The Application Process
Here is what is needed for a Self-Insurance application:
Private Standalone Employer Application Checklist
COMPLETE PRIVATE STANDALONE MASTER APPLICATION CHECKLIST:
| Form # | Description | Sealed/Notarized? |
|---|---|---|
| A – 1 | Application for a Private Entity Certificate of Consent to Self-Insure | No |
| A – 4 | Guaranty of Workers’ Compensation Liabilities (If applicant has a parent) | Yes |
| A – 5 | Corporate Resolution Authorizing Application (One time, master only) | No |
| Resolution of Agreement of Parental Assumption and Guarantee (If applicant has a parent) | Yes | |
| A – 6 | Agreement and Undertaking for Security Deposit (Master only) | Yes |
| 3 Years Audited Financial Statements | ||
| California Certificate of Status | ||
$500 Filing Fee Check |
Each subsidiary or affiliate company of a private applicant must file a separate application to become self-insured. They may apply with the parent company or individually.
COMPLETE PRIVATE STANDALONE SUBSIDIARY/AFFILIATE APPLICATION CHECKLIST:
| Form # | Description | Sealed/Notarized? |
|---|---|---|
| A - 3A | Private Interim Application | No |
| A - 3B | Application for a Permanent Certificate of Consent to Self-Insure by an Interim Self-Insurer | No |
| California Certificate of Status | ||
$500 Filing Fee Check |
Per §15203.8, the employer must contact their OSIP analyst within 30 days of a change in name, organizational structure, or business structure. If you do not know your OSIP analyst, please call OSIP headquarters at (916) 464-7000.
Private Group Employer Application Checklist
COMPLETE PRIVATE GROUP MASTER APPLICATION CHECKLIST:
| Form # | Description | Sealed/Notarized? |
|---|---|---|
| S - 1 | Group Master Application for Certificate of Consent to Self-Insure | No |
| S - 3 | Corporate Resolution (One time, master only) | No |
| S - 4 | Indemnity Agreement and Power of Attorney | No |
| S - 5 | Agreement of Assumption and Guarantee of Workers’ Compensation Liabilities for Group and Affiliate Members (One time, master only) | No |
| S - 6 | Agreement and Undertaking for Security Deposit (One time, master only) | No |
| California Certificate of Status | ||
| Feasibility Study | ||
$1,000 Filing Fee Check for Master Certificate. |
COMPLETE PRIVATE GROUP AFFILIATE MEMBER APPLICATION CHECKLIST:
| Form # | Description | Sealed/Notarized? |
|---|---|---|
| Group Affiliate Member Interim Application | No | |
| S-2B (Permanent) | Application for Affiliate Certificate of Consent to Self-Insure as a Member of a Group Self-Insurer | No |
| S - 4 | Indemnity Agreement and Power of Attorney | No |
$500 for Each Member. |
||
Per §15203.8, the employer must contact their OSIP analyst within 30 days of a change in name, organizational structure, or business structure. If you do not know your OSIP analyst, please call OSIP headquarters at (916) 464-7000.
Public/JPA Employer Application Checklist
COMPLETE PUBLIC/JPA MASTER APPLICATION CHECKLIST:
| Form # | Description | Sealed/Notarized? |
|---|---|---|
| A – 2 | Application for a Public Agency Certificate of Consent to Self-Insure | Yes (Page 5) |
COMPLETE JPA MEMBER APPLICATION CHECKLIST:
| Form # | Description | Sealed/Notarized? |
|---|---|---|
| A - 3A | Public Interim Application (Not required if A-2 is complete)* | No |
| A – 2 | Application for a Public Agency Certificate of Consent to Self-Insure | Yes (Page 5) |
*A public interim application (A-3A) is only necessary for immediate coverage when a public permanent application (A-2) is incomplete.
June 2026