WORKER’S COMPENSATION BOARD OF INDIANA 402 WEST WASHINGTON STREET, ROOM W196 INDIANAPOLIS, IN 46204-2753 www.in.gov/wcb STATE FORM 18488 9R13/3-990 FORM SI-1 (Revised 2012) Approved by State Board of Accounts WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES ACTS EMPLOYER'S APPLICATION FOR PERMISSION TO CARRY RISK WITHOUT INSURANCE The undersigned, an employer subject to the provisions of the "Indiana Worker's Compensation and Occupational Diseases Acts", hereby applies for a certificate to pay compensation directly, without insurance, to injured employees or to the dependents of employees who die in consequence of illness or injury for the period of September 1, 2012 to midnight, August 31, 2013; and, for the purpose of enabling the Worker's Compensation Board of Indiana to determine whether it possesses sufficient financial ability to render certain the payment of such compensation and medical expenses. This employer, under the penalties of perjury, hereby states the following facts: 1. EMPLOYER INFORMATION __________New Applicant _____________Renewal Applicant Applicant Name: _________________________________________________ Address: _________________________________________________ _________________________________________________ _________________________________________________ Nature of Business: _________________________________________________ _________________________________________________ Website Address: _________________________________________________ FEIN: _________________________________________________ If rated for credit standing by Dunn & Bradstreet, what is the rating? _________________________________________________ If traded publicly, what is the stock symbol? _____________________ American LegalNet, Inc. www.FormsWorkFlow.com 2. EMPLOYMENT INFORMATION/SUBSIDIARY INFORMATION Indiana Location(s) Kind of Employment # of Employees a. __________________________________________________________ b. __________________________________________________________ c. __________________________________________________________ d. __________________________________________________________ e. __________________________________________________________ SUBSIDIARIES INCLUDED UNDER SELF-INSURANCE AUTHORITY FEIN # TITLE NAME CONTACT INFORMATION a. b. __________________________________________________________ c. __________________________________________________________ d. __________________________________________________________ e. 3. __________________________________________________________ __________________________________________________________ LOSS HISTORY Please find two alternative loss history charts. is required to be filled out. Only one chart Under Amount Paid, please provide the total paid for each category during the calendar year, regardless of the date of injury. Under # of Injuries, please provide the number of injuries which occurred during the calendar year that fell within, or resulted in payments in, each category(regardless of when paid). Some injuries will be counted in more than one category. The second alternative only requires you to breakdown number of injuries based on medical and indemnity. If this information is not provided on a calendar year basis, please specify the appropriate dates:_______________ through _______________. American LegalNet, Inc. www.FormsWorkFlow.com 2009 Amount Pd 2010 # Injuries Amount Pd 2011 # Injuries Amount Pd # Injuries Medical TTD TPD PTD PPI Death Benefits Burial Expenses Settlements First Report of Injury Amputation Prosthetic Device TOTAL $ $ $ 4. BOND CALCULATION (a) Determine three-year average of total medical/compensation paid per "Loss History" 2009 Total 2010 Total 2011 Total Three-Year Paid Paid + Paid + Total Paid $____________ $____________ $____________ $____________ divided by 3 = $___________ 3yr average (b) Multiply 3 year average by 2 $____________ (c) Enter total unpaid compensation liability for fatalities $_____________ (d) Add lines (b) and (c) $____________ (e) Enter greater of $500,000 or line (d) $____________ (f) Increase/decrease in line (d) from prior year $____________ 5. SECURITY a. SURETY BOND Amount of Bond $ _________________ ($500,000.00 Minimum) Cost of Bond $ __________ (Required) (Annual Premium) American LegalNet, Inc. www.FormsWorkFlow.com Surety Name: _________________________________Telephone:______________ Address: ______________________________________________________________ Bond # blank) __________________________ (Application cannot be processed if b. EXCESS COVERAGE: Specific $______________ Self-Insured Retention $ _____________________ Aggregate $_____________ Cost of Excess $_____________(Required) (Annual Premium) c. Does the employer have a system to establish a reserve to pay claims for medical treatment or compensation? ________________________________ d. List other states, if any, in which the employer is self-insured _______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. SELF-INSURANCE ADMINISTRATION It is the obligation of the employer to timely advise the Board of any changes in the information provided below which occur during the self-insured period. Please note that the Board now sends all notices related to Self-Insurance via email. (a) Identify the person within the employer's organization who is primarily responsible for the self-insurance program. This person will receive all notices as it relates to the self-insurance program, please list an alternative if you would like two individuals to receive notices: Name: ___________________________________________________________ E-Mail: ___________________________________________________________ Address: ___________________________________________________________ Telephone: ___________________________________________________________ Fax: ___________________________________________________________ Alternative: Name: ___________________________________________________________ E-Mail: ___________________________________________________________ Address: ___________________________________________________________ Telephone: ___________________________________________________________ Fax: ___________________________________________________________ (b) Identify the person who is primarily responsible for the adjustment of Indiana employee claims made pursuant of the self-insurance program (within your company or at your third-party administrator): Name: ___________________________________________________________ E-Mail: ___________________________________________________________ Address: ___________________________________________________________ Telephone: ___________________________________________________________ Fax: ___________________________________________________________ Number of years of experience in the adjustment of worker's compensation and occupational disease claims: _________________________ American LegalNet, Inc. www.FormsWorkFlow.com (c) Identify the person who is primarily responsible to receive hearing notices and other official communications from the Worker's Compensation Board regarding Indiana disputed claims: Name: ___________________________________________________________ E-Mail: ___________________________________________________________ Address: ___________________________________________________________ Telephone: ___________________________________________________________ Fax: ___________________________________________________________ (d) All companies who carry risk without insurance must file first reports of injury electronically according to standards prescribed by the Board. Please indicate whether the applicant is able to comply with this mandate. ______ Yes _____ No _____A copy of the approved plan is attached. 7. ATTACHMENTS All applicants must attach the following items to this application: _____ (a) An audited financial statement signed by an officer of the employer, such statement to become part of this application. A copy of the employer's last annual report to its stockholders may be accepted in lieu of a financial statement, if prepared within the last six (6) months. This information shall be treated as confidential by the Board and used only in evaluating this application. It will not be provided to any other entity. _____ (b) Loss runs from the prior year to verify the information provided in the Loss History and Bond Calculation sections of the application. Detailed loss information is included, specifically claimants name and total payment amounts. _____ (c) Information concerning involvement or membership in organizations or seminars specifically directed toward self-insured workers compensation issues. _____ (d) Additional information concerning the knowledge of the Act, education and claims experience of the person responsible for receiving notices from injured employees, and the amount of time this person devotes to the workers compensation process (if self-administered). _____ (e) Please provide information regarding training that those individuals responsible for the administration of self-insurance, have received in the past year regarding Indiana worker’s compensation administration, laws, regulations, or other. Additionally, new applicants must attach the following information: _____ (i) Premium payments made the last three years and to what carrier(s). American LegalNet, Inc. www.FormsWorkFlow.com _____ (ii) Loss runs from the prior three years to verify the information provided in the Loss History and Bond Calculation sections of the application. _____ (iii) NCCI experience modification for the last three years. _____ (iv) Audited financial statements, as described above, for the past three years. _____ (v) Administrative costs anticipated in association with self-insuring, particularly if the applicant intends to utilize a third-party administrator. 8. CONDITIONS The applicant hereby expressly understands and agrees as follows: a. That this privilege may be revoked at any time at the discretion of the Worker's Compensation Board of Indiana ("Board"). b. That the applicant will fully discharge by immediately negotiable instrument payment of all installments of compensation for disability or impairment promptly when due, as well as liability for physician's fees, hospital services, hospital supplies, and burial. c. That if the Board so requires, the applicant, within thirty (30) days after its continuing liability to pay compensation to an injured employee for a definite period for a permanent injury or to the dependents of a deceased employee has been determined, by agreement or award, will make a special deposit, with a bank or trust company within the State of Indiana approved by the Board, of the full amount of such definite continuing liability. Such special deposit to be made upon such terms as are prescribed by the Board. d. That the applicant will promptly notify the Board of any change in condition which could ultimately affect its ability to pay medical expenses or compensation or administer its self-insurance program. e. That the applicant will discharge all amounts due for statutory assessments under the Acts. f. That the applicant will furnish and file with the Board any security agreement, surety bond, indemnity agreement, and/or excess insurance coverage, which may be required as a condition for approval of this application. g. That the applicant, upon approval by the Board, recognizes, understands and agrees that in all cases the total assets of the applicant and its subsidiaries, if any, are pledged and available for the payment of any valid compensation or occupational disease claims made pursuant to Indiana law. American LegalNet, Inc. www.FormsWorkFlow.com h. That the applicant understands that if its surety bond is canceled and no replacement bond is filed with the Board, its self-insured status shall terminate upon the effective date of the bond cancellation without further notice from the Board. i. That the applicant understands and agrees that the surety posted will not be released until all possibility of additional losses has terminated and the Worker’s Compensation Board has approved the bond’s release, but in no event will the bond’s release be granted prior to three years from the last date of selfinsurance. j. That the applicant understands and agrees that the surety bond posted will not be reduced until after two years from the last date of self-insurance and that the decision to reduce the bond will be based upon currently active claims and claims that have been closed within the two years prior to the date of the request for reduction of the bond. The statements made herein are true and accurate to the best information and knowledge of the undersigned and are made for the express purpose of inducing the Worker's Compensation Board of Indiana to grant the applicant self-insured status as allowed by IC 22-3-5-1. This application is executed at_____________________this ______day of ____________________,_________. FOR THE APPLICANT: __________________________________________ Company) BY:__________________________________________ (Signature) __________________________________________ (Printed Name) TITLE__________________________________________ (Must be an Officer of Applicant) TELEPHONE NUMBER:__________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com FOR BOARD USE ONLY: _______________APPROVED ______________DENIED COMMENTS: ___________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ DATED: __________ WORKERS COMPENSATION BOARD OF INDIANA _____________________________________ BY: Linda Peterson Hamilton, Chairman Application Type New application Renewal Application Late: filed after 7/31/12 or incomplete renewal application Amount Due $500.00 $250.00 Payment Information American LegalNet, Inc. www.FormsWorkFlow.com