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Form SI-11

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Form SI-11

Rev. 8/01/2006

Ark. Code Ann.

§11-9-404 &

AWCC Rule 099.05

ARKANSAS WORKERS' COMPENSATION COMMISSION

SELF-INSURANCE DIVISION

324 Spring Street, Little Rock, AR 72201

Mail: P. O. Box 950, Little Rock, AR 72203-0950

501-682-2783 / 1-800-622-4472

SI-11

APPLICATION FOR GROUP SELF-INSURANCE

To the Arkansas Workers' Compensation Commission:

The undersigned, a duly authorized representative of a group of employers subject to the provisions of the Arkansas workers' compensation laws and organized under the laws of the State of Arkansas for the purpose of qualifying as a group self-insurer, certifies that such employers have duly entered into agreements to pool their liabilities in accordance with Ark. Code Ann. §11-9-404(a)(3) and the applicable rules for group self-insurers and that such agreement is attached hereto and does make application for approval of the establishment of a group self-insurer to pay compensation benefits directly to the employees of the such employer members.

1. Name of the Group Self-Insurer:

2. Mailing address of the principal office:

3. Physical address of the principal office:

4. Telephone No.:

Fax No.:

Toll-free No.

5. Federal Employer Identification Number (FEIN):

6. Name and address of the individual who will serve as the Group Manager:

Telephone No.:

Fax No.:

Toll-free No.:

Email:

7. Desired effective date of the group:

8. Estimated number of first year members:

9. Estimated amount of first year premium:

10. Type of group self-insurer status desired:

If the application is for homogeneous self-insurance, what is the same type of business activity or pursuit?

If the application is for common self-insurance, what is the trade or professional association of which the applying employers are members?

Give the organization date of the trade or professional association.

NOTICE: ITEMS 11-15 BELOW ARE CONFIDENTIAL INFORMATION

11. Name, address, and telephone numbers of the third party administrator with which the group members have contracted to service their workers' compensation program? (Note: This third party administrator must be a company approved by the Commission to handle self-insured clients):

Telephone No.:

Fax No.:

Toll-free No.

12. If no third party administrator is used, then proof of adequate servicing is to be attached in accordance with the rules.

13. Name, address, and telephone numbers for the company which will provide loss control services:

Telephone No.:

Fax No.:

Toll-free No.

14. Name, address, and telephone numbers of the managed care organization with which the group members have contracted (if any):

Telephone No.:

Fax No.:

Toll-free No.:

15. Do you plan to carry excess insurance?

If yes, between what limits? Retention $ to $

Aggregate?

In consideration of the approval of this application, the applicant hereby agrees to the following:

A. The applicant, on behalf of its members, will fully meet and comply with all obligations imposed by the provisions of the Arkansas Workers' Compensation Laws, Rules, and Regulations of the Commission.

B. The applicant will deposit with the Commission an acceptable security deposit in an amount prescribed by the Commission; will furnish excess insurance as prescribed; will pay tax assessments as prescribed; will comply with all reporting procedures as prescribed; will furnish necessary fiduciary bonds as prescribed; will accept as future members of the Group only financially sound employers, and employers who qualify in accordance with Ark. Code Ann. §11-9-404(3); and will submit an application remittance in the amount of $100.00, payable to the Arkansas Workers' Compensation Commission.

Therefore, we respectfully request that authority be granted to our named Group for the privilege of receiving a Certificate of Authority to act as a Self-Insurer under the Arkansas workers' compensation laws.

By

State of Arkansas

County of

Subscribed and sworn to before me by

on this day of 2

My Commission expires

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What Form SI-11 Is and when it’s used

Form SI-11 is a standardized U.S. administrative form used to document authorizations, disclosures, or status information required by public agencies and regulated organizations. It collects identifying details, declarative statements, dates, and signature blocks so parties and authorities have a clear, auditable record. Depending on the issuing agency and state law, Form SI-11 may require notarization, witness attestations, or additional attachments such as supporting documentation or exhibits. Although not a federal tax return, the form must be retained under applicable recordkeeping rules and can be executed electronically where ESIGN and UETA permit.

Why completing Form SI-11 correctly matters

Use Form SI-11 to create a consistent, auditable record of authorization or status that satisfies agency requirements and supports downstream compliance. Proper completion reduces processing delays, minimizes inquiry risk, and provides clear evidence for audits or legal review.

Why completing Form SI-11 correctly matters

Who typically prepares and signs Form SI-11

Typical users include agency staff, compliance officers, legal counsel, and administrative coordinators responsible for authorizations and recordkeeping.

  • Government agencies and local offices handling permits, registrations, or certifications.
  • Healthcare administrators when the form collects patient authorizations or consent.
  • Legal and corporate compliance teams for recordkeeping, audits, and regulatory submissions.

Step-by-step: filling out Form SI-11

Follow these sequential steps to complete Form SI-11 accurately and ensure required attachments and signatures are included.

  • 01
    Prepare: Gather IDs, supporting documents, and agency instructions.
  • 02
    Complete Details: Enter legal names, addresses, and effective dates in MM/DD/YYYY.
  • 03
    Review: Verify accuracy, cross-check attachments, and correct typos.
  • 04
    Sign & Submit: Sign dated signatures; notarize or witness if required by jurisdiction.

Frequently asked questions about Form SI-11

Answers to frequent questions about completing, signing, submitting, and retaining Form SI-11, including digital execution and common validation issues.


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Core elements to include on a professional Form SI-11

Essential elements of a professional Form SI-11 include clear party identification, statutory language, signature blocks, supporting exhibits, execution instructions, and a retention notice.

Parties

List all parties' full legal names and contact details, including mailing address and business identifiers. Use consistent names to match identification documents and corporate registrations to avoid verification delays.

Effective Date

Include the effective date in MM/DD/YYYY format and clarify whether retroactive or contingent conditions apply. The effective date governs obligations and triggers time-sensitive compliance duties.

Declarations

Provide required declarative statements, checkboxes, and attestations verbatim as mandated by the issuing agency. Alterations can render the form noncompliant and result in immediate rejection.

Signature Block

Designate signature lines for each party with printed name, title, date, and witness or notarization fields when required. Specify whether initials suffice for multi-page forms.

Attachments

List and attach any supporting documents required by the agency, such as exhibits, proofs of identity, or prior filings. Use clear filenames and a cover sheet describing each attachment.

Retention Notice

Include a retention clause stating how long parties will retain the executed form and where records will be stored. Cite applicable federal retention rules when relevant.

Security and compliance controls to consider

Encryption: TLS 1.2/1.3 in transit, AES-256 at rest
Access Controls: Role-based access and MFA
Audit Trail: Immutable timestamps, IP, action log
HIPAA: BAA available for covered entities
21 CFR Part 11: Supports electronic records and signatures
Legal Frameworks: ESIGN and UETA compliance

Main risks and penalties from incorrect SI-11 filings

Processing Delays: Missing data causes slow processing
Rejection: Form may be rejected outright
Backup Withholding: Incorrect TIN triggers 24% withholding
Civil Penalties: Statutory fines may apply
Contract Risk: Invalid authorization may void actions
Notarization Failure: Missing notary invalidates form

Common preparation errors to avoid

  • Incomplete fields, such as missing dates or signatures, cause returns or administrative rejection and require resubmission that delays processing and adds administrative cost.
  • Using inconsistent party names across documents leads to verification failures; match names to government IDs and corporate filings to avoid mismatches and required corrections.
  • Uploading low-resolution or improperly formatted attachments prevents reviewers from confirming identity or supporting facts and can lead to request for certified paper copies.
  • Failing to confirm electronic consent or consumer disclosure when required under ESIGN can invalidate electronic execution for consumer-facing transactions.

Typical digital submission and e-signing workflow

Below is a concise overview of the online submission and e-signing workflow for Form SI-11.

  • Upload: Sender uploads the completed PDF or DOCX.
  • Prepare Fields: Place signature, date, and conditional fields.
  • Authenticate: Signer verifies identity via email, SMS, or KBA.
  • Finalize: Platform records audit trail and delivers final PDF.

Configuring the digital workflow for Form SI-11

Configure the digital workflow to match approval order, authentication strength, and required attachments before sending Form SI-11 for signature.

Field Configuration
Signing Order Sequential or parallel signing order per agency instructions
Authentication Email link, SMS code, or KBA as required
Attachments Require mandatory PDFs, set file type and size limits
Retention Enable copy retention and exportable audit trail

Platform capabilities to check before submitting SI-11

Ensure your signing platform supports required file formats, authentication, and retention policies for legal compliance.

  • File Formats: PDF, DOCX, and HTML supported
  • Integrations: Salesforce, NetSuite, Google Workspace, others
  • Authentication: Email, SMS, SSO, KBA options

Timelines and typical processing expectations

Key timelines for completing and submitting Form SI-11 depend on agency requests, internal deadlines, and any statutory filing windows.

Upon Request:

Provide SI-11 within 30 days of agency request unless otherwise specified.

Processing Time Expectation:

Agency review typically completes within 7–30 business days depending on complexity.

Notary Scheduling:

Allow an additional 1–5 business days for notarization or RON sessions.

Retention Start:

Retention period begins on effective date or filing date as applicable.

Correction Window:

Submit corrections promptly; missing corrections after agency deadline may be rejected.

Key milestones from preparation to archival

Milestone timeline for Form SI-11 processing from preparation through archival, useful for tracking internal approvals and agency responses.

01

Preparation

Gather IDs, attachments, and complete all fields before routing for signatures.

02

Submission & Signing

Send to signers with specified authentication and collect signatures electronically or in person.

03

Agency Review

Agency examines form and attachments; may request clarifications or additional documents.

04

Closure & Retention

Record final disposition, archive executed copies, and begin statutory retention countdown.

Comparing common eSignature vendors for Form SI-11 workflows

Comparing common eSignature vendors and basic plan features to support Form SI-11 workflows and compliance needs.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Varies by vendor and plan; verify Varies by vendor and plan; verify Varies by vendor and plan; verify Varies by vendor and plan; verify
Bulk Send Available (Business Premium) Available (limits may apply, 100 env/year) Available Available No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Representative roles that interact with Form SI-11

Agency Official

An assigned agency official or administrator completes and reviews Form SI-11 to verify compliance with statutory requirements. They must confirm document completeness, validate supporting evidence, and certify acceptance per internal procedures. Officials should retain records and produce them in audit or compliance reviews.

Authorized Signer

An authorized signer is an individual with legal authority to bind a party, such as a corporate officer or appointed agent. Provide printed name, title, and attach evidence of authority when requested by the receiving agency to prevent disputes.

Example scenarios showing Form SI-11 in practice

Real-world examples show how Form SI-11 supports administrative workflows in compliance, healthcare, and property contexts.

County Licensing Office

A county licensing office converted paper authorizations to Form SI-11 templates to streamline permitting and improve audit readiness.

  • Reduced manual follow-ups by staff.
  • Standardized fields and digital execution cut processing time, reduced lost paperwork incidents, and made it easier to produce the executed record for state audits while ensuring consistent retention and retrieval across departments.

Community Health Clinic

A clinic used Form SI-11 for patient authorizations and attachments, integrating electronic signatures within HIPAA-compliant workflows.

  • Ensured consent tracking and auditability.
  • By adding consent language and a BAA with the e-sign provider, the clinic retained complete audit trails, met HIPAA six-year retention rules, and reduced in-person signing burden for patients.

Practical tips for accurate and efficient completion

Practical tips to reduce errors, speed processing, and ensure legal validity when preparing and signing Form SI-11.

Use consistent legal entity names across documents
Always match names to government IDs and corporate records. Discrepancies trigger verification delays, rejection, or backup withholding for tax-related attachments. Confirm with all signers before finalizing to avoid costly rework and administrative penalties.
Verify taxpayer identifiers and TINs
Validate TINs or EINs against payer records and request corrected W-9s when necessary. Incorrect TINs may cause 24% backup withholding and IRS penalty exposure under IRC §6721 for faulty information returns.
Confirm notarization requirements and witness counts per state
Before signing, verify whether the agency or state requires notarization, witness signatures, or RON. If notarization is needed, schedule in advance and include audio-video recording retention for RON, per state rules.
Maintain audit-ready, searchable records with exportable audit trails
Store executed forms with an immutable audit trail including timestamps, IP addresses, and signer authentication records. Ensure exported copies are human-readable and retained according to federal and state retention schedules for potential audits.

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