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Self-insurers must complete an updated application form sixty days prior to the expiration date of the current certificate. A private employer who is approved for a certificate of authority to selfinsure is called a certified selfinsurer (CSI).This document is a synopsis of the requirements to become authorized to self-insure workers' compensation liabilities in Minnesota. Information for entities which wish to self-insure for auto or workers' compensation, or establish a self-insurance group. Organizational documents and information: 1. YOUR COMPLETED PACKAGE FOR SELF-INSURANCE SHOULD INCLUDE THE FOLLOWING: • Completed Form MV-219, "Application for Certificate of Self-Insurance". Form DP-2, item 6(c), should then be marked "No". For information on the earnings requirements, see the enclosed New Jersey Private Plan. Qualification for self-insured status: •. Application (Form 10-WC) must be completed in its entirety, either typed or written in ink.