Self-Insured Employers
Information and resources for private self-insured employers and firms wishing to become self-insured
Private/SIG Self-Insurance by the Numbers – 2021
$143 Billion total self-insured payroll
2.3 Million CA Workers covered by self-insurance
3,315 CA private entities are active self-insurers
$3.9 Billion Estimated Claims Reserves (EFL)
$1.3 Billion Medical and Indemnity payments
80,726 Open Workers' Compensation cases
REQUIREMENTS learn more about the requirements to become self-insured.
SEARCH for self-insured employers using our easy search feature.
Roster of private self-insured employers
Self-Insured Employers Forms
Below are forms for use that are specific to self-insured employers- Actuarial Summary and Study Amendments
- Excess Credit Calculation Form
- Form A-1 (1-2016)
Application for a Private Entity Certificate of Consent to Self-Insure - Form A-2 (1-2016)
Application for a Public Agency Certificate of Consent to Self-Insure - Form A-3A (1-2016)
Private/Public Interim Application - Form A-3B (1-2016)
Application for a Permanent Certificate of Consent to Self-Insure by an Interim Self-Insurer - Form A-4 (1-2016)
Guaranty of Workers' Compensation Liabilities - Form A4-50
Application for a Certificate to Administer W/C Claims - Form A4-100
Application for a Self Insurance Administrator's Examination - Form A-5 (1-2016)
Corporate Resolution Authorizing Application - Form A-6 (1-2016)
Agreement and undertaking for security deposit - Resolution of Agreement of Parental Assumption and Guarantee
September 2021