Pg. 1 1. State the name of the workers222 compensation pool (223pool224) applying for authority to self-insure. 2. State the address of the pool222s principal Arizona office. 3. State the telephone and fax numbers of the pool222s principal office. 4. State the effective date of the formation of the pool. Commission Use Only Date Division receives application Date Division mails notice that application incomplete Date Division mails notice that application complete Date of order approving or denying authorization Application approved Application denied Compliance with Time-frames A.C. Review Sub. Review Overall Review American LegalNet, Inc. www.FormsWorkFlow.com Pg. 2 6.State the effective date of formation of the industry or trade association, or professionalorganization to which member employers of the pool belong. 7. 8. State the total amount of manual workers222 compensation premiums paid by allmemberemployers in the preceding calendar year. 9. State the combined net worth of all member employers based on the members222 financialstatements for the last fiscal year. 10. State the name and address of each person appointed to the pool222s Board of Trustees. 5.State the name and address of industry or trade association, or professional organizationtowhich member employers of the pool belong.NameNameName American LegalNet, Inc. www.FormsWorkFlow.com Pg. 3 11. State the name, address, and telephone number of the administrator appointed by the Board ofTrustees. 12. State the name, address, telephone number, and contact person of the claims service companyhired by the pool, if applicable. 13. State the name, title, address, and telephone number of the person in charge of the pool222s losscontrol program.NameNameNameNameNameName Name American LegalNet, Inc. www.FormsWorkFlow.com Pg. 4 14. State the name, title, address and telephone number of the person in charge of thepool222sunderwriting programs. 15.Select a premium tax plan.Fixed Premium PlanGuaranteed Cost PlanRetrospective Rating Plan 16. Yes No a.Authorization (board resolution) for administrator to sign initialapplication, if applicable.b.Copy of contract required under A.R.S. 247 23-961.01.c.Copy of articles of incorporation, if applicable. Name American LegalNet, Inc. www.FormsWorkFlow.com Pg. 5 g.Description of loss control program required under R20-5-727.h.Proof of coverage or confirmation from an authorized insurance carrierthat the carrier will provide fidelity insurance.i.Original, signed guaranty bond or confirmation from an authorizedinsurance carrier that the carrier will provide a guaranty bond to the pool,if applicable.j. In lieu of a bond, United States bonds or confirmation fromthe pool that it will obtain United States bonds orsecurities. k. In lieu of a guaranty bond, a letter of credit or confirmation froma financialinstitution that it will provide the pool a letter ofcredit. l.Completed and signed Option/Election Form.m.Proof of coverage or confirmation from an authorized insurance carrierthat the carrier will provide excess insurance coverage.n.Copy of signed agreement between pool administrator andBoard of Trustees.o.Copy of signed agreement between pool and claims servicecompany, if applicable.p.Written statement with supporting documentation requestingauthorization to process claims in-house, if applicable. d.Copy of trust agreement, if applicable.e.Copy of resolution from Board of Trustees approving each memberemployer for admission into the pool.f.Copy of pool222s bylaws. Yes No American LegalNet, Inc. www.FormsWorkFlow.com Pg. u.Original, signed application from each employer receiving approvalby the Board of Trustees to join pool. (Use Commission form titledApplication to Add Employer to a Workers222 Compensation Pool).q.List of workers222 compensation class codes to be used by pool.r.Statement showing how pool will determine premiums.s.Detailed description of underwriting programs.t.Actuarial feasibility study that documents rate structure needed toestablish premiums to cover losses. Yes No American LegalNet, Inc. www.FormsWorkFlow.com Pg. perjury, that I have authority to sign this application, that I am of the pool (title of person signing)and in that capacity have knowledge of the affairs of the pool to which the initial application andattachments relate, that I have read the initial application and all attachments to the initialapplication, and verify that the representations and statements contained in the initial applicationand accompanying attachments, are true to the best of my knowledge, information, and belief. Signature of person signing application I, , certify under penalty of American LegalNet, Inc. www.FormsWorkFlow.com