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This should be in the form of a letter from the insurance carrier(s), showing the loss information for each year, and (4). Instructions. 1. Applicants for permission to self-insure the compulsory automobile insurance requirements should complete this application in full.Self-insured employers can either administer the claims in-house, or subcontract this service to a third party administrator (TPA). Self-insurance for businesses via a captive insurance company. Quick info on how it works. This package should be used for application for Certificate of Authority as a workers' compensation self-insurance fund pursuant to. La. R.S. 91-1200.17. Compensation (individual self-insurance) under the provisions of Miss. The employer employs three or more full-time or part-time employees. If you are not specifically involved in the trucking industry, it is not necessary to complete the Form SI-5 (Truckers Supplemental Application).

South Carolina Application To Create Self-Insurance Fund

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