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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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OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 (405) 522-3222 or In-State Toll Free (855) 291-3612 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. 2. 3. 4. 5. 6. Group Name ______________________________________________________________________________ Desired effective date (application should be submitted 60 days in advance) ___________________________ Group # (if a renewal applicant) _______________________________________________________________ Name of Sponsoring Trade Association, if any ____________________________________________________ Nature of business of members (common interest) ________________________________________________ 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 3 Rev. 09-21-15 American LegalNet, Inc. www.FormsWorkFlow.com 10. Name, address, phone number and e-mail address of Auditor ________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 11. Name, address, phone number and e-mail address of Actuary________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 12. Please include the following items with the application: a. A nonrefundable $1,000 application fee, payable to the Oklahoma Workers' Compensation Commission. b. The following items, bound in a hardcover notebook: 1) A sample of the members' indemnity agreement and power of attorney. 2) The estimated standard and discounted premium each association member will pay during the first/next fiscal year of the association. 3) A listing of the type, amount, and eligibility requirements of discounts available for the association members, including scheduled discounts. 4) Projected expenses for the association for the first/next fiscal year, in dollar amount and a percentage of the standard premium to be generated. 5) Underwriting guidelines that are used by the association. 6) A copy of the association's by-laws and any other governing instruments. 7) A designation of the members' supervisory board and administrator. 8) A copy of the contract(s) between the association and it TPA(s). 9) A copy of all fidelity bonds and errors and omissions policies secured by the association, its administrator, its TPA(s), and other organizations providing services to the association. 10) A copy of all marketing materials used, or to be used, by the association. 11) A list of workers' compensation rates to be charged to its members, broken down by classification code. 12) For new applicants: a) An executed copy of the application of each employer for membership in the association, including: i) The indemnity agreement and power of attorney executed by the employer; ii) The affidavit of acknowledgment of joint and several liability executed by the employer; iii) The employer's current balance sheet. b) A pro forma financial statement of the association, showing the estimated revenues and expenses for the first fiscal year of the association. c) A statement of the collective worth of the members of the association. d) The association's specific and aggregate excess insurance binders for the first fiscal year. e) Properly executed biographical affidavits for the initial supervisory board and administrator. 13) For renewal applicants: a) A copy of the association's current audited financial statements, unaudited midyear statements, and all current actuarial reports. b) An attestation from the administrator or chairman that the collective net worth of the members of the association exceeds Two Million Dollars ($2,000,000.00). c) A copy of the association's specific and aggregate excess insurance binders for the next fiscal year, and copies of the policies for the current year. d) Copies of the minutes of all board meetings held during the current year. e) A list of the premiums paid and losses incurred by each member of the association during the current fiscal year. Form ­ SI Group Page 2 of 3 Rev. 09-21-15 American LegalNet, Inc. www.FormsWorkFlow.com f) 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. g) Confirmation that proof of coverage filings have been made with NCCI. h) A listing of investments currently held by the association. 13. 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. Administrative Workers' Compensation Act, 85A O.S., §6(A)(1)(a): "Any person or entity who makes any material false statement or representatio
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