SDCL § 58-20-27: Application for self-insurance association--Form.

An association proposing to self-insure its workers' compensation liability shall apply to the department for the authority to self-insure, using forms available from the department. The application shall include:

(1) The association's name;

(2) The location and mailing address of the association's principal office and where its books and records are kept;

(3) The name and address of each member of the association;

(4) A copy of the bylaws or plan of operation adopted by the association;

(5) Proof of compliance with § 58-20-28;

(6) A sample copy of the agreement between the association and the members securing the payment of each member's workers' compensation liability;

(7) A pro forma financial statement, on a form acceptable to the department, showing the financial ability of the association to pay the workers' compensation liability of its members; and

(8) The required application fee.