Arizona > Workers Comp
Initial Application For Authority To Self Insure (Individual) - Arizona
| Initial Application For Authority To Self Insure (Individual) Form. This is a Arizona form and can be used in Workers Comp . |
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STATE OF ARIZONA THE INDUSTRIAL COMMISSION OF ARIZONA Initial Application for Authority to Self-Insure Read Instructions before completing All questions must be answered. If not applicable, use symbol N/A If necessary, attach supplemental sheets Workers' compensation insurance must be maintained until authorization is effective To the Director of the Industrial Commission: The undersigned, an employer, hereby applies for Authorization to Self-Insure the payment of workers' compensation as provided by A.R.S. Section 23-961 of the Workers' Compensation Law of the State of Arizona. The following information is submitted for the purpose of procuring a Resolution of Authorization of The Industrial Commission of Arizona, which may be given upon proof, satisfactory to The Industrial Commission, of ability to self-insure and pay compensation that may become due to employees. 1. Applicant's Legal Name: _____________________________________________ Effective date for authority to self-insure: ____________________ 2. Applicant's mailing address and telephone: Home office: __________________________________________ __________________________________________ __________________________________________ Phone: __________________________________________ Arizona office: ________________________________________ ________________________________________ ________________________________________ Phone: ________________________________________ 3. State under which applicant is incorporated: ______________________________ 4. Name of parent company, if applicant is a subsidiary: __________________________________________________________________ List of Arizona subsidiary companies: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Initial App 1 American LegalNet, Inc. www.USCourtForms.com 5. Name, address and status of partners (general, special and limited), if applicant is a partnership: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 6. Length of time in business in Arizona and elsewhere, if applicable:____________ 7. Type of business in Arizona:___________________________________________ 8. Current payroll for applicant's employees working in Arizona: ______________ 9. Current workers' compensation insurance carrier, policy number and expiration date: _________________________________________________________________ 10. If applicant's application for workers' compensation insurance has ever been rejected or policy of insurance cancelled, state why: _________________________________________________________________ _________________________________________________________________ 11. Listing of states where self-insurance was denied, if any, and where the applicant is currently self-insured: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 12. Arizona claims history for three years preceding application date: Year Medical-Only Claims Indemnity Total Number Claims of Claims Disability under one year Permanent Disability Death ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 13. Arizona loss history and experience modification rates for three years preceding application date: Year Net Premium Medical Only Losses Indemnity Losses Total Losses Experience Modification Rate ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Initial App 2 American LegalNet, Inc. www.USCourtForms.com 14. Name of excess insurance carrier: ___________________________________________________________________ 15. Name address and telephone number of third-party administrator or individual responsible for processing Arizona workers' compensation claims: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 16. Name and address of Arizona agent upon whom legal notices may be served: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 17. Selection of tax plan: Plan A Fixed Premium Plan Plan B Ex-Medical Plan Plan C Guaranteed Cost Plan Plan R Retrospective Rating 18. Name, address, telephone number, facsimile number and e-mail address of person responsible for completing the premium tax information: _________________________________________________________________ ______________________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 19. Name, address, and telephone number of claims office where Arizona workers' compensation claims will be processed: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Initial App 3 American LegalNet, Inc. www.USCourtForms.com 20. Name, address, telephone number, facsimile number and e-mail address of the primary and secondary points of contact (POC) for the application and selfinsurance process: Primary POC: ____________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ _____________________________________________________________
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