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Application For Group Self Insurance Association Permit Form-SI-Group - Oklahoma

Application For Group Self Insurance Association Permit Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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FORM-SI-GROUP 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 GROUP SELF INSURANCE ASSOCIATION PERMIT Date:_____________________ The undersigned, a group of employers subject to the provisions of the Administrative Workers' Compensation Act, hereby applies for permission to act as a group self insurance association. To enable the Workers' Compensation Commission to determine the applicant's ability to pay compensation to its employees, said applicant hereby states the following: 1. Group Name_______________________________________________________________________________ 2. Desired effective date (application should be submitted 60 days in advance)_____________________________ 3. Group # (if a renewal applicant)________________________________________________________________ 4. Name of Sponsoring Trade Association, if any_____________________________________________________ 5. Nature of business of members (common interest)__________________________________________________ 6. Name, address, phone number & e-mail address of Administrator______________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 7. Name, address, phone number & e-mail address of Chairman__________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 8. Name, address, phone number & e-mail address of Third Party Administrator for claims:____________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. Name, address, phone number & e-mail address of Third Party Administrator for other functions (accounting, marketing, etc.) ________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Form-SI Group, Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 10. Name, address, phone number & e-mail address of Auditor__________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 11. Name, address, phone number & e-mail address of Actuary__________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 12. A nonrefundable $1,000 application fee, made payable to the Oklahoma Workers' Compensation Commission, must be submitted with the application. 13. Please include the following items, bound in a hardcover notebook: a. b. A sample of the members' indemnity agreement and power of attorney. An executed copy of the application of each employer for membership in the association (new applicants only). A pro forma financial statement of the association, showing the estimated revenues and expenses for the first fiscal year of the association (new applicants only). A copy of the association's current audited financial statements, unaudited midyear statements, and all current actuarial reports (renewal applicants only). An attestation from the administrator or chairman that the collective net worth of the members of the association exceeds Two Million Dollars ($2,000,000). The estimated standard and discounted premium each association member will pay during the first/next fiscal year of the association. A listing of the type, amount and eligibility requirements of discounts available for the association members, including scheduled discounts. Projected expenses for the association for the first/next fiscal year, in dollar amount and a percentage of the standard premium to be generated. Specific and aggregate excess insurance binders for the first fiscal year (new applicants only). Specific and aggregate excess insurance binders for the next fiscal year, and copies of the policies for the current year (renewal applicants only). Underwriting guidelines that are used by the association. A copy of the association's by-laws and any other governing instruments. A designation of the members' supervisory board, and a copy of properly executed biographical affidavits for each. A copy of the contract(s) between the association and its TPA(s). A copy of all marketing materials utilized by the association. c. d. e. f. g. h. i. j. k. l. m. n. o. Form-SI Group, Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com p. A copy of all fidelity bonds and errors and omissions policies secured by the association, its administrator, its TPA, and other organizations providing services. A list of workers' compensation rates to be charged to its members, broken down by classification code. Copies of the minutes of all board meetings held during the current year (renewal applicants only). A report of the premiums paid and losses incurred by each member of the association during the current fiscal year (renewal applicants only). Affidavit from the chairman that the association is and has been in full compliance with the rules of the Commission during the current fiscal year (renewal applicants only). Confirmation of proof of coverage filings made with the NCCI (renewal applicants only). A listing of investments currently held by the association (renewal applicants only). q. r. s. t. u. v. In consideration of the approval of this application, the applicant hereby expressly agrees to comply with all applicable statutes, and with the Rules of the 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 & Ti
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