WORKER222S COMPENSATION BOARD OF INDIANA STATE FORM 18488 9R13/3-990 402 WEST WASHINGTON STREET, ROOM W196 FORM SI-1 (Revised 2018) INDIANAPOLIS, IN 46204-2753 Approved by State Board of Accounts www.in.gov/wcb WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES ACTS EMPLOYER'S APPLICATION FOR PERMISSION TO CARRY RISK WITHOUT INSURANCE This application is for employers subject to the provisions of the "Indiana Worker's Compensation and Occupational Diseases Acts", that wish to obtain a certificate to pay compensation directly, without insurance, to injured employees or to the dependents of employees who die as a consequence of illness or injury as a result of a workplace injury. This also covers payment of medical expenses incurred in the treatment of an injured worker. This application will cover the period of September 1, 2019 to midnight, August 31, 2020. The information provided herein is for the purpose of enabling the Worker's Compensation Board of Indiana to determine whether the applicant possesses sufficient financial ability to render certain the payment of such compensation and medical expenses. Applicant Employer, through , , (name) (position within organization) is qualified to speak on behalf of and bind the named applicant, 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: American LegalNet, Inc. www.FormsWorkFlow.com 2. 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 submit relevant Loss Run Reports electronically on a flash drive or a disc, with the information set out on the following chart. Under Amount Paid, please provide the total paid for each calendar year, regardless of the date of injury. Under # of Injuries, please provide the number of injuries which occurred during the calendar year indicated. American LegalNet, Inc. www.FormsWorkFlow.com 2016 2017 2018 Amount Pd # Injuries Amount Pd # 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" 2016 Total Paid $ 2017 Total Paid + $ 2018 Total Paid + $ Three-Year Total Paid $ divided by 3 = $ 3yr average (b) Multiply 3 year average by 2 $ (c) Enter greater of $500,000 or line (b) $ (d) Increase/decrease in line (b) from prior year $ (Additional security required) 5. SECURITY a. SURETY BOND Amount of Bond $ Cost of Bond $ (Required) ($500,000.00 Minimum) (Annual Premium) Surety Name: Telephone: Address: American LegalNet, Inc. www.FormsWorkFlow.com Bond # (Application cannot be processed if blank) Please provide a copy of the Bond herewith. and/or b. LETTER OF CREDIT 226 please attach a copy Amount of LOC $ Name of Financial Institution Routing Number Identification # of LOC c. EXCESS COVERAGE: Specific $ Self-Insured Retention $ Aggregate $ Cost of Excess $(Required) (Annual Premium) d. Does the employer have a system to establish a reserve to pay claims for medical treatment or compensation? e. 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 and would prefer email notices from employers as well. (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(s) 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 in Indiana: American LegalNet, Inc. www.FormsWorkFlow.com Describe educational training in Indiana Worker222s Compensation Law: Has this individual attended at least one seminar on Indiana Worker222s Compensation over the past year? This is mandatory, which course , , Name Location Date (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 3 years 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. Please submit electronically or on a disc/flash drive. (c) Information concerning involvement or membership in organizations or seminars specifically directed toward self-insured workers compensation issues. Is your company a member of Indiana Self-Insured Association? Yes No American LegalNet, Inc. www.FormsWorkFlow.com (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 worker222s compensation administration, laws, regulations, or other. (f) Copy of bond, LOC or other form of security approved by the Board. Additionally, new applicants must attach the following information: (i) Premium payments made the last three years and to which carrier(s). (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.This privilege may be revoked at any time at the discretion of the Worker's Compensation Board of Indiana ("Board"). b.Applicant shall fully discharge, by immediately negotiable instrument or approved debit card, 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/or burial. c.If the Board so requires, following a determination of Permanent Total Disability by agreement or award, the applicant shall demonstrate within thirty (30) days after this determination continuing liability to pay compensation to an injured employee for a definite period for a permanent injury (or to the dependents of a de