Skip to main content
NC DOI logo NC DOI

Topical Navigation

  • Home
  • Consumers
  • Assistance/Complaints
  • Insurance Industry
  • Licensees
    Licensees
    • Agent and Adjuster Licensing
    • Bail Bondsmen Licensing
    • Captive Insurance
    • Collection Agency Licensing
    • Insurance Company and County Farm Mutual Appointments and Terminations
    • Company Licensing and Registration
    • Continuing Care Retirement Community Licensing
    • Individual Self-Insured Workers' Compensation Licensing
    • Insurance Business Entity Licensing
    • Life and Health Licensing
    • Motor Club Licensing
    • Nonadmitted Domestic Surplus Lines Insurers Licensing
    • Pre-Licensing Education Providers
    • Premium Finance Company Licensing
    • Professional Employer Organizations Licensing
    • Surplus Lines Licensing
    • Third Party Administrator Licensing
    • Viatical Settlement Provider Licensing
    • Home Inspector Licensure Board
    • OSFM Licensees
    • Pharmacy Benefit Manager Licensing
  • Fraud Control
  • OSFM
  • ABOUT
  • NEWS
  • CONTACT
  • CAREERS
  • NC.GOV
NC DOI »   Licensees »   Individual Self-Insured Workers' Compensation Licensing

Individual Self-Insured Workers' Compensation Licensing

ORDER - Extension of Deadlines for Self-Insured Workers' Compensation

  • Order - Extension of Deadlines for Self-Insured Workers' Compensation

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.

Related Content

Listing of Licensed Self-Insured Workers' Compensation

Licensees

  • Agent and Adjuster Licensing
    • Become an Insurance Agent or Adjuster
    • Renew Your Agent or Adjuster License
    • Continuing Education for Agents And Adjusters
      • SBS Report Generator Service
      • CE Providers For Insurance - Licensee Reports to the Department
    • Frequently Asked Questions for Agents and Adjusters
    • Legislative Changes affecting Agent and Adjuster Licensure
    • License Changes
    • Registration Fees for Adjusters
    • Licensee Reports to the Department
    • SBS Connect Print Your Own License
    • DOI Mobile App
  • Bail Bondsmen Licensing
    • Become a Bail Bondsman
    • Renew or Change a Bail Bondsman License
    • Continuing Education for Bail Bondsmen
    • Applications and Forms for Bail Bondsmen
    • Bail Bond Regulation Contacts
    • Bail Bondsman Online Complaint Form
    • Required Bail Bondsmen Reporting to the State
    • SBS Connect Bail Bondsmen Report Generator Service (customized mailing lists)
  • Captive Insurance
  • Collection Agency Licensing
    • Become a Licensed Collection Agency
    • Renew a Collection Agency License
    • Rules and Regulations Regarding Collection Agency Licensure
  • Insurance Company and County Farm Mutual Appointments and Terminations
  • Company Licensing and Registration
  • Continuing Care Retirement Community Licensing
  • Individual Self-Insured Workers' Compensation Licensing
    • Listing of Licensed Self-Insured Workers' Compensation
  • Insurance Business Entity Licensing
    • Obtain an Insurance Business License
    • Licensing Applications and Forms for Business Entities and Agencies
    • Legislation Regarding Insurance Business Entity Licensing
    • Renew or Change an Insurance Business License
    • Licensee Reports to the Department
  • Life and Health Licensing
  • Motor Club Licensing
  • Nonadmitted Domestic Surplus Lines Insurers Licensing
  • Pre-Licensing Education Providers
  • Premium Finance Company Licensing
  • Professional Employer Organizations Licensing
  • Surplus Lines Licensing
  • Third Party Administrator Licensing
  • Viatical Settlement Provider Licensing
  • Home Inspector Licensure Board
  • OSFM Licensees
  • Pharmacy Benefit Manager Licensing

Share this page:

  • Facebook
  • Twitter
  • Email

How can we make this page better for you?

Back to top

Contact Us

North Carolina Department of Insurance

Physical Address:
Albemarle Building
325 N. Salisbury Street
Raleigh NC 27603-5926

Mailing Address:
NC Department of Insurance
1201 Mail Service Center
Raleigh NC 27699-1201

Toll Free 855-408-1212

Agent Services: 919-807-6800

Contact NCDOI
Employee Directory
Careers at NCDOI
Calendar

Recent Tweets

Tweets by @NCInsuranceDept

Follow Us

  • Facebook
  • Twitter
  • YouTube
  • LinkedIn
  • RSS Feeds
  • Accessibility
  • Terms of Use
  • Privacy Policy
  • Open Budget
NC DOI
https://www.ncdoi.gov/licensees/individual-self-insured-workers-compensation-licensing