Fillable Printable Attorney Application For Web Access

Attorney Application For Web Access

DWC151

DWC151 (Rev. 12/16)

ATTORNEY APPLICATION FOR WEB ACCESS

APPLICANT INFORMATION

1. Attorney’s Name

(Last, First, MI)

2. Firm Name (if applicable)

3. Mailing Address

(Street or PO Box, City, State, ZIP)

4. Attorney’s Bar Card Number

5. Phone Number

6. Email Address

I, the undersigned attorney, do hereby certify that by submitting this application I am responsible and liable for any information

contained in this submission, and that I am duly authorized and qualified in all respects. I certify that whether signed by an original

signature, stamp signature, encryption, or facsimile, it shall have the same effect as an original signature.

I understand and agree I will receive an access code via email, which will allow me to access the Web-enabled Attorney Fee

Processing System (WAFPS). I understand and agree I am responsible for all actions accomplished with my access code. I

understand and agree the access code is to be used only by me and must be kept confidential. I will not disclose my access code

to anyone or allow anyone to use it. Should my access code become known, I agree to change it immediately by submitting a new

application for WAFPS access. If I no longer need access to WAFPS, I will send an email to WAFPS@tdi.texas.gov

to delete my

account. Failure to follow these policies and procedures may result in loss of access to WAFPS at the division’s sole discretion.

Attorney Signature Date

INSTRUCTIONS

Submit the completed application by email, fax, mail, or personal delivery to the address at the top of this form.

The application must be submitted with the attorney’s name. An application cannot be submitted in the firm’s name. Only the

attorney listed on this application will be given an access code. A separate application must be filed for any attorney wishing to

receive an access code.

Upon receipt of a completed Attorney Application for Web Access, the division will issue an access code via email at the email

address provided on this application. For security purposes, each attorney submitting an application must have an individual email

address. Should the attorney wish to change their access code, a new application must be submitted to the division.

For questions concerning this form, send an email to [email protected]as.gov or call the Texas Department of Insurance, Division of

Workers’ Compensation Hearings Section at 512-804-4010.

NOTE: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; get and

review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government

Code, §559.004). For more information, contact agency[email protected]as.gov or you may refer to the Corrections Procedure

section at