Self-Insurance Application Checklist

SELF-INSURANCE APPLICATION CHECKLIST. This form specifies the documents required for employers applying to self-insure their workers’ compensation obligations through the Louisiana Workforce Commission (LWC), Office of Workers’ Compensation Administration. Applicants must submit a current certificate of insurance from their carrier verifying active workers’ compensation coverage and compliance with state law. Three years of audited financial statements showing assets, liabilities, and stockholder equity are required, along with three years of workers’ compensation loss runs as outlined in Section 1711(B) and (C). A $100 application fee payable to the LWC must accompany the submission. Employers must identify their third-party administrator (TPA) and provide a full copy of the service contract prior to approval. Those not using a TPA must include resumes for in-house claims personnel, safety staff, and a copy of their safety manual. A certificate showing excess coverage with the self-insured retention (SIR) amount clearly stated is required, along with a sample excess policy. The company must also list its designated self-insurance contact and phone number. Once reviewed, the LWC will advise the applicant of any security amount required under Section 1725(A)(1). www.FormsWorkflow.com