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Employer-sponsored, self-insured health plan must complete. Self-insured group health plans will use Forms 1094-B and.B to report information about covered individuals. A complete response to all applicable items is required. The following checklist is to be completed and submitted with the application. Self-Insurer Applicant: Application for workers' disability compensation self-insured authority is made on Form WC-402. Questions 1through 10 must be completed. APPLICATION FOR SELF-INSURANCE CERTIFICATE. Please completely fill out the WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION FORM. The Delivery Information section below lists various delivery options.