DWC Form-121, Claim Administration Contact Information DWC Form-121, Claim Administration Contact In 2026

1. Click ‘Get Form’ to open DWC Form-121 in the editor.
2. Begin by filling in the Austin Representative Information. Enter the representative's name, organization, mailing address, phone number, fax number, and email address in the designated fields.
3. Next, provide details for the Insurance Carrier section. Fill in the carrier's name, Federal Employer ID Number (FEIN), group affiliation if applicable, primary mailing address, contact name, phone number, fax number, and email address.
4. Choose between Option 1 or Option 2 for insurance carrier contact information. If using Option 1, enter the effective date and web address URL. For Option 2, complete the claim administration information as required.
5. Continue filling out sections for Claim Adjustment, Coverage Verification, Medical Billing, Pharmacy Billing, Preauthorization, and Workers’ Compensation Health Care Network as needed.
6. Finally, ensure you sign and date the form at the Austin Representative Affirmation section to authorize updates.

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