Provided below is information necessary to license an individual or group entity as a Self-Insurer for Workers' Compensation.  If you have additional questions about this, contact our Alternative Risk unit.

Application Information | Fees | Aggregate Benefits Paid Report Form | Annual Payroll Report Form | Confidential Treatment | Statutory Requirements

Application Information

Individual Self-Insurance

  • Initial Application for Individual Workers’ Compensation Self-Insurance Authority - Word or PDF
  • Workers’ Compensation Individual Self-Insurance Authority Renewal Application - Word or PDF

Group Self-Insurance

  • Initial Application for Group Workers' Compensation Self-Insurance Authority - Word or PDF
  • Group Workers’ Compensation Self-Insurance Authority Application for Renewal - Word or PDF
  • Regulatory Funding Worksheet (RFW) for Group Self-insurers - Excel
  • Application for Establishment of Alternative Reinsurance Account for Self-Insured Groups - Word or PDF

Fees

  • Fee Schedule (24-A M.R.S.A.  601(16) -- (Scroll down to 16)
  • Authorization of Credit Card Payment - Word - PDF

Self-Insured Aggregate Benefits Paid Report Form

Self-Insurer Annual Payroll Report Form

Requesting Confidential Treatment of Documents

Statutory Requirements

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The documents on this page are also available in hard copy by contacting the Bureau.