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Financial Evaluation

Financial Evaluation > Special Entities

Individual Self-Insured Workers' Compensation

Licensing Procedures

  • Instructions
  • Forms

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

Jennette King
Jennette.King@ncdoi.gov
919.807.6628

Kimball Andresen
Kimball.Andresen@ncdoi.gov
919.807.6632

All forms can be viewed and downloaded from this site.