Application for Self-Insured Liability Plans for Providers
Section Ins 17.50, Wis. Adm. Code

Note: The following address is a link to the administrative code in pdf format:

To link to chapters in the administrative code, add insxxx.pdf to the end of the address. xxx represents the chapter number in three digits (003 for chapter 3).

The following materials related to an application for self-insured liability plan for providers under s. Ins 17.50, Wis. Adm. Code, must be completed and returned. Note that 1997 Act 11 modifies the coverage limits for self-insured plans to $1,000,000/occurrence, $3,000,000/policy year.

Application Forms

The application forms are available to be downloaded below. Note, however, that you will need an Adobe Acrobat Reader to view or print the application forms, which you can download at no cost from Adobe .

Application Forms (opens in new window)

Please direct questions to: Steve Caughill, (608) 267-2049,, or (please include your name, phone number, and e-mail address).