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Workers' Comp Self-Insurance Regulation Coverage Packages

Division of Workers Compensation Main Forms page

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.

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

Workers' Comp Self-Insurance Regulation Coverage Packages
TDI Form Number Description File FormatLanguage
DWC020SI
Indicates forms available for electronic filing
Self-Insured Governmental Entity Coverage Information
Rev. 08/12 - Using Google Chrome or Mozilla Firefox to file electronically? See more at “Electronic Filing - Online Forms” above.
PDF English
Notice 10 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 10 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 10 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 7 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 7 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 7 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese

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