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Application For Certificate Of Self Insurance Form. This is a Connecticut form and can be use in Workers Compensation.
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Tags: Application For Certificate Of Self Insurance, Connecticut Workers Compensation,
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
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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
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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
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