Application for self-insurance shall be made as follows:

1. (a) A first time applicant shall complete and file with the department a “Workers Compensation Self-Insurance Application” form WSCI-1 (2/2016), contained in appendix II if the applicant is a single employer, or a “Workers Compensation Self-Insurance Application-Group” form WSCI-1A (2/2016) contained in appendix II if the applicant is an association or group of employers , together with balance sheet data or the most recent annual report containing such data, payroll data, and an “Annual Financial Statement” form WCSI-11 (3/1975) contained in appendix II .
2. (b) Annually after first receipt of a self-insurance permit, the self – insurer shall complete and file with the department an “Annual Financial Statement” form WCSI-11, a “Report of Outstanding Liabilities” form WCSI-9 (3/1975), contained in appendix II, a “Workers’ Compensation Self-Insurance Questionnaire” form WCSI-16 (9/2015), contained in appendix II, a full report of actuarial analysis and opinion, and the “Actuarial Opinion Summary Sheet” form WCSI-7 (9/2015), contained in appendix II.

Source. #2264, eff 1-6-83; ss by #2935, eff 12-27-84, EXPIRED: 12-27-90 New. #5235, eff 9-27-91, EXPIRED: 9-27-97 New. #6631, INTERIM, eff 11-16-97, EXPIRED: 3-16-98 New. #6806, eff 7-18-98; ss by #8682, INTERIM, eff 7-15-06, EXPIRED: 1-11-07 New. #9019, eff 11-1-07; ss by #11066, eff 4-1-16