ILLINOIS WORKERS’ COMPENSATION COMMISSION APPLICATION FOR SELF-INSURANCE Read all instructions before completing this application. Answer all questions. RETURN TO: APPLICANT’ S LEGAL NAME/MAILING ADDRESS/WEB SITE DESIRED SELF-INSURANCE EFFECTIVE DATE: Office of Self-Insurance Admin. 4500 S. Sixth St. Springfield, IL 62703-5118 The employer (applicant) applies for the privilege of being a certified self-insurer in the State of Illinois, as provided in the Illinois Workers’ Compensation and Occupational Diseases Acts. An applicant may not operate as a certified selfinsurer until the Commission issues a Certificate of Approval to Self-Insure. 1. LIST THE COMPANY REPRESENTATIVE FOR SELF-INSURANCE. Name Title Company name Street address City/State/Zip Telephone Fax E-mail address 2. APPLICANT’S FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) 3. STATUS: Individual Partnership Corporation 4. NATURE OF BUSINESS Primary NAICS codes NAICS = North American Industry Classification System, which replaces SIC. 5. INCORPORATED OR ORGANIZED UNDER THE LAWS OF THE STATE OF ON 6. DATE OF COMMENCEMENT OF BUSINESS IN ILLINOIS 7. IF THE APPLICANT IS A SUBSIDIARY, COMPLETE THE FOLLOWING ITEMS. Exact legal name of ultimate parent Date parent incorporated State FEIN Web site 1 American LegalNet, Inc. www.FormsWorkFlow.com 8. LIST THE CORPORATE PRINCIPALS FOR THE ULTIMATE PARENT OR APPLICANT IF NO PARENT. If necessary, attach a list. NAME TITLE STREET ADDRESS, CITY, STATE, ZIP TELEPHONE 9. LIST THE SUBSIDIARIES OR AFFILIATES TO BE INCLUDED IN THE SELF-INSURANCE PROGRAM. If necessary, attach a list. LEGAL NAME DATE OF INCORP. STREET ADDRESS, CITY, STATE, ZIP FEIN NAICS NATURE OF CODE BUSINESS SUB. OR AFF.? 10. LIST THE PHYSICAL LOCATIONS OF EACH OPERATION TO BE SELF-INSURED. If attaching a list, follow the same format. OPERATION NAME AND ADDRESS FEIN NAICS NATURE OF BUSINESS CODE AVERAGE # OF EMPLOYEES IN PRODUCTION OFFICE/SALES 11. LIST THE NAME OF CURRENT WORKERS’ COMPENSATION INSURANCE CARRIER. Name Policy number Effective dates: From to Provide evidence of applicant’s current workers’ compensation coverage. 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. INDICATE THE ESTIMATED ANNUAL WORKERS’ COMPENSATION PREMIUM FOR THE LAST COMPLETED CALENDAR YEAR. INCLUDE THE PREMIUM OF ALL SUBSIDIARIES TO BE COVERED BY SELF-INSURANCE IN ILLINOIS. If necessary, attach a list. INSURANCE CLASS CODE INSURANCE CLASSIFICATION DESCRIPTION # EMPLOYEES EST. ANNUAL PAYROLL CURRENT MANUAL RATE EST. ANNUAL PREMIUM TOTAL 13. PROVIDE THE FOLLOWING CLAIMS INFORMATION FOR YOUR PROPOSED SELF-INSURED OPERATIONS IN ILLINOIS FOR THE LAST THREE COMPLETED YEARS. Attach detailed loss runs for the last three completed years. YEAR ENDING YEAR ENDING YEAR ENDING A. Number of accidents requiring only medical attention B. Number of accidents requiring lost time of more than 3 days C. Total paid claims D. Outstanding reserves (incl. medical, indemnity, & expenses) If the reserves vary by more than 20% during these years, provide an explanation. E. Total incurred losses (paid and reserves) F. Number of fatalities Attach a description of each fatality, including the employee’s name, date of accident, cause of accident, current status of the claim, and the outcome of any OSHA investigation and/or citations relating to the fatality. 14. LIST THE PERSON TO WHOM INFORMATION REGARDING ASSESSMENTS FOR THE SELF-INSURERS SECURITY FUND, SECOND INJURY FUND, RATE ADJUSTMENT FUND. AND OPERATIONS FUND SHOULD BE SENT. Contact person Title Street address City/State/Zip Telephone Fax E-mail address 15. LIST THE NAME OF THE PROPOSED CLAIMS SERVICE AGENCY. Company name Contact person Title Street address City/State/Zip Telephone Fax E-mail address 3 American LegalNet, Inc. www.FormsWorkFlow.com 16. IF YOU DO NOT PLAN TO RETAIN A CLAIMS SERVICE AGENCY, LIST THE COMPANY REPRESENTATIVE WHO WILL BE RESPONSIBLE FOR THE SELF-INSURANCE PROGRAM. Contact person Title Street address City/State/Zip Telephone Fax E-mail address Describe the experience and qualifications of this person. 17. LIST THE DESIGNATED SAFETY REPRESENTATIVE. Name Title Street address City/State/Zip Telephone Fax E-mail address Attach a narrative description of the safety and loss control program components for your operations in Illinois. Do not send a manual. 18. WHAT MEDICAL FACILITIES ARE AVAILABLE TO YOUR EMPLOYEES? Local clinic Hospital Other (please explain) First aid In-plant doctor/nurse 19. IF ANY OF THE APPLICANT’S EMPLOYEES HAVE EXPOSURE IN ANY DEGREE TO SUBSTANCES THAT MAY CAUSE OCCUPATIONAL DISEASE, INDICATE THE SUBSTANCE AND APPROXIMATE PERCENTAGE OF EMPLOYEES EXPOSED. If necessary, attach a list. Include asbestos, silica dusts, any toxic, injurious, or hazardous substances, compounds, or chemicals, caustics, fumes, noise, radiation, communicable diseases, and any other occupational disease exposures. SUBSTANCE PERCENTAGE OF EMPLOYEES EXPOSED 20. HAS AN APPLICATION FOR WORKERS’ COMPENSATION INSURANCE EVER BEEN REFUSED OR A POLICY CANCELLED? # ACCIDENT REPORTS FILED Yes No Yes No Yes No If yes, attach an explanation of circumstances, including the date, jurisdiction, and carrier. 21. HAS AN APPLICATION FOR SELF-INSURANCE EVER BEEN DENIED OR A CERTIFICATION REVOKED? If yes, attach an explanation of circumstances, including the date and jurisdiction. 22. IS THE APPLICANT SELF-INSURED IN ANY OTHER JURISDICTION? If yes, attach a list of jurisdictions. 23. IF THE APPLICANT IS RATED, PROVIDE THE LATEST RATINGS, INCLUDING THE DATE OF THE RATING. IF NOT RATED, MARK N/A. Use the parent company’s rating if the applicant is a subsidiary. RATING DATE Moody’s Investors Service Standard & Poor’s Dun & Bradstreet Other 4 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR SELF-INSURANCE AGREEMENTS In consideration of being granted the privilege of self-insurance under the Illinois Workers’ Compensation and Occupational Diseases Acts, the applicant hereby agrees: 1. To promptly pay benefits due to injured employees or their dependents in accordance with the Illinois Workers’ Compensation and Occupational Diseases Acts. 2. To promptly report compensable injuries, diseases, and deaths to the Commission as required by law. 3. To promptly notify the Commission of any change in financial condition that will impact the company’s ability to self-insure. 4. To immediately notify the Commission before the contemplation of liquidation, sale, or transfer of ownership is made, and to make arrangements satisfactory to the Commission for the payment of all existing liabilities. This application should be signed and sworn to by the appropriate person or persons as stated below: if the applicant is an individual, the owner shall sign; if the applicant is a partnership, all of the partners shall sign; if the applicant is a corporation, its president or vice-president and its secretary or assistant secretary shall sign. AFFIDAVIT State of Illinois County of ____________________ Each person listed below, first being sworn on oath, deposes and states that he or she is acquainted with the affairs of this applicant employer, including the representations and statements set forth in this application; that he or she has read said application and all documents submitted, knows their contents, and verifies that the representations and statements are true in substance and in fact. ___________________________________________ Applicant’s legal name ___________________________________________ ___________________________________________ Signature of affiant and Date Signature of affiant and Date ___________________________________________ ___________________________________________ Name and title of affiant Name and title of affiant Subscribed and sworn to before me on ______________________ _________________________________________ Notary public 5 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR SELF-INSURANCE LIST OF ATTACHMENTS A. A nonrefundable application fee of $500 for each separate legal entity applying for the self-insurance privilege, made payable to “Illinois Self-Insurers Administration Fund.” B. Evidence of each applicant’s current experience modification factor. Explain if factor is greater than one. C. An organizational chart showing the hierarchical position of all corporate entities, including the ultimate parent. Note the percentage of ownership and clearly indicate which entities with operations in Illinois are seeking coverage under the certificate of self-insurance. D. (1) If the applicant has an ultimate parent, provide the ultimate parent company’s audited financial statements for the most recent three years. (2) If the applicant has no ultimate parent, provide the applicant’s audited financial statements for the most recent three years. (3) If certified audited financial statements are not prepared, provide the financial statements prepared by an outside accountant for the most recent three years. E. Provide the most current 10-Q or internal quarterly balance sheet and income statement of applicant and parent. F. Copies of the applicant’s excess insurance quotations, should the applicant purchase excess insurance. (A copy of the excess policy must be submitted if the application is approved.) G. Evidence of the applicant’s current workers’ compensation coverage. See question 11. H. Detailed Illinois loss runs for each applicant for the last three completed years. See question 13. I. A narrative description of the safety program components for each operation in Illinois. See question 17. J. Provide an explanation of workers’ compensation insurance being refused or cancelled, if applicable. See question 20. K. Provide an explanation of application for self-insurance being denied or revoked, if applicable. See question 21. L. A list of all other self-insured jurisdictions, if applicable. See question 22. ALL OF THE ABOVE-MENTIONED ITEMS MUST BE SUBMITTED BEFORE A REVIEW OF THE APPLICATION MAY BE COMPLETED. SUBMISSION OF AN INCOMPLETE APPLICATION MAY DELAY THE REVIEW PROCESS. Disclosure of this information is voluntary under the Illinois Workers’ Compensation Act, but failure to complete the form may prevent the IWCC from processing it. IC50 5/09 Illinois Workers’ Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth St. Springfield, IL 62703-5118 217/785-7084 6 American LegalNet, Inc. www.FormsWorkFlow.com