Security Branch
The Security Branch audits the individual self-insured employers’ claim files, monitors their financial strength and determines the surety requirements necessary to secure benefits for the self-insured employers’ workforce.

To request copies of Self-Insurance files or information, please use the form(s) below.
Word PDF - Self Insurance Open Records Request Form
Request for copies/inspection of Self-Insurance files.
* Click the PDF or Word icon to view the form in that format.
Mike Watts, Branch Manager
Phone: 502-782-4510
Fax: 502-564-0916
Email: KYWC.SelfInsurance@ky.gov
Requirements for Becoming Self-Insured
The Security 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.

First
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).

Second
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.

Third
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.

Fourth
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.

Self Insurance Forms
Word PDF - Form SI-01
Self-Insurers' Guarantee Agreement
Word PDF - Form SI-02
Self Insurance Application
Word PDF - Form SI-02 Attachment
Self Insurance Application Attachment
Word PDF - Form SI-03
Continuous Bond
Word PDF - Form SI-03 Attachment
Surity Rider
Word PDF - Form SI-04
Letter of Credit
Word PDF - Form SI-08
Loss Report
Word PDF - Managed Care-UR Form
Managed-Care/Utilization Review
Word PDF - Self Insurance Open Records Request Form
Request for copies/inspection of Self-Insurance files.
Word PDF - Service Contract Agreement
Service Contract Agreement
Word PDF - Workers' Compensation Posting Notice
Workers' Compensation Posting Notice
* Click the PDF or Word icon to view the form in that format.
Reporting Requirements for Individual Self-Insurers
The files listed below 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 - 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.
Guaranty Funds
House Bill 1 (December 1996) established three nonprofit, unincorporated guaranty associations to protect disabled workers and dependents in the event of a self-insured's insolvency. Separate guaranty funds now exist for individual self-insureds, group self-insureds, and coal employer self-insureds. Membership in a guaranty fund is mandatory. These funds are listed below.
KENTUCKY COAL EMPLOYERS' SELF-INSURANCE GUARANTY FUND
P.O. Box 910623
Lexington, KY 40591-0623

KENTUCKY INDIVIDUAL SELF INSURERS GUARANTY FUND
1501 Twilight Trail
Frankfort, KY 40601
Phone: 502-223-5322
Fax: 502-223-4937
Chairperson: Barbara Parker
Secretary: Tom Underwood
Board Roster
Board By Laws

KENTUCKY GROUP SELF-INSURANCE GUARANTY FUND
Groups are now regulated by the Department of Insurance please call 502-564-3630 for more information.