DWC020SI Texas Department of Insurance Division of Workers’ Compensation 7551 Metro Center Drive, Suite100 • MS-96 Austin, TX 78744-1645 (800) 372-7713 phone • (512) 804-4346 fax Self-Insured Governmental Entity Coverage Information I. Governmental Entity Information 1. Governmental Entity Name 2. Self-Insurance Effective Dates (mm/dd/yyyy) From: To: 3. Federal Tax ID No. (FEIN) 4. Workers’ Compensation Point of Contact 5. Point of Contact Phone Number 6. Point of Contact E-mail Address 7. Business Mailing Address (Street or PO Box, City, State, Zip Code) 8. Is the governmental entity a member of a pool/group? Yes No If yes, you must complete Section II. 9. Is the governmental entity a political subdivision that provides medical benefits pursuant to and in the manner described by §504.053(b)(2) of the Labor Code, relating to directly contracting with health care providers or contracting through a health benefits pool? Yes No If yes, you must complete Section III. II. Self-Insurance Pool/Group Information (complete only if Yes is checked in Box 8) 10. Self-Insurance Pool/Group Name 11. Effective Dates (mm/dd/yyyy) From: To: 12. Federal Tax ID No. (FEIN) 13. Workers’ Compensation Point of Contact 14. Point of Contact Phone Number 15. Point of Contact E-mail Address III. Medical Benefits Plan Information (complete only if Yes is checked in Box 9) 16. Health Plan Name/Address 17. Effective Dates, as applicable (mm/dd/yyyy) From: To: 18. Health Plan Point of Contact 19. Point of Contact Phone Number 20. Point of Contact E-mail Address IV. Signature / Date 21. Signature of Governmental Entity Representative For TDI-DWC Use Only 22. Printed Name 23. Title DWC020SI Rev. 08/12 24. Date of Signature (mm/dd/yyyy) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC020SI Frequently Asked Questions Self-Insured Governmental Entity Coverage Information (DWC Form-020SI) Under what circumstances am I required to file a DWC Form-20SI? You must file a DWC Form-020SI: • • • • • within 10 days after the effective date of self-insurance coverage and annually thereafter no later than 10 days after the anniversary date of coverage; within 30 days after the date the political subdivision begins to provide medical benefits in accordance with Texas Labor Code §504.053(b)(2); within 30 days of any change in the manner the political subdivision provides medical benefits; upon joining, leaving, or changing pools or groups; and upon buying a workers’ compensation insurance policy. Failure to file the form may subject the self-insured governmental entity to administrative penalties. Are any fields on the DWC Form-020SI optional? No, all applicable fields must be completed each time the DWC Form-020SI is filed. Where do I file the DWC Form-020SI? Fax the DWC Form-020SI to the Texas Department of Insurance, Division of Workers’ Compensation at (512) 804-4346 or mail it to the following address: Texas Department of Insurance Division of Workers’ Compensation 7551 Metro Center Drive, Suite 100 • MS 96 Austin, Texas 78744-1645 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). DWC020SI Rev. 08/12 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com