Renewal Certificate Of Self Insurance {07-6130}

Form 07-6130 (Rev 12/2018) INSTRUCTIONS FOR RENEWING STATUS AS A SELF-INSURED EMPLOYER IN ALASKA REQUIREMENTS 8 AAC 46.010, 8 AAC 46.040, and 8 AAC 46.080 provide that a company may maintain its Certificate of Self-Insurance in Alaska if it has: (1) a safety/loss control program; (2) in combination with its parent company or subsidiary companies of the employer, a minimum of 100 employees either in Alaska or in another state or states; (3) a tangible net worth of at least $10,000,000; (4) the financial ability to meet the self-insured222s financial obligations in Alaska; (5) available claims facilities through its own staffed adjusting facilities located within the state or through independent, licensed, resident adjusters with power to effect settlement within the state. For purposes of this paragraph, insurance companies with a certificate of authority from the Department of Commerce and Economic Development222s Division of Insurance, and with staff adjusters in this state, are considered independent, licensed, resident adjusters; (6) a security deposit in the amount of $600,000 or 125% of the total outstanding accrued self-insured workers222 compensation liabilities for the year immediately preceding the application, whichever amount is greater. The security deposit must be in a 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; and (7) submit an independent actuary222s review at least once every three years. FILING REQUIREMENTS An application for Renewal of Certificate of Self-Insurance must be made on Form 07-6130. 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. When the applicant is a wholly owned subsidiary of another company, a Parent Company Guarantee must be included with the Renewal of Certificate of Self-Insurance. If the applicant is a joint venture, the partner with the majority interest in the venture must be self-insured 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 venture222s operating agreement. The application must be accompanied by the applicant's audited financial statements for the previous fiscal or calendar year immediately preceding the year in which the self-insured applies for renewal. 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 employer222s or the employer222s parent company payroll and loss runs for the fiscal or calendar year immediately preceding the filing of the application. The summary must 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. American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6130 (Rev 12/2018) The applicant shall submit a description (binder) 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. If approved, the applicant shall provide excess policy insurance coverage to the Division. 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 workers222 compensation liabilities for the year immediately preceding the application, whichever amount is greater. If the employer has been self-insured in Alaska for five or more years, the employer may submit a written request for an exemption from posting a security deposit. The exemption request should state the reasons why the employer should not be required to post a security deposit. Each self-insurance renewal applicant is required to submit an independent actuary222s report once every three years, accompanied by a letter signed by an officer of the company that reserves are adequate and have been accounted for in the company222s balance sheet. The applicant shall submit with the application a detailed outline of its safety/loss control program. The above material shall be mailed to the Division of Workers222 Compensation at least 60 days prior to the expiration of its Certificate of Self-Insurance. American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6130 (Rev 12/2018) STATE OF ALASKA DIVISION OF WORKERS222 COMPENSATION P. O. Box 115512 Juneau, AK 99811-5512 RENEWAL OF CERTIFICATE OF SELF-INSURANCE All questions must be answered, and requested material submitted. If not applicable, use symbol N/A. 1. Legal Name of Alaskan Employer 2. Mailing Address of Alaskan Employer 3. Name and Address of Person Responsible for the Self-Insured Program Name Title Mailing Address Telephone Number Fax Number Email Address 4. List past fiscal year222s compensation experience in Alaska Reporting Year Number of Alaskan Employees Total Alaskan Payroll Number of Incident Only & Medical Claims Number of Time - Loss Claims Number of Fatalities Total Amount of Incurred Losses in Year Total Amount of Paid Losses in Year Total Outstanding Loss Reserves at Year End Total Amount Within Retention Limit Total Amo unt Subject to Excess Coverage Total Amount Subject to Subrogation Recovery Annual Alaskan Workers222 Compensation Premium 5. An independent actuary222s report is due once every three years, accompanied by a letter signed by an officer of the company that reserves are adequate and have been accounted for in the company222s balance sheet. 6. A security deposit is required for each Alaskan self-insured employer, unless the employer has sought and obtained an exemption from this requirement. The amount of the security deposit must be in the amount of $600,000 or 125% of the total outstanding accrued self-insured workers222 compensation liabilities for the year immediately preceding the application, whichever amount is greater. The employer may submit a written request for an exemption from posting a security deposit after five or more years of self-insurance in Alaska. The exemption request should state the reasons why the employer should not be required to post a security deposit. 7. Description of proposed excess insurance Name of proposed excess insurance carrier Proposed Self-Insurance Retention Specific: Aggregate: Proposed Policy Limits Specific: Aggregate: 8. Name and address of the Alaska Employer's adjuster handling claims in the State of Alaska American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6130 (Rev 12/2018) 9. Applicant must provide the following documents with this application for renewal of their Certificate of Self-Insurance Audited financial statements for the year immediately preceding the year in which the self-insured applies for renewal. If the