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INFORMATION AND MATERIAL WHICH MUST BE SUBMITTED: 1) Completed Form LS-271, Application for Self-Insurance. A complete response to all applicable items is required.The following checklist is to be completed and submitted with the application. Self-Insured Group Application. Learn more about self-insured plans and whether or not they may be right for you. A complete copy of financial statements for each fiscal year is required of all self-insured employers. Application for group self-insured authority is made on form WC-402G. Every company that wants to self-insure must apply to the WCA and receive written approval from the Director. The insurance company processes the claim and pays the bill according to the health plan. The total amount of the annual aggregate limit specified in s.