Document Tag: Self-Insured Employers Forms & Reports

Self-Insured Consent of the Board of Directors

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Self-Insured Indemnity and Guaranty Agreement

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Self-Insurer’s Compensation Bond

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Self-Insurance Application Supplemental (IC-4006sup)

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Application for Waiver of In-State Check Writing Requirement

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Semi-Annual Premium Tax Form for Self-Insurers (IC-4010)

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Computation Form (IC-4010a)

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IC-211 Instructions

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IC-211 Report of Total Unpaid Liability

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Workers’ Compensation Payment on Medical-Only Claims and Indemnity Payments (IC2-327)

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