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No authorization for self-insurance will be approved unless a completed application form has been received. Please completely fill out the WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION FORM.The Delivery Information section below lists various delivery options. Instructions. Please completely fill out the HC-61 HEALTH CARE APPLICATION FOR SELF-INSURANCE AUTHORIZATION FORM. The Division can grant approval to an employer to operate as a self-insured employer if it meets the requirements set forth in the regulations. This form is only available as a downloadable PDF which will be made available to you after you complete your purchase. OFFICE OF SELF-INSURANCE PLANS. This application is for approval to self-insure workers compensation liabilities from September 1, 2022, to August 31, 2023. Application process: Application Filing; Application Form; Insurance; Certificate of Self-Insurance. Workers' Compensation Administrative Regulation regarding