Locations Of Employers Business(es) {DWC205}

DWC205 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-96 Austin, TX 78744-1645 (800) 372-7713 phone · (512) 804-4146 fax For TDI-DWC Use Only Locations of Employer's Business(es) Addendum to DWC Form-005 or DWC Form-020 Type or print each item on this form in black ink Check the appropriate box: Addendum to DWC Form-005 Employer Notice of No Coverage or Termination of Coverage Addendum to DWC Form-020 Insurance Carrier Notice of Coverage or Cancellation/Non-renewal of Coverage I. PRIMARY EMPLOYER INFORMATION Primary Employer's Business Name Federal Employer ID Number II. ADDITIONAL BUSINESS LOCATIONS Use this section to add or delete coverage for locations, subsidiaries, and/or separate entities of the primary employer. Check One: Name Address (Street or PO Box, City State Zip) ADD DELETE Effective Date Federal Employer ID Number Check One: Name ADD DELETE Effective Date Federal Employer ID Number Address (Street or PO Box, City State Zip) Check One: Name ADD DELETE Effective Date Federal Employer ID Number Address (Street or PO Box, City State Zip) Check One: Name ADD DELETE Effective Date Federal Employer ID Number Address (Street or PO Box, City State Zip) Check One: Name ADD DELETE Effective Date Federal Employer ID Number Address (Street or PO Box, City State Zip) Check One: Name ADD DELETE Effective Date Federal Employer ID Number Address (Street or PO Box, City State Zip) Check One: Name ADD DELETE Effective Date Federal Employer ID Number Address (Street or PO Box, City State Zip) NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). American LegalNet, Inc. www.FormsWorkFlow.com DWC205 Rev. 11/10