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To become an unaffiliated insurance agent, an agent must self-appoint as an unaffiliated agent for the corresponding license type(s). Self-insurers must complete an updated application form sixty days prior to the expiration date of the current certificate.The license itself does not create any authority, actual, apparent or inherent, in the holder to represent or commit an insurance carrier. If an applicant qualifies for self-insurance, the chairman will first issue a notice of conditional approval to the applicant. Items 14 - 33 — Providers may use these instructions to complete this form. This term includes self-insurers. HTMLPDF, 296-15-171, Surety for a self insured pension or fatality claim. Carriers must submit an "Original" application if there has been no previous IRP registration in Florida, and provide various forms of proof. Hereafter in this text, "the Board" or "Board" refers to the Georgia State Board of Workers'. Compensation. For full details on the requirements, see Minnesota.