Department of Labor and Industry

Active/New Carrier Information

Active/New Carrier

Workers' Compensation Self-Insurance Application

Introduction: This section is intended for employers who are currently self-insuring their workers' compensation liabilities in Montana or for employers who desire to apply to be self-insured in Montana. 

New Since 2001: the self-insurance applications are available in either (1) Microsoft Excel format or (2) Adobe PDF format. These two versions can be found on the internet at the links in the left menu:

(1) The Microsoft Excel Version. Please fill in your application information in the colored cells of the Microsoft Excel form. The totals on page 2 of the application are calculated automatically (accidents by year, claims by year, three-year average, unpaid liability, and cash pay-outs). Dates should be entered as mm/dd/yyyy (month, day, year). You may send the application via email to speed up the application process, but we will still need a hard copy of the application that includes your signature.

(2) The Adobe PDF application version has been designed for you to print out on your local printer, so you can then fill in the appropriate information by typewriter or pen.

The instructions for completing the application are in Microsoft Word.

We will still mail out your renewal application packet 30 days before the due date.

These changes and improvements are intended to provide better customer service. We welcome your comments and suggestions.

Application

Instructions

Self-Insurance Application (MS Excel)

Self-Insurance Application (pdf)

Contact Information

Erin Weisgerber
Program Manager for Self-Insurance
(406) 444-1555
EWeisgerber@mt.gov