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Self-Insured Forms

Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)
Annual Report of Self-Insurer's Payroll (Form 26)
Annual Report of Self-Insurer's Payroll by City, Town or County School Boards (Form 26B)
Application for Individual Self-Insurance (Form 20)
Claim Summary Addendum for 2025 Annual Survey
Detailed Claims Addendum for Claims in Excess of $100000
Letter of Credit
Parental Guarantee (Form 22)
Self-Insurance Bond (Form 21A)

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