Forms for self-insurers

The following forms are for self-insurers to use.

Self Insurer Forms

 PDF Self insurer form - Permit Application  (Pub No SI-500, 01/01/2011, 1.0 133.0 KB)

This is the permit application form for self insurers.

 PDF Self insurer form - Financial Undertaking  (Pub No FUF 1, 01/01/2011, 1.0 38.5 KB)

This is the financial undertaking template for self insurers.

 PDF Self insurer form - Irrevocable Power of Attorney  (Pub No IPAF 1, 01/01/2011, 1.0 59.5 KB)

This is the Irrevocable Power of Attorney form and schedule for self insurers.

 PDF G-3 End of Year Reconciliation Certificate  (Pub No G-3, 01/01/2003, G-3 260.4 KB)

This form is to be used for the end of year reconciliation certificate.

 PDF G-5 Insurer form - Independent audit report template  (Pub No LI-675, 01/01/2011, 1.0 150.5 KB)

This document helps insurers submit the required independent audit report.

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