Individual Self-Insured Workers' Compensation Licensing

Instructions

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:

• 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)
• Biographical Affidavit- to be completed by the appropriate individual(s) and properly signed and notarized. (Form No. 19-WC)
• Parental Guaranty- 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)
• Power of Attorney - Service of Process- to be completed by the appropriate individual(s) and signed and notarized. (Form No. 20-WC)
• Power of Attorney - Securities- to be completed by the appropriate individual(s) and signed and notarized. (Form No. 12-WC)

Contact Person

Nancy Wise
Nancy.Wise@ncdoi.gov
919-807-6178

Mike McKinney
Mike.McKinney@ncdoi.gov
919-807-6628

All forms can be viewed and downloaded from this site.