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DWC121DWC121 Rev. 03/20Page 1 of 3 Claim Administration Contact InformationAUSTIN REPRESENTATIVE INFORMATION1.Austin Representative’s Name(First, Last)2.Austin Representative’s Organization Name3.Austin Representative’sMailing Address(Street or P.O. Box, City, State, ZIP)4.Austin Representative’sPhone Number()5.Austin Representative’sFax Number()6.Austin Representative’sEmail AddressINSURANCE CARRIER7.Insurance Carrier’s Name8.Insurance Carrier’s Federal Employer IDNumber (FEIN)9.Insurance Carrier’s Group Affiliation (if applicable)10.Insurance Carrier’s Primary Mailing Address(Street or P.O. Box, City, State, ZIP)11.Insurance Carrier Contact Name(First, Last)12.Insurance Carrier Contact Phone Number()13.Insurance Carrier Contact Fax Number()14.Insurance Carrier Contact Email AddressOPTION 1 – INSURANCE CARRIER CONTACT INFORMATION WEB ADDRESS15.Effective Date16.Web Address URLOPTION 2 – Insteadof an insurancecarrier web address, complete applicable claim administration information.CLAI...