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Self-Insurer Applicant: Application for workers' disability compensation self-insured authority is made on Form WC-402. Questions 1through 10 must be completed.Application. An employer must complete and submit an Application for registration as a single or group self-insured employer. Small employers that aren't subject to the employer shared responsibility provisions sponsoring self-insured group health plans will use Forms 1094-B and. A complete response to all applicable items is required. The following checklist is to be completed and submitted with the application. Employers should request them from their carrier. Employers may choose to become a member of one of these groups to comply with their statutory obligation to maintain workers' compensation coverage. APPLICATION TO SELF-INSURE. The undersigned, an employer subject to the current and future provisions of the North Carolina.