Missouri > Workers Comp
Group Application Checklist WC-239 - Missouri
| Group Application Checklist Form. This is a Missouri form and can be used in Workers Comp . |
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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 GROUP APPLICATION CHECKLIST Group application Individual member applications (At least 10 members with separate ownership. Net worth of all members combined, not less than $5,000,000.) financial experience modification rate sheet loss runs (three-year minimum) proof of deposit (25% or more) By-laws of trust By-laws of association Trust/indemnity agreement Combined EAP for group (at least $1,000,000) Combined loss history Excess Binder/COI (AM best rated, A- or better) (specific & aggregate) Escrow agreement/surety bond (not less than $500,000) Executed service agreement copy of TPA license List of board members and their titles include address and phone number List of administrators and marketers include address and phone number Projected expenses (not to exceed 30% of actual premiums collected) Check for $500.00 nonrefundable filing fee Underwriting guideline Safety program visit by safety Fiscal year Combined financial statements Rates by classification codes Fidelity bond/employee dishonesty not less than $1,000,000 trustees plan administrator claims administrator marketers Director's and officer's/errors and omission/professional liability trustees plan administrator claims administrator marketers Security to be determined by the Division but not less than $500,000. Escrow: US Government obligations only. T-bills, notes or bonds deposited in Missouri bank only. Surety Bond: issued by a company AM best rated, A- or better and admitted by the Missouri Department of Insurance to transact such business in the state of Missouri. WC-239 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com
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