STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET BALTIMORE, MARYLAND 21202 INSURANCE COMPLIANCE AND REPORTING DIVISION GENERAL INSTRUCTIONS FOR A-01 1. All questions must be answered. State “None” or “Not Applicable” if such is the case. 2. If additional space is required to respond to any of the questions, please include a separate sheet of paper. Be sure to mark it “Form A-01 2007” with the name of the self-insured employer and the date. 3. Mail completed form to: Tom Murphy, CPA Director, Insurance Compliance and Reporting Division MD Workers’ Compensation Commission 10 East Baltimore Street, Room 615 Baltimore, MD 21202 4. Please make sure that you have had the A-01 certified and notarized before returning it. 5. Please provide loss runs on a disk or CD in text or Excel format. DEFINITIONS FOR A-01 Section V – Claims Data a. Accidents during current reporting year (Form SF-1) – First Report of Injury Submitted to Commission. b. Accidents resulting in injured workers submitting claims to the Commission during the year – Total issued Commission claim numbers based on date filed with the Commission (not date of injury). c. Accidents during the year (reporting period) with incurred losses – All claims listed on loss run for the current year including those not submitted to the Commission based on date of accident. Section VI – Reserves A-01Inst. (Rev 6/2007) 1 -4 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET BALTIMORE, MARYLAND 21202 a. Ultimate loss net of payments including incurred but not reported – If not supported by an independently prepared actuarial report, an internally prepared estimate is acceptable. b. Open claims/case reserves – This amount should agree with the sum of all unpaid losses plus reserves for future anticipated losses as shown on the loss run. Section VII – Incurred Losses The incurred losses reported on this schedule should be supported by the loss run data submitted with this report (this statement also applies to loss runs submitted with prior year reports). For each of the three years, the “Total Incurred As Adjusted” column should agree with the sum of all incurred losses on the current year loss run based on date of accident. The incurred losses “originally reported,” for the current year should be the same as the “as adjusted” column. The first and second prior year amounts should be as reported in the prior year A-01 report in the “as adjusted” column for the current and first prior year. The “Adjustment To Prior Year” should be the calculated difference between the original and as adjusted columns. The assumption is that the amount of the adjustment represents changes in payments and reserves since the last report and loss run submission. Section VIII. Excess Coverage and Security Deposit Information a. Report the self-insured retention on the Excess Workers’ Compensation policy b. Report the policy limit (i.e., Statutory, 100,000,000, etc.) The A-01 is to be submitted no later than August 31, 2007. If an extension of time to file this report is needed, a written request must be received by the Commission (Insurance Compliance and Reporting Division) no later than August 15, 2007. Failure to respond by the designated date may result in a penalty pursuant to COMAR 14.09.10.08C. If you have any questions, please contact the Insurance Compliance and Reporting Division: Tom Murphy, CPA (410) 864-5292 (410) 864-5291 (FAX) tmurphy@wcc.state.md.us NOTE: The Report of Payroll (Form A-02) and Assessment Notice are sent separately by the Commission’s Fiscal Services Division and should be returned to that office. If you have any questions regarding the Form A-02 and Assessment Notice contact James Moore in the Commission’s Fiscal Services Division at (410) 864-5257. A-01Inst. (Rev 6/2007) 2 -4 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET BALTIMORE, MARYLAND 21202 TERMS AND CONDITIONS OF SELF-INSURANCE Please carefully read the following which are policies and procedures established by the Maryland Workers’ Compensation Commission (hereinafter referred to as “Commission”) acting under the mandate of Title 9 Workers’ Compensation (Subtitle 4. Insurance Coverage) of the Labor and Employment Article and COMAR 14.09.10. Failure to comply with the statues and regulations constitutes grounds for revocation of selfinsurance privileges. • SECURITY DEPOSIT The amount and form of the self-insurance security deposit is set by the Commission and cannot be changed without the prior approval of the Commission. • SURETY BONDS The self-insured employer must use the surety bond form required by the Commission. All surety bonds must be continuous until canceled. The thirty (30) day cancellation notice for surety bonds will be strictly adhered to. A canceled surety bond must be replaced, on the Commission’s bond form, effective upon the termination of the prior bond, or by acceptable securities deposited with the Commission. Gaps in coverage and retroactive notices are not acceptable. • EXCESS COVERAGE All employers must provide annual certificates of insurance showing the amount of retention and limits, as well as confirming the term (period) of coverage. The initial policy, binders, new policies, amending endorsements must be submitted to the Insurance Compliance and Reporting Division (formerly the Insurance Division) at the Commission. If there is a change in the policy number or a change in excess carrier, you are required to submit the entire policy to the Commission with the Maryland endorsements. The amount of the self-insurance retention or limits, or any other essential provisions of coverage, cannot be changed without the prior approval of the Commission. The Commission will not accept cancellation of insurance without thirty (30) days advance notice as stipulated in the required endorsement to all excess policies written in Maryland. Canceled policies must be replaced by another policy effective at the expiration date of the prior policy. • CHANGE IN CORPORATE STRUCTURE A self-insured employer must notify the Commission immediately of any prospective mergers, acquisitions or any change in corporate structure. All of these events must be reviewed and approved by the Commission. For example, if a self-insured employer acquires another company that has employees in Maryland, the newly acquired company is not automatically included in the self-insurance program. An application to add a subsidiary must be filed and approved by the Commission. A-01Inst. (Rev 6/2007) 3 -4 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET BALTIMORE, MARYLAND 21202 • REPORTING Complete and prompt submission of all required reports is mandatory. All self-insured employers must submit the Annual Information Report (A-01 form) and annual audited financial statements. The audited financial statements are due to the Commission within 120 days of the end of the Fiscal Year. If the selfinsured employer is subject to the Securities Act of 1933 and/or the Securities Exchange Act of 1934, it is required to file a copy of the latest SEC Form 10-K or other Securities Exchange Commission filings to the Insurance Compliance and Reporting Division to satisfy the financial reporting requirements of the Commission. An independent actuarial report is due every three years or as directed by the Commission. Any special reports required by the Commission as a condition of self-insurance or ad hoc requests for the purpose of carrying out its regulatory responsibilities should also be expeditiously provided. • CHANGE IN THIRD PARTY (OR IN-HOUSE) ADMINISTRATOR The Commission must be notified of changes in Third Party (or In-house) Administrator. This information will only be changed on the Commission’s records upon written notification to the Commission (Insurance Compliance and Reporting Division) by the self-insured employer. If there is a change in administrator, the Commission should be advised if the new company is handling ALL claims or only claims filed on, or after, a certain date. A-01Inst. (Rev 6/2007) 4 -4 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. Baltimore Street Baltimore, MD 21202 INFORMATION REPORT - June 30, 2007 All Questions Must be Answered Complete in Adobe Reader, type or print Under LE § 9-405 e of Maryland Workers’ Compensation Law Insurer ID: Commission use only SECTION I - Corporate or Organization Data Federal I.D. #: Name of Self-Insurer: Corporate Address: Contact Person for Self-Insurance Program at Corporate Headquarters: Phone #: Fax #: Email: Type of Organization: Corporation Toll Free Phone #: Partnership Other Specify: Fiscal Year Ends: Organization’s Contact Person in Maryland do not provide the name of a service company or attorney. If none, explain : Name: Address: Phone #: Fax #: Email: Organization’s In-house Legal Counsel: Name: Address: Phone #: Fax #: Email: Organization’s Chief Financial Officer: Name: Address: Phone #: Fax #: Email: MDWCC Form A-01 (Rev. 6/2007) 1- 5 American LegalNet, Inc. www.FormsWorkflow.com SECTION II - Workers’ Compensation Commission Represe ntative as required by LE Sec. 9 -405 d , Annotated Code of Maryland Service Company or In-house Administrator: Name of Contact Person: Firm Name: Address: Phone #: Fax #: Email: NOTE: The above information will be changed on the Commission’s records only upon written notification to the Commission by the self-insured employer. SECTION III – Participating Payroll Office List all payroll offices writing payroll for employees covered under this plan. If the name on the check is different than the self-insured, indicate if it is a subsidiary, affiliate, division, plant or office; include the effective date when each became self-insured. If additional space is needed, please attach exhibit. This report includes payroll of the following: Federal I.D. #: Business Name: Address: Phone #: Self-Insured Fax #: Subsidiary Affiliate Division Principal Classification Plant Office #. Employees Business Name: Address: Phone #: Subsidiary Effective date of self-insurance: #. All Other Employees Federal I.D. #: Affiliate Division Plant Principal Classification Fax #: Office #. Employees Business Name: Effective date of self-insurance: #. All Other Employees Federal I.D. #: Address: Phone #: Fax #: Subsidiary Affiliate Principal Classification Division Plant Office Effective date of self-insurance: #. Employees #. All Other Employees Business Name: Federal I.D. #: Address: Phone #: Subsidiary Affiliate Principal Classification Division Plant Fax #: Office Effective date of self-insurance: #. Employees #. All Other Employees Business Name: Federal I.D. #: Address: Phone #: Subsidiary Affiliate Division Principal Classification MDWCC Form A-01 (Rev. 6/2007) Plant Fax #: Office Effective date of self-insurance: #. Employees #. All Other Employees 2-5 American LegalNet, Inc. www.FormsWorkflow.com SECTION IV - Payroll Data a. Annual period covered by this report: From: b. Number of employees covered: To: c. Annual Maryland Payroll: To the nearest dollar Types of work performed: SECTION V - Claims Data a. How many accidents occurred during this period ( SF-1) ? b. How many accidents resulted in claims to the Commission du ring this period (received Comm. Claim #) ? c. How many accidents occurred during the current reporting period for which costs were incurred or paid? d. Claims paid – Provide a copy of the Annual Claims Payment Summary that is due to the Commission August 14, 2007. Section VI Reserves a. Ultimate loss net of payments for all years , including IBNR net of any expected excess carrier payments indemnity, medical, vocational rehab. and all other . $ b. Total value of open claims/case reserves for all years . This amount should agree with Total Reserves on Loss Run. If not, please attach an explanation. $ Section VII Incurred Losses Workers’ Compensation claims incurred by year paid and case reserves by this organization in the past three years including medical, vocational rehab., indemnity and all other direct claim costs . Please provide a detailed listing of claims that comprise the adjustments to prior year incurred losses: Reporting Period Originally Reported Adjustments To Prior Year Total Incurred As Adjusted 1. Current Year 2. First Prior Year 3. Second Prior Year SECTION VIII - Excess Coverage and Security Deposit Information a. Amount of risk retained by self-insurer: $ b. Excess workers compensation policy limits: $ c. Does your excess insurance provide for an annual aggregate limit? If so, what is the annual aggregate amount? Yes No $ d. Name of Excess Carrier: e. Do you have umbrella coverage applicable to workers’ compensation? Amount MDWCC Form A-01 (Rev. 6/2007) Yes No $ 3-5 American LegalNet, Inc. www.FormsWorkflow.com f. Amount of surety bond: $ -ORAmount of security on deposit: $ -ORAmount of letter of credit: $ g. Issuer of security instrument: SECTION IX. Additional Information please provide the following by attachment or exhibit : a. Loss Runs in detail for the immediate past 5 years and in annual summary for up to an additional 15 years not to exceed the period of self-insurance . b. Employee Locations list worksites where the number of employees is greater than 10 c. Copies of OSHA citations, if applicable, for operations in the State of Maryland issued within the payroll period covered by this report. d. Copy of contract with Third Party Administrator, if any. Note: Not required if TPA has not changed since 2006 reporting. e. Listing of claims which issues were filed with the Commission requesting penalties. f. Listing of claims with penalties assessed may be combined with f. above . g. A statement whether there has been any change in the reporting period in accounting for Workers’ Compensation costs as a result of audit or internal recommendations. h. Listing of the states in which you are self-insured for Workers’ Compensation; the number of states in which you have employees but are not self-insured. i. Certificate of Status Good Standing for Third Party Administrator, if applicable. The Certificate should be from the State of Maryland. j. Number of independent contractors and associated payroll covered by the self-insurance program. Is the payroll, if any, included in Section IV? Note: If any of the requested items in a – j above would result in no information being submitted, please state so according to letter above i.e., Exhibit F, No data . MDWCC Form A-01 (Rev. 6/2007) 4-5 American LegalNet, Inc. www.FormsWorkflow.com I certify that to the best of my knowledge and belief the information contained in this report and any attachments thereto is true and correct. IN WITNESS WHEREOF, I have hereunto subscribed my name and caused the official seal to be affixed this of day , 2007. Name of Self-Insured Employer By: Printed Name in Full Signature: Title: Phone #: Notary: State of City or County of I hereby certify that on this of the State of day of , 2007, before me the subscriber, a resident , in and for said County, personally appeared , title of Self-Insured Employer and made oath in due form of law that the matters and facts set forth in the foregoing reporting form and attached documents are true. seal My Commission Expires: NOTES MDWCC Form A-01 (Rev. 6/2007) 5-5 American LegalNet, Inc. www.FormsWorkflow.com