Self-Insurance Forms
- 2012 Self-Insurance Application for New & Renewal Applicants
- 2012 Self-Insurance Guidelines
- Surety Bond Form
- Certificate of Excess Insurance
- Subsidiary Application
- Parental Indemnity Agreement
- Truckers Supplemental Application
To: Indiana Self-Insured Employers
From: Linda Peterson Hamilton, Chairperson
Re: 2012 Applications
Attached are the 2012 guidelines and renewal application for self insuring in the State of Indiana. Please keep in mind that it is extremely important that you answer all of the questions on the application. All of the attachments and additional information requested in item 7 must be provided. Incomplete applications cannot be processed and will not be approved. The completed application should be returned to our office no later than July 31, 2012. Late and incomplete applications are subject to a late fee as described below.
Please note the following regarding the supplemental forms attached to the application.
- Form SI-4 (Indemnity Agreement by the Parent Corporation for Wholly Owned or Majority Subsidiary) should be completed if you are adding or revising any subsidiaries.
- A valid surety bond or other approved security must be on file with the Board at all times. If we already have a bond (on the revised 2003 form) or other approved security, it is not necessary to include another with this application.
- A current SI-3 (Certificate of Excess Insurance) must be on file with the Board at all times. If we already have a current SI-3 on file for your company, it is not necessary to include another with this application.
- If you are not specifically involved in the trucking industry, it is not necessary to complete the Form SI-5 (Truckers Supplemental Application).
Pursuant to IC 22-3-5-1(b), renewal applications must be accompanied by a payment of $250.00. The agency will not accept cash payments. Checks or money orders must be payable to "Worker’s Compensation Supplemental Administrative Fund." Incomplete applications and renewal applications received after July 31, 2012, will be charged an additional $250.00 late fee. Deadline extensions shall be granted only under extraordinary circumstances and at the Board’s discretion.
All renewal applications and enclosures should be sent to the attention of Mary Taivalkoski at the above address. If you have any questions, she can be reached at (317) 232-3811 or via email at mtaivalkoski@wcb.in.gov.
(Revised 2012)
