- Make a Payment
- Complete my Self Insurer's Annual Report
- Get information about self insurance and the requirements to self insure
- Apply to take the Self Insurance Administrator's examination
- Determine if an employer is self insured
- Determine if a person is a self insured administrator
- Self-Insurers' Security Fund
- California Self Insurers' Association
- Self Insurance Institute of America
- California WC & Risk Conference
Self Insured Employers
Information and resources for private self insured employers and firms wishing to become self insured
REQUIREMENTS - Learn more about the requirements to become self insured.
SEARCH for self insured employers using our easy search feature.
SI EMPLOYER FORMS - Below are forms for use that are specific to self insured employers.
- Actuarial Summary
- Form A4-1
Application for a private entity Certificate of Consent to Self Insure
- Form A4-5
Application for a permanent certificate of consent to self insure by an interim self insurer
- Form A4-50
Application for a Certificate to Administer W/C Claims
- Form A4-6 (Rev 11/97)
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.
- Corporate resolution authorizing application
- Resolution of agreement of parental assumption and guarantee
- Request for Interim Certificate