Application For Group Self-Insurance {SI-11}

Form SI-11 - APPLICATION FOR GROUP SELF-INSURANCE. This form is used by a group of employers in Arkansas to apply for approval as a group self-insurer under the Arkansas Workers' Compensation Commission (AWCC). This form is necessary for a collective of employers who wish to pool their liabilities and pay workers' compensation benefits directly to their employees, instead of purchasing traditional workers' compensation insurance. The form collects key details about the applying group, including its name, contact information, Federal Employer Identification Number (FEIN), group manager details, estimated number of members, first-year premium, and type of self-insurance status (homogeneous or common). It also requires information about any third-party administrators, loss control service providers, managed care organizations, and excess insurance plans the group may use. By submitting this application, the group agrees to comply with all Arkansas Workers’ Compensation Laws, deposit the required security, obtain necessary excess insurance, pay assessments, and follow all reporting procedures. The form must be notarized and submitted with a $100 application fee. If approved, the group will receive a Certificate of Authority to operate as a self-insured entity. www.FormsWorkflow.com