Group Application Checklist {WC-239}

WC-239 - GROUP APPLICATION CHECKLIST. This form is issued by the Missouri Division of Workers’ Compensation to guide associations applying to form a group self-insurance trust. It lists required components, including: a group application plus at least 10 member applications with separate ownership; combined member net worth ≥ $5,000,000; combined EAP ≥ $1,000,000; three-year loss runs; proof of deposit (≥25%); trust/association by-laws; trust/indemnity agreement; excess insurance binder/COI (specific & aggregate, AM Best A- or better); escrow agreement or surety bond (≥$500,000); executed service agreement and TPA license; rosters for trustees/administrators/marketers with contacts; projected expenses ≤30% of actual premiums; rates by class codes; fidelity/employee-dishonesty coverage ≥$1,000,000 and D&O/E&O for key roles; a $500 nonrefundable filing fee; and fiscal year, combined financials, and safety program details. Security is set by the Division (not less than $500,000) with escrow limited to U.S. government obligations in Missouri banks. www.FormsWorkflow.com