Alaska > Workers Comp
Application For Certificate Of Self Insurance 07-6129 - Alaska
| Application For Certificate Of Self Insurance Form. This is a Alaska form and can be used in Workers Comp . |
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INSTRUCTIONS FOR QUALIFYING AS A SELF-INSURED EMPLOYER IN ALASKA REQUIREMENTS8 AAC 46.010 provides that a person may self-insure their workers compensation liability under the Alaska Workers' Compensation Act (Act) if it has (1) the financial ability to meet the self-insured's financial obligations in Alaska; (2) available claims facilities through its own staffed adjusting facilities located within this state or through independent, licensed, resident adjusters with power to effect settlement within this state. For purposes of this paragraph, insurance companies with a certificate of authority from the division of insurance, Department of Commerce and Economic Development, and with staff adjusters in this state, are considered independent, licensed, resident adjusters; (3) been in business within Alaska for at least five years immediately preceding the filing of the application for self-insurance; (4) a safety/loss control program; (5) in combination with its parent company or subsidiary companies, a minimum of 100 employees either in Alaska or in another state or states; and (6) a tangible net worth of at least $10,000,000. The board will, in its discretion, waive the requirement in (3) of this section (1) if the employer has self-insured its workers' compensation obligations in another jurisdiction for a period of at least five years immediately preceding the filing of the application; or (2) if the employer is a wholly-owned subsidiary and its parent company has been in business for at least five years immediately preceding filing and guarantees the subsidiary's obligations under the Act. FILING REQUIREMENTSAn application for a Certificate of Self Insurance must be made on form 07-6129. An applicant that has multiple subsidiaries must list each subsidiary to be covered under the certificate of self-insurance, including the legal name, mailing address, federal identification number, and ownership information for each subsidiary. An applicant that is a wholly owned subsidiary of another company, must submit a parent company guarantee of the applicant's obligations under the Act. If the applicant is a joint venture, the partner with the majority interest in the venture must be selfinsured in Alaska, or qualified to be self-insured in this state. The joint venture application must include financial information for each partner in the venture, and the application must be accompanied by a copy of the joint venture's operating agreement. The application must be accompanied by the applicant's audited financial statements for the three fiscal or calendar years immediately preceding the filing of the application. The applicant may submit consolidated financial statements of its parent company if the applicant does not have its own audited financial statements and the employer is a majority or wholly-owned subsidiary. A public entity must submit audited comprehensive annual financial reports, including detailed schedules. The applicant shall provide a summary of the employer's or the employer's parent company payroll and loss runs for the three fiscal years or calendar years preceding the filing of the application. The summary must be categorized by year, and include the number of employees, amount of payroll, number of medical-only claims, number of indemnity claims, number of fatalities, the dollar amount of total incurred losses, the dollar amount of paid losses, the dollar amount of reserves for incurred but unpaid losses, the dollar amount of losses within the retention limit, the dollar amount of losses subject to reinsurance or excess recovery, and the dollar amount of losses subject to subrogation recovery. 07-6129 (rev 8/2/10) American LegalNet, Inc. www.FormsWorkFlow.com The applicant shall submit a description of its proposed excess insurance coverage, including effective dates, type of coverage, conditions and exclusions, with specific and aggregate retentions and policy limits. Excess coverage must be written by a casualty insurance company or reinsurance company authorized to transact business in Alaska, and must be rated A- or higher with a stable outlook by a nationally recognized rating organization. The application for self-insurance must be accompanied by a security deposit in the form of an irrevocable letter of credit from a financial institution authorized to conduct business in Alaska under AS 06.01.010-06.40.190, with the State of Alaska, Department of Labor and Workforce Development listed as the beneficiary. The amount of the security deposit must be in the amount of $600,000 or 125% of the total outstanding accrued self-insured workers' compensation liabilities for the year immediately preceding the application, whichever amount is greater. The applicant shall submit with the application a detailed synopsis of its safety/loss control program. The above material shall be mailed to the Division of Workers' Compensation at least 90 days prior to the desired effective date of self-insurance. 07-6129 (rev 8/2/10) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ALASKA DIVISION OF WORKERS COMPENSATION P.O. Box 115512 Juneau, AK 99811-5512 APPLICATION FOR CERTIFICATE OF SELF-INSURANCE All questions must be answered, and requested material submitted. If not applicable, use symbol N/A. Workers compensation insurance must be maintained until self insurance authorization is effective. 1. Legal name of the Alaskan employer 2. Mailing address of the Alaskan employer 3. Name and address of the individual responsible for the employer's self-insured program Name Title Mailing address Telephone number Fax number Email address 4. Type of business structure of the Alaskan employer (Check One) Corporation Partnership Joint Venture Limited Partnership Limited Liability Company Limited Liability Partnership Municipality or Public Authority Other (explain below) 5. If the Alaskan employer is a wholly owned or majority owned subsidiary, provide the legal name, mailing address, and percent of ownership of the parent or controlling company. 6. If the Alaskan employer is a joint venture, provide the legal names, mailing address, and ownership percentage of each person having an ownership interest in the venture (attach additional pages if necessary). 7. Provide the North American Industry Classification System (NAICS) code number that the Alaskan employer conducts its affairs under and a brief description of its business activities NAICS Code Description of business Activities
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