Get Self-insurance Application Form (pdf) - Industrial Commission Of ...

Filling out the Self-Insurance Application Form is a vital step for employers seeking authorization to self-insure their workers' compensation. This guide provides clear and structured steps to assist you in completing the form accurately and efficiently online.

Follow the steps to successfully complete your self-insurance application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred viewer.
2. Begin by entering the applicant’s legal name and the effective date for the authority to self-insure.
3. Provide your mailing address along with the home office and Arizona office telephone numbers.
4. Indicate the state under which your application is incorporated.
5. If you are a subsidiary, provide the name of the parent company and list any Arizona subsidiary companies.
6. If applicable, list the names, addresses, and statuses of partners if the applicant is a partnership.
7. State the length of time your business has been operating both in Arizona and elsewhere.
8. Detail the type of business conducted in Arizona.
9. Enter the payroll figures for the past three years for employees working in Arizona.
10. Provide the total employee count for the current and previous three years.
11. List your current workers’ compensation insurance carrier details, including policy number and expiration date.
12. If your application for insurance has ever been rejected or canceled, state the reasons.
13. Detail states where self-insurance was denied and where you are currently self-insured.
14. Summarize your Arizona claims history over the past three years.
15. Provide details of your Arizona loss history and experience modification rates for the last three years.
16. Indicate the name of your excess insurance carrier.
17. Enter the contact details for the third-party administrator responsible for processing workers’ compensation claims.
18. Provide the name and address of the agent to receive legal notices.
19. Select a tax plan that best suits your needs from the available options.
20. Include the contact details of the person responsible for completing the premium tax information.
21. Enter the information regarding the claims office responsible for processing Arizona workers' compensation claims.
22. List the names and contact details of the primary and secondary points of contact for the application.
23. Attest that all information provided is accurate and true by providing the necessary signatures.
24. Review all the sections for completeness and accuracy before saving your changes.
25. Finally, save your changes, download, print, or share the completed form as needed.

Complete your Self-Insurance Application online today to secure your authorization.