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Application For Certificate Of Self Insurance Form. This is a Alaska form and can be use in Workers Comp.
Tags: Application For Certificate Of Self Insurance, 07-6129, Alaska Workers Comp,
07-6129 (rev 12/2018) INSTRUCTIONS FOR QUALIFYING AS A SELF-INSURED EMPLOYER IN ALASKA REQUIREMENTS 8 AAC 46.010(a) provides that an employer may self-insure its workers' compensation liability in Alaska if it has: (1) been in business within Alaska for at least five years immediately preceding the filing of the application; (2) a safety/loss control program; (3) 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; and (4) a tangible net worth of at least $10,000,000. In addition to these requirements, 8 AAC 46.010(b) provides an employer must also have: (1) the financial ability to meet the self-insured222s financial obligations in Alaska; (2) 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; and (3) agreed to post any security deposit required. The Alaska Workers' Compensation Board will, in its discretion, waive the requirement in 8 AAC 46.010(a)(1) if: (1) the employer has self-insured its workers' compensation obligations in another jurisdiction for a period of at least five years immediately preceding the filing of the application; or (2) the employer is a wholly-owned subsidiary and its parent company has been in business for at least five years immediately preceding filing and guarantees the subsidiary's obligations under the Act. Under 8 AAC 46.010(d), an employer that is a majority or wholly-owned subsidiary must have the employer222s obligations under the Act guaranteed by its parent company. FILING REQUIREMENTS An application for a Certificate of Self-Insurance must be made on Form 07-6129. 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 Application for 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 three fiscal or calendar years immediately preceding the filing of the application. 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 three fiscal years or calendar years preceding the filing of the application. The American LegalNet, Inc. www.FormsWorkFlow.com 07-6129 (rev 12/2018) summary must be categorized by year, and 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. 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. 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 90 days prior to the desired effective date of self-insurance. American LegalNet, Inc. www.FormsWorkFlow.com 07-6129 (rev 12/2018) STATE OF ALASKA DIVISION OF WORKERS222 COMPENSATION P.O. Box 115512 Juneau, AK 99811-5512 APPLICATION FOR CERTIFICATE OF SELF-INSURANCE All questions must be answered, and requested material submitted. If not applicable, use symbol N/A. Workers compensation insurance must be maintained until self-insurance authorization is effective. 1. Legal name of the Alaskan employer 2. Mailing address of the Alaskan employer 3. Name and address of the individual responsible for the employer222s self-insured program Name Title Mailing address Telephone number Fax number Email address 4. Type of business structure of the Alaskan employer (Check One) Corporation Partnership Joint Venture Limited Partnership Limited Liability Company Limited Liability Partnership Municipality or Public Authority Other (explain below) 5. If the Alaskan employer is a wholly owned or majority owned subsidiary, provide the legal name, mailing address, and percent of ownership of the parent or controlling company. 6. If the Alaskan employer is a joint venture, provide the legal names, mailing address, and ownership percentage of each person having an ownership interest in the venture (attach additional pages if necessary). 7. Provide the North American Industry Classification System (NAICS) code number that the Alaskan employer conducts its affairs under and a brief description of its business activities NAICS Code Description of business Activities in Alaska 8. Alaska employer's federal employer identification number 9. Provide the Alaska employer's Alaska State Business License number and, if applicable, the Alaska Department of Commerce ID number. Business License Number Commerce ID Number 10. Date the Alaskan employer started business in Alaska American LegalNet, Inc. www.FormsWorkFlow.com 07-6129 (rev 12/2018) 11. List past three years 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 Tot al amount of incurred losses in y ear Total amount of paid losses in year Total outstanding loss reserves at year end Total amount within retention limit Total amount subject to excess coverage Total amount subject to subrogation recovery Annual Alaskan workers222 compensation premium 12. Description of proposed excess insurance Name of proposed excess insurance carrier Proposed Self-Insurance Retention Specific: Aggregate: Proposed policy limits Specific: Aggregate: 13. Effective dates when self-insurance is desired: From To 14. Name and mailing address of the Alaska claims adjuster to be located in the State of Alaska 15. Applican