Free Untitled Document - Alaska

STATE OF ALASKA
DIVISION OF WORKERS' COMPENSATION P. O. Box 25512 Juneau, AK 99802-5512

APPLICATION FOR CERTIFICATE OF SELF-INSURANCE
All questions must be answered, and requested material submitted. If not applicable, use symbol N/A. Workers' compensation insurance must be maintained until self-insurance authorization is effective.

1. Legal name of Alaska employer 2. Mailing address of Alaska employer

3. Name and address of person responsible for the self-insured program Name Title Company Name Mailing Address Telephone Number Fax Number 4. Type of business structure of Alaska employer (Check One) ! Corporation ! Partnership ! Joint Venture ! Limited Partnership ! Limited Liability Company ! Limited Liability Partnership ! Municipality or Public Authority ! Other (explain below) 5. If Alaska employer is a wholly owned or majority owned subsidiary, provide the legal name and address of the parent or controlling company

6. If Alaska employer is a joint venture, provide the legal name and address of the person having controlling interest in the venture

7. Provide the Standard Industrial Classification (SIC) Code number that the Alaska employer conducts its affairs under and a brief description of its business activities in Alaska SIC Code Description of business activities in Alaska

8. Alaska employer's federal employer identification number 9. Provide the Alaska employer's Alaska State Business License number and, if applicable, the Alaska Department of Commerce and Economic Development ID number Business License Number Commerce ID Number 10. Date business started in Alaska 11. Current number of employees in Alaska Company total

07-6129 (rev 1/2/99)

12. Is Alaska employer self insured in other jurisdictions? ! Yes ! No If yes, provide Self-insurance retention limits The amount of total incurred losses Amount of loss within retention limit Amount of loss subject to excess coverage Loss amount subject to subrogation If no, provide Name of current Workers' Compensation insurance provider Insurance Policy Number Effective dates From

To

13. Has the Alaska employer ever been denied workers' compensation insurance? If so, state why and when

14. Has the Alaska employer ever been denied an application for self-insurance in another jurisdiction? If so, state why and when

15. List past three years compensation experience in Alaska 19 Number of medical claims Number of indemnity claims Number of fatalities Total incurred losses Paid losses Outstanding loss reserves Annual payroll Annual compensation premium NCCI experience modification rating 16. Description of proposed excess insurance Specific Self-insurance retention Policy limit Specified limitations to excess coverage

19

19

Aggregate

Name of excess insurance carrier 17. Date when self-insurance is desired From To

18. Name and address of the Alaska Employer's proposed adjuster to be located in the State of Alaska

07-6129 (rev 1/2/99)

19. Applicant must provide the following documents with this application for Certificate of SelfInsurance · Audited Financial Statements for the three years preceding the filing of the application. If the employer is a joint venture, financial statements must be submitted for each general partner. · If a wholly owned subsidiary or a joint venture, a written parent company's guarantee of the subsidiaries' liabilities under the Alaska Workers' Compensation Act. · A written detailed outline of the company's loss prevention program. · A binder of the proposed excess insurance coverage. · A list of subsidiaries to be covered under this application, including the names, mailing addresses, and ownership information for each subsidiary. 20. In consideration of the approval of this application, the applicant expressly agrees · To comply with any additional excess insurance coverage stipulated by the Alaska Workers' Compensation Board and/or comply with any security requirements stipulated by the board · That this privilege may be revoked at any time at the discretion of the Alaska Workers' Compensation Board · That the applicant will promptly provide benefits within the time limits specified by the Alaska Worker' Compensation Act · That the applicant will discharge liability for compensation to injured employees or their dependents in accordance with the requirements of the Alaska Workers' Compensation Act · That the applicant or its adjuster will provide annual reports no later that March 1st of each calendar year · That a request for renewal of the employer's Certificate of Self-Insurance will be made annually on a form prescribed by the Alaska Workers' Compensation Board · That the applicant will notify the board within 30 days of any change in conditions which would affect the applicant's ability to administer its self-insurance program, including sale, merger, or other organic changes in ownership interest

(Signature of Authorized Person) (Title of Authorized Person)

State of County of , being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his/her knowledge, information and belief. Sworn to and affirmed this day of ,

(Notary Public) (Notary seal) My commission expires on 07-6129 (rev 1/2/99)