FAQ
First responder’s annual certification for lifetime income benefits (LIBs)

Who should file this form?
First responders who get LIBs because of a serious bodily injury file this form.

Learn more about LIBs for first responders:

• Texas Labor Code Section 408.1615 and Texas Penal Code Section 1.07
• tdi.texas.gov/wc/employee/lifetimeben.html
• tdi.texas.gov/wc/employee/firstresponder.html

When do I file this form?
You must file this form annually with the insurance carrier to certify that you were not employed in any capacity during the preceding year.
Send this form to the insurance carrier no later than 30 days after the anniversary of the date your LIBs began to accrue. The insurance carrier must provide you with an annual notice of the anniversary date.

What is the accrual date for LIBs?
This is the date that an injured employee becomes eligible to get LIBs.

Where do I send this form?
Send this form to the insurance carrier. Contact your insurance carrier adjuster for the mailing address, fax number, or email address.

Questions?
Call 800-252-7031, Monday through Friday, 8 a.m. to 5 p.m., Central time.
Go to www.tdi.texas.gov/wc to learn more about workers’ compensation.

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.