STATE OF CONNECTICUT WORKERS’ COMPENSATION COMMISSION 21 Oak Street, Hartford, CT 06106 APPLICATION FOR CERTIFICATE OF SELF-INSURANCE (APPLICATION MUST BE COMPLETED IN FULL BY APPLICANT) 1. 2. 3. 4. 5. 6. 7. 8. A. Name of employer: _____________________________________________________ B. Form of business entity: _____________________________________________________ C. Location of principal office: _____________________________________________________ D. Contact person/Title:______________________________________(phone no.)_____________ E. Number of years in business: ________________________ FEIN#_______________________ Locations of Connecticut operations-INDICATE IF SUBSIDIARY OR DIVISION& INCLUDE FEIN# FOR EACH ENTITY. (Attach additional sheet if necessary.) A. _________________________________________________________________________(S/D) B. _________________________________________________________________________(S/D) Will the above subsidiary(s)/division(s) be covered under this Certificate? Yes … No … Current number of employees in Connecticut_____________All locations_______________ (NEW APPLICANTS ONLY) Name of current workers’ compensation insurance carrier and policy expiration date____________________________________________________________________ Please provide the following information: A. Surety underwriter ___________________________________________________________ B. Security amount $ _____________________________Bond/LOC No. __________________ C. Self-insured retention amount $ _____________________________________per occurrence D. Excess insurance limit per occurrence$___________________________________________ E. Excess insurance carrier (Connecticut licensed only)_______________________________ Policy No. ____________________________ Policy Term: __________________________ Most recent audited financial statements (Renewal Applications) or the last three years (New Applications) (please attach). FY _______ FY _______ FY ______ Requested effective date of Certificate of Self-Insurance __________________________________ (Not earlier than 90 days from date of application for new applicants. Renewals MUST be submitted at least 60 days prior to expiration of current certificate). THE PRIVILEGE OF SELF-INSURANCE IS GRANTED TO THOSE EMPLOYERS WHO DEMONSTRATE THE CAPABILITY OF FINANCIAL STRENGTH AND STABILITY TO MAKE PAYMENT OF ALL WORKERS’ COMPENSATION LIABILITIES. FAILURE TO MAINTAIN FINANCIAL STABILITY, e.g., BANKRUPTCY, SHALL RESULT IN IMMEDIATE REVOCATION PROCEEDINGS. I, , hereby swear that the information provided with this Application for Self-Insurance is true and accurate. I make this statement subject to the penalties for perjury. Signature______________________________________________ MUST BE SIGNED BY CORPORATE OFFICER, PARTNER OR PROPRIETOR Title_______________________________________________ Subscribed and sworn to before me this day of , 20 . ______________________________________ Notary WCC Application for Certificate of Self-Insurance – Rev. 11/14/08 Page 1 American LegalNet, Inc. www.FormsWorkflow.com 9. Please attach the following: a. description of the light-duty programs at your Connecticut locations b. explanation of procedures used to notify workers of their rights and obligations when injured on the job c. procedures in effect to administer and investigate claims 10. Do you employ 25 or more employees? Yes ________ No ________ If yes, do you have a Safety Committee established per the CT WC Regulations? Yes ________ No ________ 11. Payroll History For Connecticut Operations: Year ___________ Total Payroll $____________________________________________ Year ___________ Total Payroll $____________________________________________ Year ___________ Total Payroll $____________________________________________ 12. Loss History For Last 3 Full Years For Connecticut Operations. (INCLUDE LOSS RUNS TO VERIFY AMOUNTS): Year # Claims Amount Paid Amount Open Total Incurred Loss ____ _______ ___________ (medical) ___________ (medical) ________________ (medical) ___________ (indemnity) ____________ (indemnity) _________________ (indemnity) ___________ (total paid) ____________ (total open) _________________ (total incurred) Year # Claims Amount Paid Amount Open Total Incurred Loss ____ _______ ___________ (medical) ___________ (medical) ________________ (medical) ___________ (indemnity) ____________ (indemnity) _________________ (indemnity) ___________ (total paid) ____________ (total open) _________________ (total incurred) Year Amount Paid Amount Open Total Incurred Loss ____ _______ ___________ (medical) ___________ (medical) ________________ (medical) ___________ (indemnity) ____________ (indemnity) _________________ (indemnity) ___________ (total paid) 13. # Claims ____________ (total open) _________________ (total incurred) Total Reserves For Claims Incurred In All Self-Insured Years (Renewals Only): $ __________________ Valued as of ____________________ (INCLUDE LOSS RUNS TO VERIFY AMOUNT) WCC Application for Certificate of Self-Insurance – Rev. 11/14/08 Page 2 American LegalNet, Inc. www.FormsWorkflow.com STATE OF CONNECTICUT WORKERS’ COMPENSATION COMMISSION 21 Oak Street, Hartford, CT 06106 CERTIFICATION OF CLAIMS SERVICING FORM NAME OF SELF-INSURER _________________________________________________________ NAME OF CLAIMS AGENCY _________________________________________________________ A. Claims Office Location: __________________________________________________________________________________________ ____________________________________________________________________________________ B. Mailing Address (if different from above): __________________________________________________________________________________________ ____________________________________________________________________________________ C. Name of person responsible for adjusting claims: _______________________________________ Connecticut Adjuster’s License Number: _________________ Expiration Date: _____________ Phone: (____)__________-______________ Ext. _____________________________ Toll-Free number for out-of-state offices: (1-800) ______________________________ D. Will any past claims of the self-insured be serviced under this contract? E. Effective date of service contract Yes … No … __________________________________________________ NOTICE: Personnel responsible for adjusting claims MUST hold valid workers’ compensation adjusters licenses issued by the State of Connecticut Insurance Commissioner pursuant to §38a-792. Dated: _________________________ Claims Office Manager or Self-Insured Applicant ________________________________________________ (signature) ________________________________________________ (print name) WCC Application for Certificate of Self-Insurance – Rev. 11/14/08 Page 3 American LegalNet, Inc. www.FormsWorkflow.com