FAQ
Governmental entity coverage information

When do I file this form?
You must file DWC Form-020SI, Governmental entity coverage information:

• Within 10 days after the effective date of self-insurance coverage or claim administration agreement and each year after that, no later than 10 days after the anniversary date of coverage or agreement;
• Within 30 days after the date the political subdivision begins to provide medical benefits in accordance with Texas Labor Code Section 504.053(b)(2);
• Within 30 days of any change in the manner the political subdivision provides medical benefits;
• On joining, leaving, or changing pools or groups; and
• On buying a workers’ compensation insurance policy.

Note: A governmental entity may be subject to administrative penalties if it fails to file the DWC Form-020SI.

I provide workers’ compensation coverage through a private workers’ compensation insurance carrier. Am I required to file this form?
No, you are not required to file the DWC Form-020SI.

Are any fields on the form optional?
If self-insurance is selected in question 9, complete Part 2. If interlocal agreement is selected in question 9, complete the pool details in 9 a. through 9 e.

Where do I send this form?

• Email: [email protected]
• Fax: 512-804-4146
• Create a profile in TXCOMP and upload documents.

Questions?
Email questions to [email protected].

Note: With few exceptions, on your request, you are entitled to:

• Be informed about the information DWC collects about you;
• Receive and review the information (Government Code Sections 552.021 and 552.023); and
• Have DWC correct information that is incorrect (Government Code Section 559.004).

For more information, contact [email protected] or go to the Corrections Procedure section at www.tdi.texas.gov.