Free Untitled Document - Alaska

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

RENEWAL OF CERTIFICATE OF SELF-INSURANCE
All questions must be answered, and requested material submitted. If not applicable, use symbol N/A.

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. Current number of employees in Alaska Company total

5. 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 6. List past 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 7. Description of proposed excess insurance Specific Self-insurance retention Policy limit Specified limitations to excess coverage Aggregate

Name of excess insurance carrier 07-6130 (rev 1/2/99)

8. Name and address of the Alaska employer's adjuster handling claims in the State of Alaska

9. Applicant must provide the following documents with this application for renewal of its Certificate of Self-Insurance · Audited financial statements for the year 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 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. 10. 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 Workers' Compensation Act · That the applicant will discharge liability for compensation to injured employees or their dependents in accordance with 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 07-6130 (rev 1/2/99)