South Dakota Code § 58-20-27

Application for self
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insurance association--Form.
An association proposing to self
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insure its workers' compensation liability shall apply to the department for the authority to self
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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
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(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.

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