North Carolina Department of Insurance, Wayne Goodwin Commissioner
 
Financial Evaluation Division
SPECIAL ENTITIES
 
Individual Self-Insured Workers' Compensation
 
  • Licensing Procedures
    		•
     
    Thank you for your interest in becoming licensed as an individual to self-insure for workers' compensation in the State of North Carolina. Licensing by the North Carolina Department of Insurance is governed by the N.C. Gen. Stat. §97-170.
     
    Forms required for completion and submission for review include:
     
    • An Application to be completed, containing all appropriate attachments and properly signed and notarized by the proper individual(s) representing the applicant employer. (Form No. 10-WC)

    • A Biographical Affidavit(s) to be completed by the appropriate individual(s) and properly signed and notarized. (Form No. 19-WC)

    • A Parental Guaranty is to be completed in its entirety for those applicants that assume the role of a subsidiary to a parent company. The document is to be completed by the appropriate individual(s) and properly signed and notarized. (Form No. 15-WC)

    • A Power of Attorney-Service of Process is to be completed by the appropriate individual(s) and signed and notarized. (Form No. 20-WC)

    • A Power of Attorney-Statutory Deposit is to be completed by the appropriate individual(s) and signed and notarized. (Form No. 12-WC)
    Contact Person E-mail Address Phone Number
    Paul Francis paul.francis@ncdoi.gov 919.807.6628
    Yan Ouyang yan.ouyang@ncdoi.gov 919.807.6627
     
    All forms can be viewed and downloaded from this site.