Application for Self-Insured Liability Plans

​​​​​​​Last Updated: August 13, 2021

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: docs.le​gis.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 ocifinancial@wisconsin.gov. (Include your name, phone number, and email address.)