I want to . . .
- Get information about self insurance and the requirements to self insure
- Apply to become self insured
- Get information on posting a security deposit for self insurance
- Complete my Self Insurer's Annual Report
- Apply to take the Self Insurance Administrator's examination
- Determine if an employer is self insured
- Access self insurance regulations
- Receive notices about SIP rulemaking
Boards, Commissions & Programs
Self Insurance Plans (SIP)
Publications & forms
Rosters
- SIP Private self insured employers (
.pdf) - SIP Joint powers authority (JPA) public list (.pdf)
- SIP Public stand alone roster (.pdf)
- SIP Third-party administrators (.pdf)
- SIP Group self insurers roster (.pdf)
Security deposit
- Information bulletin: Approved securities (.pdf format, 21K)
- Information bulletin: Cash in trust (.pdf format, 25K)
- Information bulletin: Letter of credit (.pdf format, 253K)
- Information bulletin: Surety bond (.pdf format, 13K)
Private self insurers' annual report
- Click here to get the Private/Group Self Insurer’s Annual Report (
pdf forms) - Instructions for Private and Group Self Insurer's Annual Reports ( pdf)
- FAQ's ( pdf)
Public self Insurers' annual report
For joint and non-joint powers authority and members
- Click here to get the Public Self Insurer’s Annual Report (pdf forms)
- Instructions for Public Self Insurer's Annual Report (
pdf)
- A4-3 (1/94) (.pdf
format, 89K)
Application for a certificate of consent to self insure by a group of employers - A4-3M (1/94) (.pdf
format, 158K)
Application for an affiliate certificate of consent to self insure as a member of a group self insurer - Form A4-50 (Rev 8/96) (.pdf
format, 20K)
Application for a Certificate to Administer W/C Claims - Form A4-1 (Rev 2/92) (.pdf
format, 88K)
Application for a private entity Certificate of Consent to Self Insure - Form A4-2 (Rev 2/92) (.pdf
format, 21K)
Application for a Pubilc entity Certificate of Consent to Self Insure - Form A4-5 ( Rev 11/97) (.pdf
format, 77K)
Application for a permanent certificate of consent to self insure by an interim self insurer - Form A4-6 (Rev 11/97) (.pdf
format, 15K)
Agreement of assumption and guarantee of workers' compensation liabilities
NOTE: This form must be submitted to SIP as a two-sided form, please print or copy it appropriately. - Corporate resolution authorizing application (.pdf
format, 7K)
- Resolution of agreement of parental assumption
and guarantee (.pdf
format, 9K)
- Request for Interim Certificate (.pdf
format)
- Request for Interim Certificate for a Group Member (.pdf
format, 12K)
- US Life expectancy tables for
men and women (.pdf
format, 301K)