Texas Department of Insurance

Workers' Compensation


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Workers' Compensation Self-Insurance Regulation Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Division of Workers Compensation Main Forms page

 


Self-Insurance Regulation Forms
TDI Form NumberDescriptionFile FormatLanguage
DWC020SI Self-Insured Governmental Entity Proof of Coverage
(Rev. 10/06)		 PDFEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 WORDEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 PDFEnglish
DWC215 Surety Bond Amount Rider
(Rev. 1/06)		 WORDEnglish
DWC215 Surety Bond Amount Rider
(Rev. 1/06)		 PDFEnglish
DWC216 Surety Bond Name Change Rider
(Rev. 1/06)		 PDFEnglish
DWC216 Surety Bond Name Change Rider
(Rev. 1/06)		 WORDEnglish
DWC223 Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORDEnglish
DWC223 Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 PDFEnglish
DWC224 Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07)		 WORDEnglish
DWC224 Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07)		 PDFEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 PDFEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORDEnglish
DWC226 Parental Guaranty
(Rev. 01/07)		 WORDEnglish
DWC226 Parental Guaranty
(Rev. 01/07)		 PDFEnglish
DWC227 Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07)		 WORDEnglish
DWC227 Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07)		 PDFEnglish
DWC228 Power of Attorney
(Rev. 01/07)		 WORDEnglish
DWC228 Power of Attorney
(Rev. 01/07)		 PDFEnglish

 


Self-Insurance Regulation Coverage Packages
Employers in the State of Texas who become certified self-insurers are required to post notices to their employees. Below you will find the required notice packages, which contain the forms and notices you will need.
TDI Form NumberDescriptionFile FormatLanguage
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 PDFEnglish
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 WORDEnglish
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 PDFEnglish
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 WORDEnglish
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 PDFSpanish
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 WORDSpanish

Initial Applications
Self-Insurance Regulation provides an Initial Application Packet for use in applying for a Certificate of Self-Insurance in Texas.

Renewal Applications
All renewal forms for Certified Self-Insurers in Texas are customized for each individual renewal involved. The Self-Insurance program in Texas does not use blank stock forms; however, Self-Insurance Regulation can provide example forms upon request.

Please contact Self-Insurance Regulation by calling (512) 804-4775 or faxing (512) 804-4776 during normal business hours of 8-5 Monday through Friday CST for further information or to request an Initial Application Packet.

Self-Insurance Regulation's mailing address is as follows:
Self-Insurance Regulation
Texas Department of Insurance, Division of Workers' Compensation
7551 Metro Center Drive, MS-60
Austin, Texas 78744-1609

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