Forms for self-insurersThe following forms are for self-insurers to use.
Self Insurer Forms
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.
Self insurer form - Permit Renewal (Pub No SI-510, 01/01/2011, 1.0 134.0 KB)
This is the application for self insurers to renew their permit.
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.
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.
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.
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.