Self-Insurance Groups

Private Group Master Employer Self-Insurance Entry Prerequisites

Current regulatory financial requirements for an organization wanting entry into self-insurance are:

CCR § 15484(e) requires that each group self‐insurer needs to have enough income from group members to annually fund the following:

1. 1.5 times the group self‐insurer's three‐year average total benefits paid as reported on their most recent Self‐Insurer's Annual Report;
2. The expected administrative expenses needed for the group self‐insurer's daily operations during the current calendar year;
3. The continued posting of the required security deposit; and
4. Any additional amount determined by the Chief to ensure adequate funding of the group self‐insurer.

Private Group Self-Insurance Application Process

Here is what is needed for a private employer Self-Insurance application:

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 MEMBER APPLICATION CHECKLIST:

Form #	Description	Sealed/Notarized?
S-2A (Interim)	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.

Private Group Self-Insurance Yearly Maintenance

Here are the yearly requirements needed to maintain Self-Insured status. The table below shows what is due, the due date, and how to submit.

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.

What is Due	Due Date	How to Submit
Annual Report	March 1	https://efiling.dir.ca.gov/OSIPO/
Unaudited Financial Statements	March 1	https://efiling.dir.ca.gov/OSIPO/
The budget for the current year together with: The rates of contribution from members in effect for the current year. Any deviation from these rates. All actuarial reports and other documents supporting the rates of contribution. All minutes of board of trustees meetings or other evidence of board of trustee’s action where rates of contributions from members were discussed or approved.	March 1	Send to OSIP via mail or email your OSIP analyst. If you do not know your OSIP analyst, please call OSIP headquarters at (916) 464-7000.
Actuarial Study & Summary	April 15	https://efiling.dir.ca.gov/OSIPO/
Audited Financial Statements	July 1	https://efiling.dir.ca.gov/OSIPO/
Security Deposit	30 Days From Notice of Security Deposit Demand Letter (July 1)	You may post a surety bond, letter of credit, cash, securities, or any combination of these.
License Assessment Fee	December 31	Mail Check to OSIP or Use EFT Payment