South Dakota > Workers Compensation
Application To Self-Insure Workers Compensation Liabilities - South Dakota
| Application To Self-Insure Workers Compensation Liabilities Form. This is a South Dakota form and can be used in Workers Compensation . |
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STATE OF SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION DIVISION OF LABOR AND MANAGEMENT Kneip Building 700 Governors Drive Pierre, South Dakota, 57501-2291 Phone: 605.773.3681 APPLICATION TO SELF-INSURE WORKERS' COMPENSATION LIABILITIES This application is for approval to self-insure workers compensation liabilities from September 1, 2012 to August 31, 2013. If the application is being made after September 1, 2012, the Certificate of Exemption will be valid only from the date of execution until August 31, 2013. A renewal application will be required for self-insurance during the 2013/2014 year. This is an application for employers seeking to self-insure workers' compensation in South Dakota. The attached schedules are to facilitate the submission of proof of solvency and financial ability to compensate under the provision of the Workers' Compensation Law of South Dakota. Answer all applicable questions fully. Specifically indicate N/A in any areas not applicable. If you are not completing this application electronically, please use black ink or type. If any questions are left unanswered, the application may be returned for completion, causing a delay in approval. 1. STATEMENT OF EMPLOYER IN SUPPORT OF APPLICATION TO: State of South Dakota, Department of Labor and Regulation Division of Labor and Management 700 Governors Drive Pierre, South Dakota 57501-2291 Phone: 605.773.3681 The undersigned, having elected to remain under the provisions of the Workers' Compensation Law, hereby agrees to provide and pay all legal obligations under the Workers' Compensation Law, including but not limited to compensation for the injuries to employees as required by Title 62 of the South Dakota Codified Laws or as may be awarded by the South Dakota Department of Labor and Regulation. In making application for exemption from the insurance provisions of SDCL 62-5-1, the applicant hereby submits evidence of solvency and financial ability to pay compensation and other obligations contemplated. (1.1) Name and address, including ZIP + 4 of applicant. (1.2) Federal Identification Number of applicant. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (1.3) Names and addresses, including ZIP + 4, of all businesses to be self-insured in South Dakota (if necessary, additional businesses may be added on "Additional Notes" tab). (1.4) Federal Identification Number of all businesses to be self-insured in South Dakota. (1.5) Nature of businesses. (1.6) Are all businesses listed on application authorized to operate in South Dakota? Yes No (1.7) Name and address, including ZIP + 4, of person in South Dakota on whom legal service can be made. (1.8) Name(s), address(es), and title of owner(s), partners or senior corporate officers. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 2. COMPANY BACKGROUND (2.1) Date Established. (2.2) If incorporated, under laws of what state? (2.3) Did firm succeed another firm? (2.4) If yes, state whom and date of transition. Yes No (2.5) Name(s) and addresse(es) of parent, subsidiary, and affiliate companies if any. Please specify affiliation. (2.6) Is the parent, subsidiary or affiliated company guaranteeing the workers' compensation of the applicant? Yes No *If yes, attach notarized Assumption of Self-Insurance Obligations form. *If yes, the financial data below should relate to all entities to be self-insured and the guarantor. *If no, the financial data below should relate only to the entities to be self-insured. (2.7) List all subsidiaries and affiliates to be self-insured and state the self-insurance retention limit on each. If necessary, additional subsidiaries and affiliates may be added on "Additional Notes" tab. (2.8) List name and address, including ZIP + 4, of all administrative branch offices and/or locations in South Dakota (if necessary, use Additional Notes tab). If applicable, specify which are subsidiaries and which are divisions of the applicant. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. FINANCIAL DATA Please provide audited annual financial statements for the three (3) most recent years. If audited annual financial statements are not available, please provide a balance sheet, income statement and statement of change in financial position for each year. If the most recent audited annual financial statement does not report your financial position at a date within six (6) months of the beginning of the self-insurance year (September 1, 2012), provide an interim financial statement. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. INSURANCE INFORMATION (4.1) Has applicant been approved by the South Dakota Department of Labor and Regulation to self-insure its workers' compensation liabilities in the State of South Dakota prior to this application? Yes No (4.2) If yes, date applicant commenced self-insurance. (4.3) Has applicant carried workers' compensation insurance in South Dakota during any or all of the last three (3) years? Yes No (4.4) If yes, please attach the name of insurer and attach declaration pages or binder for each policy showing policy effective date, experience modifications, and South Dakota class codes and payroll. (4.5) If no, has applicant been an approved self-insurer during the last three (3) years? Yes No (4.6) If no, how was workers' compensation coverage provided? (4.7) Expiration date of workers' compensation policy now in effect. (4.8) Is applicant authorized to self-insure its workers' compensation liability in any other states? Yes No (4.9) If yes, please list the name of each state. If necessary, additional states may be added on "Additional Notes" tab. (4.10) Has applicant ever been denied authority to self-insure its workers' compensation or other liability in any state, or has such authority ever been revoked or suspended? Yes No (4.11) If yes, please list state(s) and date(s) (including South Dakota). Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com (4.12) Please fill out the Retention Limits Form below: Per Occurrence Excess* Retention Limit Aggregate Coverage Retention Limit Year 2008 2009 2010 2011 2012 Excess Insurer Effective Date *Dollar Limit or "Statutory" (4.13) Please provide a copy of Certificate of Insurance for the most recent year to verify excess coverage levels and insurers. (4.14) Does the applicant intend to maintain excess coverage through the upcoming self-insurance year (September 1, 2012 to August 31, 2013)? Yes No Page 2 of 4 American LegalNet, Inc
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