Application for Self-Insured Liability Plans

​​Last Updated: November 28, 2016

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

The following address is a link to the administrative code: http://docs.legis.wisconsin.gov/code/admin_code/ins​

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.

Application Forms


Please direct questions to: Amy Malm, (608) 267-9482, amy.malm@wisconsin.gov, or ocifinancial@wisconsin.gov (please include your name, phone number, and e-mail address).​