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Application For Individual Own Risk Employer Permit (Self Insured Employer Application) SI-Employer - Oklahoma

Application For Individual Own Risk Employer Permit (Self Insured Employer Application) Form. This is a Oklahoma form and can be used in Workers Comp .
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FORM-SI-EMPLOYER OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 (405) 522-3222 or In-State Toll Free (800) 522-8210 APPLICATION FOR INDIVIDUAL OWN RISK EMPLOYER PERMIT Date__________________________________ The undersigned, an employer subject to the provisions of the Administrative Workers' Compensation Act, hereby applies for permission to carry its own risk without insurance. To enable the Workers' Compensation Commission to determine whether or not the applicant possesses sufficient financial ability to render certain the payment of any award made by the Commission, said applicant hereby states the following: 1. 2. 3. 4. 5. 6. 7. 8. Employer's Name______________________________________________________Own Risk #______________ Employer's Federal Identification Number__________________________________________________________ Home Office Address__________________________________________________________________________ Oklahoma principal office address________________________________________________________________ Incorporated or organized under the laws of the State of _______________________________________________ If foreign corporation, give date licensed to do business in Oklahoma_____________________________________ Nature of business_____________________________________________________________________________ General Information on Company: a. b. Years engaged in continuous business______________________, Payroll in each of the preceding three (3) years: Year:_______, $___________________; Year:_______, $___________________; Year:_______, $___________________ Payroll in Oklahoma in each of the preceding three (3) years: Year:_______, $___________________; Year:_______, $___________________; Year:_______, $___________________ c. Number of employees presently employed_______________ In Oklahoma______________ Estimated payroll in Oklahoma for the next twelve (12) months______________________________________ In Oklahoma_______________________ d. Form-SI-Employer, Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 9. Excess Insurance Information, if any at the time of this application: a. b. c. Name of carrier_________________________________________ Policy #___________________________ Policy dates: Effective_____________________________ Expiration _____________________________ Under this policy: Self Insured Retention____________________ Limits of Liability_________________ NOTE: The Commission may require an individual own risk employer to provide proof of excess coverage with such terms and conditions as are commensurate with the employer's ability to pay the benefits required by the Administrative Workers' Compensation Act. 10. 11. a. Estimated manual premium for your company____________________________________________________ In the section below, state the loss history for the past five (5) calendar years. Copy the requested information from your loss runs (if the hard copy of your loss runs are required you will be notified). Also include the current year's history, indicating how many months of the current year are included: Total incurred losses in Oklahoma (include for all injuries, both open and closed claims) CY or FY 2014 mo 2013 2012 2011 2010 2009 $ Medical Paid $ Indemnity Paid $ Total Paid $ Total Reserves Outstanding CY or FY 2014 mo 2013 2012 2011 2010 2009 b. Cases Opened Cases Reopened Cases Closed Death Cases List of Death and Permanent Total Disability (PTD) Claims for all years of self insurance (use separate sheet if necessary): _______________________________________________________________________________ _________________________________________________________________________________________ Total Self Insurance Reserves Outstanding: (for all years of self insurance) Total Self Insured Open Cases: (for all years of self insurance) $_____________________________ c. ________________________________ Form-SI-Employer, Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 12. a. Enclose current audited financial report or financial statement signed by two authorized company executives, including balance sheets, income statements and notes. A governmental entity must provide a definite statement of the amount it has specifically appropriated for workers' compensation claims for the latest and the next fiscal year. Amount appropriated for current fiscal year Next fiscal year (if available) ______________________________ ______________________________ b. 13. a. Is the applicant a subsidiary of another employer? ______ If yes, submit the parent company's financial statements in accordance with Paragraph 12(a) above. Does the applicant have subsidiary companies that it wants to include under this permit?___________________ (Attach a list of the names and addresses of ALL entities to be included under this permit, including subdivisions.) b. c. If you answered yes to either question 13a or 13b, attach a copy of a written agreement whereby the ultimate parent employer guarantees that it will be fully responsible for any liabilities that its subsidiaries may incur under the Administrative Workers' Compensation Act. Name, address and email address of the company's Third-Party Administrator for the servicing of the self insurance claims. _____________________________________________________________________________ _____________________________________________________________________________ 14. a. b. If an approved Third-Party Administrator is not employed, please submit qualifications of benefits administrator. 15. In consideration of the approval of this application, the applicant hereby expressly agrees as follows: a. The applicant's privilege to carry its own risk without insurance may be revoked at any time for good cause by the Workers' Compensation Commission. The applicant agrees to comply with all applicable statutes and the rules of the Workers' Compensation Commission. b. Include an annual, nonrefundable, application fee of $1,000, made payable to the Oklahoma Workers' Compensation Commission. I declare under penalty of perjury that I have examined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Signed this __________ day of _______________________________________, 20________. __________________________________________________ Print Name and Title (note: person signing should be authorized to bind the ap
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