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Self-insured Companies effective Sept. 1, 2021 – Aug. 31, 2022
Cold Spring Granite Company
Federal Express Corporation
Kohl's Department Stores
MidAmerican Energy Company
Monument Health, Inc.
Otter Tail Power Company
Smithfield Foods (Sioux Falls, South Dakota)
Tyson Foods, Inc.
Self-Insurance Application Policy
The self-insurance year commences on Sept. 1 and ends on Aug. 31 of the following year. All current certificates of exemption will expire on Aug. 31, 2021. All employers currently approved to self-insure their workers compensation liabilities are required to submit a renewal application, along with their most recent annual report and the nonrefundable application fee in the amount of $2,250.
If you are currently self-insured, you do not need to resubmit a new security form unless that form of security or amount is being changed.
New applicants must submit their application, security form, $2,250 application fee, and the most recent four years of annual reports.
The Self-Insurance Application and Aggregate Surety Bond are available on our Forms page.
As indicated in the application, every question must contain a response or indication that the question is not applicable. Any application containing questions that have not been responded to may be returned to the applicant for completion. Any delay in the completion of the application may result in a delay in granting approval to self-insure.