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Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation

SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION

Division of Labor and Management

123 W. Missouri Ave. Pierre, South Dakota 57501

Tel: 605.773.3681

Fax: 605.773.4211

dlr.sd.gov

APPLICATION TO SELF-INSURE WORKERS' COMPENSATION LIABILITIES

This application is for approval to self-insure workers compensation liabilities from September 1, 2016 to August 31,

2017. If the application is being made after September 1, 2016, the Certificate of Exemption will be valid only from the

date of execution until August 31, 2017. A renewal application will be required for self-insurance during the 2017/2018

year.

This is an application for employers seeking to self-insure workers' compensation in South Dakota. The attached

schedules are to facilitate the submission of proof of solvency and financial ability to compensate under the provision

of the Workers' Compensation Law of South Dakota.

Answer all applicable questions fully. Specifically indicate N/A in any areas not applicable. If you are not completing

this application electronically, please use black ink or type. If any questions are left unanswered, the application may

be returned for completion, causing a delay in approval.

1. STATEMENT OF EMPLOYER IN SUPPORT OF APPLICATION

TO:

State of South Dakota, Department of Labor and Regulation

Division of Labor and Management

123 W. Missouri Ave.

Pierre, South Dakota 57501-2291

Phone: 605.773.3681

The undersigned, having elected to remain under the provisions of the Workers' Compensation Law, hereby agrees to

provide and pay all legal obligations under the Workers' Compensation Law, including but not limited to compensation

for the injuries to employees as required by Title 62 of the South Dakota Codified Laws or as may be awarded by the

South Dakota Department of Labor and Regulation. In making application for exemption from the insurance provisions

of SDCL 62-5-1, the applicant hereby submits evidence of solvency and financial ability to pay compensation and

other obligations contemplated.

(1.1) Name and address, including ZIP + 4 of applicant.

(1.2) Federal Identification Number of applicant.

Rev 2/2017

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Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation