Workers' Compensation Self-Insurance Application Checklist 2026

1. Click ‘Get Form’ to open the Workers' Compensation Self-Insurance Application Checklist in the editor.
2. Begin by uploading a certificate of insurance from your current carrier, ensuring it evidences compliance with workers’ compensation statutes.
3. Next, attach the most recent three years of audited financial statements, highlighting current assets, liabilities, and total stockholder equity.
4. Include the last three years of workers’ compensation loss runs as required by Sections 1711 (B) & (C).
5. Pay the $100 application fee directly through our platform for seamless processing.
6. Indicate if you have enlisted a Third Party Administrator and provide a complete copy of your service contract.
7. If not using a third-party administrator, upload resumes of personnel managing claims along with safety program information.
8. Provide a certificate evidencing your excess coverage, clearly stating the SIR amount.
9. Lastly, indicate your self-insurance contact person and their phone number for any future communications.

Start filling out your Workers' Compensation Self-Insurance Application Checklist today for free on our platform!