Indiana > Workers Compensation > Self-Insurance
Employers Application For Permission To Carry Risk Without Insurance (For New And Renewal Applicants) SI-1 - Indiana
| Employers Application For Permission To Carry Risk Without Insurance (For New And Renewal Applicants) Form. This is a Indiana form and can be used in Self-Insurance Workers Compensation . |
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WORKER'S COMPENSATION BOARD OF INDIANA 402 WEST WASHINGTON STREET, ROOM W196 INDIANAPOLIS, IN 46204-2753 www.in.gov/wcb STATE FORM 18488 9R13/3-990 FORM SI-1 (Revised 2012) Approved by State Board of Accounts WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES ACTS EMPLOYER'S APPLICATION FOR PERMISSION TO CARRY RISK WITHOUT INSURANCE The undersigned, an employer subject to the provisions of the "Indiana Worker's Compensation and Occupational Diseases Acts", hereby applies for a certificate to pay compensation directly, without insurance, to injured employees or to the dependents of employees who die in consequence of illness or injury for the period of September 1, 2012 to midnight, August 31, 2013; and, for the purpose of enabling the Worker's Compensation Board of Indiana to determine whether it possesses sufficient financial ability to render certain the payment of such compensation and medical expenses. This employer, under the penalties of perjury, hereby states the following facts: 1. EMPLOYER INFORMATION __________New Applicant Applicant Name: Address: _____________Renewal Applicant _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Nature of Business: _________________________________________________ _________________________________________________ Website Address: FEIN: _________________________________________________ _________________________________________________ If rated for credit standing by Dunn & Bradstreet, what is the rating? _________________________________________________ If traded publicly, what is the stock symbol? _____________________ American LegalNet, Inc. www.FormsWorkFlow.com 2. EMPLOYMENT INFORMATION/SUBSIDIARY INFORMATION Indiana Location(s) a. b. c. d. e. Kind of Employment # of Employees __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ SUBSIDIARIES INCLUDED UNDER SELF-INSURANCE AUTHORITY FEIN # a. b. c. d. e. 3. TITLE NAME CONTACT INFORMATION __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ LOSS HISTORY Please find two alternative loss history charts. is required to be filled out. Only one chart Under Amount Paid, please provide the total paid for each category during the calendar year, regardless of the date of injury. Under # of Injuries, please provide the number of injuries which occurred during the calendar year that fell within, or resulted in payments in, each category(regardless of when paid). Some injuries will be counted in more than one category. The second alternative only requires you to breakdown number of injuries based on medical and indemnity. If this information is not provided on a calendar year basis, please specify the appropriate dates:_______________ through _______________. American LegalNet, Inc. www.FormsWorkFlow.com 2009 Amount Pd Medical TTD TPD PTD PPI Death Benefits Burial Expenses Settlements First Report of Injury Amputation Prosthetic Device TOTAL # Injuries 2010 Amount Pd # Injuries 2011 Amount Pd # Injuries $ $ $ 4. BOND CALCULATION (a) Determine three-year average of total medical/compensation paid per "Loss History" 2009 Total 2010 Total 2011 Total Three-Year Paid Paid + Paid + Total Paid $____________ $____________ $____________ $____________ divided by 3= $___________ 3yr average (b) Multiply 3 year average by 2 (c) Enter total unpaid compensation liability for fatalities (d) Add lines (b) and (c) (e) Enter greater of $500,000 or line (d) (f) Increase/decrease in line (d) from prior year $____________ $_____________ $____________ $____________ $____________ 5. SECURITY a. SURETY BOND Amount of Bond $ _________________ ($500,000.00 Minimum) Cost of Bond $ __________ (Required) (Annual Premium) American LegalNet, Inc. www.FormsWorkFlow.com Surety Name: _________________________________Telephone:______________ Address: ______________________________________________________________ Bond # blank) __________________________ (Application cannot be processed if b. EXCESS COVERAGE: Specific $______________ Self-Insured Retention $ _____________________ Aggregate $_____________ Cost of Excess $_____________(Required) (Annual Premium) c. Does the employer have a system to establish a reserve to pay claims for medical treatment or compensation? ________________________________ d. List other states, if any, in which the employer is self-insured _______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. SELF-INSURANCE ADMINISTRATION It is the obligation of the employer to timely advise the Board of any changes in the information provided below which occur during the self-insured period. Please note that the Board now sends all notices related to Self-Insurance via email. (a) Identify the person within the employer's organization who is primarily responsible for the self-insurance program. This person will receive all notices as it relates to the self-insurance program, please list an alternative if you would like two individuals to receive notices: Name: E-Mail: Address: Telephone: Fax: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Alternative: Name: E-Mail: Address: Telephone: Fax: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ (b) Identify the person who is primarily responsible for the adjustment of Indiana employee claims made pursuant of the self-insurance program (within your company or at your third-party administrator): Na
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