Provide the types of coverage and minimum dollar amounts specified on the. Required Insurance and Minimum Limits sheet (Form Gen.Practitioners sending professional and supplier claims to L.A. Care Health Plan on paper must use Form CMS 1500 in the latest valid version. To access the forms below, you will need Adobe Acrobat Reader. Forms to Complete Online and Print. Download and fill out a Request for Proof of Self-Insurance. Tip: The Request for Proof of Self-Insurance is a fillable PDF. It uses the standard insurance industry form known as the ACORD Form 25 Certificate of Liability Insurance in electronic format.