrier representative?

The DWC Form-027 Carrier Representative is a form used by insurance carriers to designate a representative for the purpose of receiving notices and communications from the Division of Workers' Compensation (DWC).

Who is required to file dwc form-027 carrier representative?

Insurance carriers are required to file the DWC Form-027 Carrier Representative.

How to fill out dwc form-027 carrier representative?

To fill out the DWC Form-027 Carrier Representative, the insurance carrier must provide details of the designated representative, including their name, contact information, and authorization to receive notices on behalf of the carrier.

What is the purpose of dwc form-027 carrier representative?

The purpose of the DWC Form-027 Carrier Representative is to ensure that the Division of Workers' Compensation has a designated contact person within the insurance carrier to facilitate communication and the exchange of information.

What information must be reported on dwc form-027 carrier representative?

The DWC Form-027 Carrier Representative must include the representative's name, contact information, and written authorization to receive notices and communications from the Division of Workers' Compensation.

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