Texas Department of Insurance DWC Use Only (Microfilm #) Division of Workers’ Compensation 7551 Metro Center Drive, Suite 100, MS 96 Austin, Texas 78744-1609 512-804-4345 512-804-4346 fax www.tdi.state.tx.us SELF-INSURED GOVERNMENTAL ENTITY PROOF OF COVERAGE GOVERNMENTAL ENTITY 1. Governmental Entity 2. Federal Tax ID No. (FEIN) 3. Workers Compensation Point of Contact 4. Telephone 5. Email Address 6. Business Mailing Address 7. Address Line 2 8. City 9. State 10. ZIP Code INSURER / CARRIER NAME 11. Insurance Carrier Name 12. Type Self-Insurer, Individually Self-Insurer Collectively 13. Type of Transaction (Check only one. Use separate forms for additional transactions.) New Policy Renewal Reinstatement Carrier 10 day Cancellation/Non Renewal Carrier 30 day Cancellation/Non Renewal 14. Federal Tax ID No. (FEIN) POLICY INFORMATION 15. Policy Number / Contract Number 16. Effective Date of Cancellation/Reinstatement: (mm-dd-yy) 17. Effective Dates of Policy: (mm-dd-yy) 18. Date Carrier Notified Employer of Cancellation: (mm-dd-yy) From To 19. Signature of Governmental Entity or Insurer Representative 20. Date of Notice DWC Use Only (stamp date received) Form DWC020 SI (Self-Insured Governmental Entity Proof Of Coverage) Rev. 10/06 Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com Instructions for Form DWC020 SI - Self-Insured Governmental Entity Proof Of Coverage This form is used by self-insured governmental entities and joint insurance funds (Texas Labor Code §504.016) to report proof of coverage information to the Texas Department of Insurance, Division of Workers’ Compensation in accordance with Texas Labor Code §§ 402.042(b)(11), 406.006 and 406.009 and Workers’ Compensation Rule 110.1. There is an annual filing requirement as well as requirements to report specific events. Instructions for specific blocks: 1. Governmental Entity Name: The formal, legal name of the governmental entity. 2. Federal Tax ID No. (FEIN): The federal tax ID number of the entity whose name appears in 1. above. 3 - 5. Name and contact information for the workers’ compensation point of contact at the self-insured governmental entity. 6.-10. Address Information for the governmental entity – as indicated. 11. Insurance Carrier Name: The name of the self-insured governmental entity if the governmental entity self-insures individually or, if self-insuring collectively, the name of the joint insurance fund. 12. Type: Select the appropriate type of self-insurance. 13. Select only one transaction type per form. If correction or revision of a previous submission is required, use DWC FORM-20a, Correction/Revision/Endorsement to Existing Policy. 14. Federal Tax ID No. (FEIN): The federal tax ID number of the entity whose name appears in 11 above. 15. Policy Number/Contract Number: The Policy Number can be up to 18 characters long using any combination of numbers and letters (no special characters, marks of punctuation or spaces between characters). If the Self-Insured Governmental Entity or Joint Insurance Fund has a number, such as a contract or certificate number, that meets these parameters and is unique to the Insured, that number may be used as the policy number. If an existing, suitable number is not available, use the Self-Insured Governmental Entity’s FEIN followed by a sequence number to make an identifier unique to the Insured. The same number may be used year-to-year, and “renewed” by providing new Policy Effective and Expiration Dates. This same Policy Number must be used in the First Report of Injury (EDI 148, DN028) when reporting claims for this Self-Insured Governmental entity. 16. Effective Date of Cancellation/Reinstatement: The effective date of cancellation of the governmental entity’s current insurance coverage (Cancellation) or the effective date that the current insurance coverage was reinstated if it had been previously cancelled (Reinstatement). If canceling the governmental entity’s current insurance coverage and moving to another source of insurance coverage the new insurance coverage must be reported separately in the form appropriate to the new insurance coverage. 17. Effective Dates of Policy: From: The date the governmental entity’s insurance coverage became or will become effective. To: If self-insuring individually, the date one year after the From date. If self-insuring collectively through a joint insurance fund, a date consistent with the financial arrangements between the governmental entity and the joint insurance fund but not greater than one year from the From date. (Conforms to annual filing requirement of Rule 110.1(h)). 18. Date Carrier Notified Employer of Cancellation: If the insurance coverage is cancelled by a joint insurance fund, the date that the joint insurance fund notified the governmental entity that insurance coverage was being cancelled. Notice must conform to Rule 110.1(h). 19.- 20. Signature of the representative of the entity submitting the form and the date of signature. Note: A copy of this form must be provided to DWC at the address on the form and to the governmental entity’s claimprocessing agent. Form DWC020 SI (Self-Insured Governmental Entity Proof Of Coverage) Rev. 10/06 Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com