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Proof of workers' compensation insurance coverage must accompany this form. Notice of intent to deny or terminate self-insured status shall be mailed to the self-insurer.The notice must include the grounds for denial or termination. Servicing company of record for . Self-insured employer. Employer must display the Notice to Employees and the Required Posting addressing rebuttable presumption at all Ohio locations. 5.02: Licensing of Self Insurers. Insurance and Industry Information. Forms. Approved self-insurers are required to pay the state a self-insurance tax at the end of their fiscal year. Public liability insurance and self-insurers.