DWC150 at a glance
What it is: DWC150 is the Notice of Representation. It is provided as an option for claimant attorneys to provide notice of representation to the division.
Who signs: Box 23 is the Representative's Signature with its Date Signed.
A filled-in DWC150 example: an attorney files for an injured employee
How to fill out DWC150, box by box
Boxes 1 to 5, the injured employee
Box 1 is the Injured Employee's Name (Last, First, MI).
Box 2 is the Injured Employee's Address (Street or PO Box, City, State, ZIP).
Box 3 is the Injured Employee's Phone Number, Box 4 the Date of Injury (mm/dd/yyyy) and Box 5 the DWC Claim Number.
Boxes 6 to 10, the beneficiary
Beneficiary information is only required when representing an individual in a death benefits claim. Box 6 is the Beneficiary's Name (Last, First, MI).
Box 7 is the Beneficiary's Address (Street or PO Box, City, State, ZIP).
Box 8 is the Beneficiary's Phone Number, Box 9 the Beneficiary's SSN and Box 10 the Beneficiary Type.
Box 11, the insurance carrier
Box 11 is the Insurance Carrier's Name.
Boxes 12 to 20, the representative information
Box 12, Representing: Employee, Beneficiary, Insurance Carrier, Other. Box 13 is the Name (Last, First, MI) and Box 14 the Firm Name (if applicable).
Box 15 is the Address (Street or PO Box, City, State, ZIP), Box 16 the Attorney's Bar Card Number and Box 17 the Date of License.
Box 18 is the Phone Number, Box 19 the Fax Number and Box 20 the Email Address (optional).
Box 21, when the representation began
Box 21: I represent the interests of the party indicated in Box 12. Please check the appropriate box (optional): My representation began on: ____________________. I am not aware of any other person or attorney representing this party at this time. Or: My representation began on: ____________________. I am aware that ____________________ was previously representing this party.
Boxes 22 and 23, the signatures
Box 22 is the Claimant's Signature (optional) with its Date Signed. For TDI Use Only is after Box 22.
If your situation is different
You are not a claimant's attorney
Other representatives, such as non-attorney representatives under §150.3 or insurance carrier representatives, are not required to notify the division; however, they may use the DWC Form-150 to submit notice of representation.
Under Labor Code §401.011 a representative is a person, including an attorney, authorized by the division to assist or represent a claimant or carrier. Under 28 Texas Administrative Code (TAC) §150.3(a), a non-attorney representative may not receive a fee or remuneration either directly or indirectly from the claimant.
The DWC-150 is not a required form
The DWC-150 is not a required form. However, a claimant attorney may provide notice of representation in any manner that qualifies under §152.2(a) and §150.2(b).
Common questions about DWC150
Is there a deadline?
A claimant's attorney must notify the division in writing within 10 days of undertaking the representation.
Where do I file it?
Attorneys may submit the DWC Form-150, or other notice of representation, to the division by mailing the form to the address at the top of the form, faxing the form to 512-804-4378, or personally delivering the form to the division field office handling the claim or the central office of the division.
Sources
[1] DWC150 Rev. 12/16, Notice of Representation, Texas Department of Insurance, Division of Workers' Compensation (the Official source link on this page).