Dwc Form 150 – Fill Out and Use This PDF

NOTICE OF REPRESENTATION OR WITHDRAWAL OF REPRESENTATION

GENERAL CLAIM AND REPRESENTATIVE IDENTIFICATION INFORMATION

Section I. Injured Employee Information

1a.

Last Name

1b. First Name

1c.

Middle Name

1d. Name Suffix

2. Date of Birth (mm/dd/yyyy)

3.

Social Security Number

4a. Phone Area

4b. Phone Number

4c.

Phone Extension

5. Date of Injury (mm/dd/yyyy)

Code

6a.

Street Address

6b. City

6c. State

6d.

Zip Code

Section II. Beneficiary Information (if represented person is a beneficiary)

7a.

Last Name

7b. First Name

7c.

Middle Name

7d. Name Suffix

8. Date of Birth (mm/dd/yyyy)

9.

Social Security No. (last 4)

10a. Phone Area

10b. Phone Number

10c. Phone Extension

11.

Relation of Injured Employee

Code

12a. Street Address

12b. City

12c. State

12d. Zip Code

Section III. Representative Information

13a. Last Name			13b. First Name				13c. Middle Name			13d.	Name Suffix
14a. Street Address					14b. City				14c. State	14d.	Zip Code
15. Email Address
16.	Firm Name
17.	Representative’s State Bar #	18. Date of License (mm/dd/yyyy)		19a. Phone Area		19b. Phone Number		19c. Phone Extension		20. Fax Number
				Code
			NOTICE OF REPRESENTATION

NOTE: Both the claimant and the representative must sign and date the Notice of Representation below before the relationship becomes

Effective. Send this form to DWC at the address shown above and a copy to the insurance carrier.

I certify that I am representing the interests of the above named claimant’s workers’ compensation claim for the above date of injury under the

Following circumstances: (PLEASE CHECK THE APPROPRIATE BOX)

My representation began on: ____________________. I am not aware of any other person or attorney representing this injured employee at

this time.

My representation began on: ____________________. I am aware that _______________________________________________________

was previously representing this claimant. I hereby certify I have verified that the previous representative has withdrawn representation for the above referenced claimant.

By signing below, I affirm that I qualify as a representative either as an attorney, or, if other than an attorney, I affirm that I qualify as a non-attorney representative under the Texas Workers’ Compensation Act and the Workers’ Compensation Rules, and that as a non-attorney representative, no fee or remuneration shall be received by me either directly or indirectly from a claimant.

By signing below the claimant acknowledges the person indicated above will represent the claimant for the above date of injury.

Claimant’s Signature	Date Signed	Representative’s Signature	Date Signed

NOTICE OF WITHDRAWAL OF REPRESENTATION

NOTE: Either the representative or the claimant may terminate this representation relationship at any time, however, Rule 152.1(e) states,” A Client who discharges an attorney does not, by this action, defeat the attorney’s right to claim a fee.” The party terminating the relationship must sign below and provide a copy to the other party, the insurance carrier, and the DWC field office handling the claim.

By my signature below, I am terminating this representation relationship effective the date indicated below. I will provide a copy of this Representation withdrawal notice to the other party, the insurance carrier, and the DWC filed office handling the claim.

Claimant’s Signature	Date Signed	Withdrawing Representative’s Signature	Date Signed

DWC FORM-150 (Rev. 10/05) Page 1

DIVISION OF WORKERS’ COMPENSATION