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To comply with the renewal application requirements, please submit the documents listed below: 1. Renewal Application, see attached form;. 2.Coverages: THIS lS TO CERTIFV THAT THE STATE OF TENNESSEE SELF-INSURES ITS EXPOSURE lN GENERAT LlABltlTY, AUTOMOBILE tlABlLITY,. PROFE5SIONAI. To be authorized to self-insure, you must submit a completed. A private employer who is approved for a certificate of authority to selfinsure is called a certified selfinsurer (CSI). Proof of insurance for all system vehicles; Research awards sub-grants; Professional Services Agreements. 00 fee per self-insurance certificate issued. Self-Insurance Annual Permit Renewal. PRIVATE SELF-INSURING EMPLOYER; ANNUAL RENEWAL OR DEPOSIT OF NEW SECURITY FOR PAYMENT OF COMPENSATION. 79A. 05, REVOCATION OF CERTIFICATE TO SELF-INSURE. 79A.