SELF-INSURANCE APPLICATION CHECKLIST The following items are needed to fully complete your Self-Insurance application. _____ A certificate of insurance from your current insurance carrier evidencing that you have workers' compensation coverage and that you are in compliance with the workers' compensation statute at the time of your application. Your application can not be processed without this information. The most current last three (3) years audited financial statements. The financials included with your annual statements will need to show current assets, liabilities as well as total stockholder equity. The most current last three (3) years of workers' compensation loss runs. (See Sec. 1711 (B) & (C). $100.00 application fee payable to the Office of Workers' Compensation Administration. Indication of Third Party Administrator (Service Company). You will be required to provide our office with a complete copy of your service contract before final approval is granted. If the services of a third party administrator are not enlisted, then furnish resumes of the company personnel who will administer your claims. Also include safety manual/information on your safety program and resumes on your safety coordinator. Certificate evidencing your excess coverage. (SIR amount should be clearly stated on certificate). You will be required to provide our office with a sample copy of your excess policy before final approval is granted. Please indicate your self-insurance contact person & phone number. If your company is approved and your contact person subsequently changes, you are required to immediately notify our office. _____ _____ _____ _____ _____ _____ _____ NOTE: Once your application is reviewed, if approval of your self-insurance program is granted by our office, we will contact you concerning the security amount required. (See Sec. 1725(A)(1). All questions may be directed to the Audit & Security Section at (225) 342-5658. 1001 North 23rd Street - Post Office Box 94040 - Baton Rouge, LA 70804-9040 phone 225-342-7561 - fax 225-342-5665 - www.LAWORKS.net AN EQUAL OPPORTUNITY EMPLOYER American LegalNet, Inc. www.FormsWorkflow.com