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Publications & forms

Fiscal Year


Newsline


Rosters


Security deposit


Private self insurers' annual report


Public self insurers' annual report

For joint and non-joint powers authority and members


  • Form A4-1 (acrobat pdf.pdf format, 572K)
    Application for a private entity Certificate of Consent to Self Insure
  • Form A4-2 (Rev 2/92) (acrobat pdf.pdf format, 21K)
    Application for a Pubilc entity Certificate of Consent to Self Insure
  • Form A4-3 (1/94) (acrobat pdf.pdf format, 1,264K)
    Application for a certificate of consent to self insure by a group of employers
  • Form A4-3M (1/94) (acrobat pdf.pdf format, 401K)
    Application for an affiliate certificate of consent to self insure as a member of a group self insurer
  • Form A4-5 (acrobat pdf.pdf format, 431K)
    Application for a permanent certificate of consent to self insure by an interim self insurer
  • Form A4-50 (acrobat pdf.pdf format, 690K)
    Application for a Certificate to Administer W/C Claims
  • Form A4-6 (Rev 11/97) (acrobat pdf.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.
  • Form A4-7 (acrobat pdf.pdf format, 244K)
    Request for Interim Certificate for a Group Member
  • Corporate resolution authorizing application (acrobat pdf.pdf format, 7K)
  • Resolution of agreement of parental assumption and guarantee (acrobat pdf.pdf format, 9K)
  • Request for Interim Certificate (acrobat pdf.pdf format)

  • Life tables for men and women: United States 2009 (.pdf ) New icon
    NOTE: These tables are to be used by qualified administrators when estimating future liabilities in 2014 and will be utilized by OSIP in 2015 to determine if the figures provided on the 2014 Annual Report are accurate.

  • Life tables for men and women: United States 2008 ( .pdf)
    NOTE: These tables are to be used by qualified administrators when estimating future liabilities in 2013 and will be utilized by OSIP in 2014 to determine if the figures provided on the 2013 Annual Report are accurate.