Individual Self Insurance Application Checklist {WC-128}

WC-128 - INDIVIDUAL SELF-INSURANCE APPLICATION CHECKLIST. This form is used by the Missouri Division of Workers’ Compensation to guide employers through the process of applying for self-insurance status for workers' compensation coverage. This checklist ensures that applicants submit all required documentation and meet the necessary financial and administrative criteria before being approved to self-insure. The form requires detailed financial records, insurance certificates, claim history, safety programs, and third-party administrator (TPA) agreements. It also includes regulatory documents such as board resolutions and a Guaranty to Satisfy Compensation Claims if applicable. Employers must contact the Division to schedule a meeting to present these materials. www.FormsWorkflow.com