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Self-Insurance Branch





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Records Request Form

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Below are six files that will assist in meeting the reporting requirements for the 2016 simulated premium calculation and the 2016 security review. 
  • Data Reporting Instructions Data reporting requirements for loss report and simulated premium calculation report.
  • Certification of Submitted Loss Data This certificate must be submitted annually to certify the loss information is accurately reported.
  • Loss Report Enclosure A This is an example of how the loss report should look.
  • Loss Report This is an example of how the loss report should look.  This version will assist in assuring that the claims in litigation status on 12/31/15 are meeting the Department of Workers' Claims (DWC) minimum indemnity reserve requirements.
  • Simulated Premium Calculation Report This file will calculate the simulated premium by entering yearly loss and payroll totals in the proper cells.
  • Payroll Enclosure E This sheet must include quarterly payroll information for each self-insured entity.

If you have any questions contact Mike Watts, Self-Insurance Branch manager, 502-782-4510; fax 502-564-0916.  The Division of Security and Compliance's e-mail address is:

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The Self-Insurance Branch, Division of Security and Compliance, often receives inquiries from employers about the requirements for becoming individually self-insured. This web page has been created to disseminate that information more conveniently.
The applicant or guarantor must have assets in excess of all liabilities of at least $10 million. If this initial requirement is met, the employer may obtain a Self-Insurance Package. This package includes an application (Form SI-02).
Two months prior to the planned date for self-insured status, the employer must submit the completed Form SI-02 along with certified, audited financial statements for the prior three years of operation. DWC will then review the application and statements and will inform the employer of initial approval or denial.
If the application and statements are initially approved, the employer must submit loss data for the past five years. The employer will then be informed of the security requirement.
The employer must submit the following information as applicable:
Security  Prior to being certified as a self-insured employer and continuing thereafter, primary security adequate to secure the employer's workers' compensation liabilities shall be posted pursuant to the provisions found in KRS 342.340 and 803 KAR 25:021 Section 5. The initial security amount will be based upon the average of indemnity and medical losses during the three highest years of the preceding five years, or a minimum of $500,000.

Guarantee Agreement  A parent company must submit a Guarantee Agreement for all subsidiaries that it intends to include under its self-insured program, including the names and addresses of each subsidiary and location. A subsidiary that has separate financial statements may qualify on its own to be self-insured.
Resolution of Board  A corporation must submit its board of directors' resolution, authorizing and directing the corporation to undertake to become self-insured.
Coverage limit  Specific excess insurance must have a minimum coverage limit of $10 million per occurrence.
T.P.A. Service Agreements  If a service organization is used, a statement from the service organization and self-insured employer stating that the contract between the two parties meets the requirements pertaining to claims adjustment.
Starting in 2006, the individual self-insurance certificates will remain in effect until revoked or modified by the Commissioner of the DWC.  In the past, certificates were issued annually.
If you have any questions contact Mike Watts, Self-Insurance Branch manager, 502-782-4510; fax 502-564-0916.  The Division of Security and Compliance's e-mail address is:

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Reporting Requirements for Individual Self-Insurers

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Requirements for Becoming Self-Insured

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Contact Info

Department of Workers' Claims
657 Chamberlin Avenue
Frankfort KY  40601
Phone: (502) 564-5550

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Content Type: Article Page
Version: 21.0
Created at 3/9/2011 10:50 AM by System Account
Last modified at 11/5/2015 3:06 PM by System Account