Individual Self-Insurer Application {SI-1}

Form SI-1 - INDIVIDUAL SELF-INSURER APPLICATION. This form is used by employers in Arkansas to apply for self-insurance status for workers' compensation. Instead of purchasing workers' compensation insurance from a third-party provider, the employer seeks approval from the Arkansas Workers' Compensation Commission (AWCC) to directly cover the cost of employees' workers' compensation benefits. This form serves as a detailed application demonstrating the employer’s financial stability and ability to meet its obligations under Arkansas workers' compensation laws. Applicants must provide essential business details, including their Federal Employer Identification Number (FEIN), business structure, payroll data, and accident history. Additionally, they must submit a certified, audited financial statement to verify financial viability. The application also requires information on how claims will be managed, specifying whether the employer will administer them internally or contract with an approved third-party administrator. Employers must disclose whether they plan to reinsure any portion of the risk and describe their workplace safety measures and inspections. By submitting the application, the employer agrees to comply with all relevant laws, maintain the required security deposits, and pay any necessary fees or taxes. If the employer is a subsidiary, the parent company must provide a guarantee ensuring full compliance with the Arkansas Workers' Compensation Act. www.FormsWorkflow.com