ILLINOIS WORKERS’ COMPENSATION COMMISSION APPLICATION FOR SELF-INSURANCE FOR SUBSIDIARY OR AFFILIATE 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 A FFILIATE SUBSIDIARY 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. EXACT LEGAL NAME OF ULTIMATE PARENT Web site address FEIN 1 American LegalNet, Inc. www.FormsWorkFlow.com 8. 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 9. LIST THE NAME OF THE CURRENT WORKERS’ COMPENSATION INSURANCE CARRIER. Name Policy number Effective dates: From to Provide evidence of applicant’s current workers’ compensation coverage. 10. INDICATE THE ESTIMATED ANNUAL WORKERS’ COMPENSATION PREMIUM FOR THE LAST COMPLETED CALENDAR YEAR. If necessary, attach a list. INSURANCE CLASS CODE INSURANCE CLASSIFICATION DESCRIPTION # EMPLOYEES EST. ANNUAL PAYROLL CURRENT MANUAL RATE EST. ANNUAL PREMIUM TOTAL 11. 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. 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. 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. 13. WHAT MEDICAL FACILITIES ARE AVAILABLE TO YOUR EMPLOYEES? Local clinic Hospital Other (please explain) First aid In-plant doctor/nurse 14. 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 # ACCIDENT REPORTS FILED LIST OF ATTACHMENTS A. A nonrefundable application fee of $500, made payable to “Illinois Self-Insurers Administration Fund.” B. Evidence of 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 entity with operations in Illinois is seeking coverage under the certificate of self-insurance. D. (1) Provide the ultimate parent company’s audited financial statements for the most recent year. (2) If certified audited financial statements are not prepared, provide the financial statements prepared by an outside accountant for the most recent year. E. Provide the most current 10-Q or internal quarterly balance sheet and income statement of parent. F. Evidence of the applicant’s current workers’ compensation coverage. See question 9. G. Detailed Illinois loss runs for the last three completed years. See question 11. H. A narrative description of the safety program components for each operation in Illinois. See question 12. 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. IC50s 12/04 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR SELF-INSURANCE FOR SUBSIDIARY OR AFFILIATE 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 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. IC50s 5/09 Illinois Workers’ Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth St. Springfield, IL 62703-5118 217/785-7084 4 American LegalNet, Inc. www.FormsWorkFlow.com