Kansas > Workers Compensation
Application For Self Insurance K-WC-120 - Kansas
| Application For Self Insurance Form. This is a Kansas form and can be used in Workers Compensation . |
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KANSASDEPARTMENTOFLABOR www.dol.ks.gov K-WC120(Rev.6-12) Page1of11 APPLICATION FOR SELF-INSURANCE ____________________________________________________________ ___________________ ___________________ Applicantorganizationname Dateofapplication Permitnumber herebyappliesfortheprivilegeofbeingaself-insurerundertheKansasWorkersCompensationActandsubmitsthefollowing reportinsupportofsaidapplication. All Questions Must Be Answered - If Not Applicable - put N/A 1. Address of principal office:____________________________________________________________________________ 2. Applicant is: Individual Partnership Corporation PublicAuthority LLC 3. Applicant's general officers, partners or public officials: Name/Title Businessaddress __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 4. Date applicant's business/public authority commenced:________________________________________________________ 5. Person responsible for self-insurance program: _________________________________________________________________________________________________ Name Title Phone __________________________________________________________________________________________________________ Addressofresponsibleperson(if different from item 1 above) 6. Service company information a. Losspreventionservices: (1) Nameofservicecompany_________________________________________________________________________ (2) Addressofservicecompany_______________________________________________________________________ (3) Phone_______________________________________________________________________________________ (4) Contactperson_________________________________________________________________________________ (5) Givedetailsofservicesfurnishedbyservicecompany___________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone(785)296-4000·wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com KansasDepartmentofLabor K-WC120(Rev.6-12) Application for Self-insurance Page2of11 b. Claimshandlingservices: (1) Nameofservicecompany_________________________________________________________________________ (2) Addressofservicecompany_______________________________________________________________________ (3) Phone______________________________________________________________________________________ (4) Contactperson_________________________________________________________________________________ (5) Givedetailsofkindsofservicesthatwillbefurnishedbyservicecompany___________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ IfyouDONOTplantouseanadjustingcompany,pleaseexplainonaseparateattachmenttheplanyouhaveforadjusting claimsforyourcompany.Suchexplanationshouldincludethenameofthepersondirectlyinchargeoftheadjustingactivity. Explainwhatprocedureyouplantofollowinregardtoinvestigatingandadjustingclaimsandwhetherthoseindividuals adjustingclaimswillbeexclusivelyengagedinthatactivity. TheDivisionofWorkersCompensationmayrequiretheuseofanadjustingcompanyifwedonotfeelthatyourin-house adjustingprocedurewouldbeadequatetoservetheinjuredworkers. DOTHEABOVE5.AND6.(a)AND(b)HAVEAWORKINGKNOWLEDGEOFTHEKANSASWORKERSCOMPENSATION ACT? Yes No 7. Safety program a. Personincharge____________________________________________________________________________________ b. Pleasefurnishacopyoftheengineeringreportwhichgivesadescriptionoftherisksoperationsfromrawmaterial receivedtofinishedproductandtheengineer'sevaluationofthesafetyprogram. Ifunavailable,acopyofyoursafetymanualwillbeacceptable.Ifpreviouslyfiled,onlychangesneedtobesubmitted. c. Whenwerepremiseslastinspected?____________________________________________________________________ Inspectingagency__________________________________________________________________________________ 8. Medical and hospital care a. Doyouemployafullorpart-timedoctor? Yes No Name__________________________________________________________________________________________ b. Whereareinjurednormallysent?____________________________________________________________________ c. Doyouhaveahospitalintheplant? Firstaidroom? Yes No Yes No Yes No Professionalnurseonpremises? DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone(785)296-4000·wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com KansasDepartmentofLabor K-WC120(Rev.6-12) Application for Self-insurance Page3of11 9. Loss history (5 years) in State of Kansas (NEW PERMIT APPLICATIONS ONLY) LiabilityPeriod From To Gross Payroll Total Losses Paid Losses Reserves NationalCouncil onCompensation Experience Modification 10. Give the following information regarding the State of Kansas:(If more space is needed, use separate page.) W.C. CodeNo.* Classification* Numberof Employees EstimatedAnnual GrossPayroll Current ManualRates* Manual Premium *Generallyavailablefromyourinsuranceagentorexcesscarrier.UsethecurrentapprovedAssignedRiskRates. Theseratesaremeasurableformanualpremiumdetermination. Totalestimatedannualgrosspayroll:_______________ ____________________ _ TotalnumberofemployeesinKansas:___________________________________ Total estimated manual premium: _____________________________________ 11. For the state of Kansas, indicatetheworkers'estimatedaverageweekly wageatyourcompany(exclude clerical and executive wages): $____________________________________ DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone(785)296-4000·wc
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