Self Insured Governmental Entity Coverage Information {DWC-20SI}

GOVERNMENTAL ENTITY COVERAGE INFORMATION. This form is used by governmental entities in Texas to provide details about their workers' compensation coverage. It is required when a governmental entity either self-insures or enters into an interlocal agreement (or pool) with other entities for workers' compensation benefits. The form collects information such as the coverage effective dates, contact details, and specifics on how the entity provides workers' compensation benefits (e.g., self-insurance or through a pool). It also includes sections for claim administration, medical billing, and other related processes. The form must be filed within 10 days of the coverage's effective date, or within 30 days of any changes, and failure to file it may result in administrative penalties. www.FormsWorkflow.com