Forms, Publications, and Reports

Statewide Totals

Forms

  • Excess Credit Calculation Form
  • Form A-1 (1-2016)
    Application for a Private Entity Certificate of Consent to Self-Insure
  • Form A-2 (1-2016)
    Application for a Public Agency Certificate of Consent to Self-Insure
  • Form A-3A (1-2016)
    Private/Public Interim Application
  • Form A-3B (1-2016)
    Application for a Permanent Certificate of Consent to Self-Insure by an Interim Self-Insurer
  • Form A-4 (1-2016)
    Guaranty of Workers' Compensation Liabilities
  • Form A4-50
    Application for a Certificate to Administer W/C Claims
  • Form A-5 (1-2016)
    Corporate Resolution Authorizing Application
  • Form A-6 (1-2016)
    Agreement and undertaking for security deposit
  • Form S-1 (1-2016)
    Group master application for certificate of consent to self-insure
  • Form S-2A (1-2016)
    Group affiliate member interim application
  • Form S-2B (1-2016)
    Application for affiliate certificate of consent to self-insure as a member of a group self-insurer
  • Form S-3 (1-2016)
    Corporate resolution
  • Form S-4 (1-2016)
    Indemnity agreement and power of attorney
  • Form S-5 (1-2015)
    Agreement of assumption and guarantee of workers’ compensation liabilities for group and affiliate members
  • Form S-6 (1-2016)
    Agreement and undertaking for security deposit
  • Resolution of Agreement of Parental Assumption and Guarantee
  • Report of Transfer of Records
  • Life tables for men and women: United States 2013
    NOTE: These tables are to be used by qualified administrators when estimating future liabilities in 2018 and will be utilized by OSIP in 2019 to determine if the figures provided on the 2018 Annual Report are accurate.

  • Life tables for men and women: United States 2012
    NOTE: These tables are to be used by qualified administrators when estimating future liabilities in 2017 and will be utilized by OSIP in 2018 to determine if the figures provided on the 2017 Annual Report are accurate.

  • Life tables for men and women: United States 2011
    NOTE: These tables are to be used by qualified administrators when estimating future liabilities in 2016 and will be utilized by OSIP in 2017 to determine if the figures provided on the 2016 Annual Report are accurate.

June 2017