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ADVISORY 2004-05

SUBJECT: Submission of Proof of Coverage (Self-Insured Governmental Entities)

The Texas Workers' Compensation Commission (Commission) has developed a new form, TWCC-20SI, Self-Insured Governmental Entity Proof of Coverage, to replace the TWCC-20, Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage (Rev. 10/93), for filing proof of coverage information by self-insured governmental entities. The TWCC-20a, Correction/Revision/ Endorsement to Existing Policy (Rev. 10/93), may still be used by self-insured governmental entities for the purpose of submitting corrections or changes to an existing policy. Although the TWCC-20 will no longer be used by self-insured governmental entities, it will continue to be used by commercial insurance carriers when hard copy submission of proof of coverage information is required. A copy of the TWCC-20SI is attached to this Advisory.

All self-insured governmental entities, (including joint insurance funds that report for such entities), must begin using the TWCC-20SI and TWCC-20a to submit Proof of Coverage information to the Commission in accordance with the Texas Labor Code 402.042(b)(11), 406.006 and 406.009 and Commission Rule 110.1 not later than June 1, 2004. Other methods of submitting Proof of Coverage information such as spreadsheets, data runs, or other documents will no longer be accepted. Large volume filers such as joint insurance funds may elect to submit proof of coverage information electronically as prescribed in Advisories 2002-07 and 2002-07B, Electronic Submission of Proof of Coverage (Commercial Carriers), at their option.

It is critical that coverage information submitted in conjunction with a claim first report of injury (EDI 148 transaction: Employer FEIN, DN-16; Policy Number, DN-28; and Policy Effective Date, DN29) exactly match the information submitted for these same elements through the Proof of Coverage process for the associated coverage (policy). To facilitate this requirement, self-insured governmental entities and joint insurance funds shall provide a copy of the TWCC-20SI to their claim-processing agent in addition to filing the form with TWCC.

Questions concerning this change in process should be directed to Wanda Diggs, Acting Manager, Records Processing, (512) 804-4387,

Signed this 4th day of May, 2004

Richard F. Reynolds, Executive Director

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