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WORKERS' COMPENSATION SELF-INSURANCE APPLICATION- GROUP. The undersigned on behalf of a homogenous group of employers intends to pay direct the.INFORMATION AND MATERIAL WHICH MUST BE SUBMITTED: 1) Completed Form LS-271, Application for Self-Insurance. All required information must be submitted with the application form to: OSIP, 11050 Olson Drive. Private Group Application. Self-insurers must complete an updated application form sixty days prior to the expiration date of the current certificate. Superintendent and pay the appropriate application fee. The following examples and information are provided to help employers complete the self-insurance renewal application. Self-Insurer Applicant: Application for workers' disability compensation self-insured authority is made on Form WC-402. Questions 1through 10 must be completed.