Form SI Employer Page 1 Rev. 0 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 (405)522 - 3222 or In - State Toll Free (8 55 ) 291 - 3612 APPLICATION FOR INDIVIDUAL OWN RISK EMPLOYER PERMIT Date The undersigned, an employer subject to the provisions of the Administrative Workers' Compensation Act, hereby applies for permission to carry its own risk without insurance. To enable the Workers' Compensation Commission to determine whether or not the applicant possesses sufficient financial ability to render certain the payment of any award made by the Commission , said applicant hereby states the following: 1. Legal Business Name 2. If the Employer does business, or has done business under another name in Oklahoma , including any trade name, list those other names 3. Own Risk # (if a renewal applicant) 4. (FEIN ) 5. Home Office Mailing Address (P lease include City, State, Zip) 6. Home Office Physical Address ( i f d ifferent ) (P lease include City, State, Zip) 7. Oklahoma P rincipal O ffice A ddress ( if d ifferent ) (P lease include City, State, Zip) 8 . If the Employer is an out - of - state company , give year licensed to do business in Oklahoma 9 .Nature of business 10 . Name of the E Medicare Reporting contact ( If managed through a third party vendor , list contact) 1 1 . Primary contact for E mployer ( W ho m we should contact for additional information about this application) Name Title American LegalNet, Inc. www.FormsWorkFlow.com Form SI Employer Page 2 Rev. 0 Email address Telephone Number 1 2 . Secondary contact for E mployer ( W ho m we should contact if the primary contact is not available) Name Title Email address Telephone Number 1 3 . General Company Information : a. Years engaged in continuous business In Oklahoma b. Number of employees presently employed In Oklahoma c. Estimated payroll in Oklahoma for the next twelve (12) months d . Payroll in each of the preceding three (3) years: Overall In Oklahoma Year :, $ Year:, $ Year :, $ Year:, $ Year:, $ Year:, $ 1 4 . a . Is the Employer applying for an Oklahoma Own Risk License owned by another employer or parent company ? ( Check appropriate answer) Yes No If yes, l ist owner name: b. Does the Employer want to cover other employers /companies under the permit ? ( Check appropriate answer) Yes No If yes, list other employers/companies; Attach a list of other employers/compa nies, with the employer/company FEIN, address, and covered locations. c . Does the Employer own other employers/companies that it does not want to cover under the permit ? ( Check appropriate answer) Yes No If yes, list other employers/companies ; Attach a list of other employers/companies, with the employer/company FEIN, address, and covered locations. 1 5 . a. Does the Employer use a Third - party Administrator (TPA) or an In - house Benefit Administrator to service self insurance claims ? ( Check appropriate answer) TPA In - house Benefit Administrator b. If the Employer uses a TPA, provide the name and address (including City, State, and Zip) of the TPA, contact name, contact phone number, and contact email address: c. If the Employer uses an In - number: American LegalNet, Inc. www.FormsWorkFlow.com Form SI Employer Page 3 Rev. 0 1 6 . In the section below, state the l oss history for the past five ( 5 ) years. Copy the requested inform ation from your loss runs . Also include the current year's history, indicating how many months of th e current year are included. Note : A n actuarial report may be requested by the Commission. a. Total incurred losses in Oklahoma (include for all injuries, both open and closed claims): (Please report by date of injury, not date reported or date paid) Calendar Yr or Fiscal Yr Ending Medical $ Paid Indemnity $ Paid Total $ Paid (including any expenses) $ Total Reserves Outstanding 201 7 # mos. 2016 2015 2014 2013 2012 C alendar Y r or Fiscal Yr Ending # of Cases Opened # of Cases Reopened # of Cases Closed # of Cases Currently Open 201 7 # mos. 2016 2015 2014 2013 2012 b. Total Self Insurance Net Reserves Outstanding for All Years of Self Insurance : ( Net Reserves Outstanding = Current Reserves Minus Any Expected Excess Carrier Reimbursements) c. Total Self Insured Open Cases for All Years of Self Insurance: d. Estimated manual premium: s excess insurance carrier , agent or broker ) 1 7 . Excess Insurance Information: a. Name of Carrier Policy # b. Policy dates: Effective Expiration c. Self Insured Retention d. Does the Employer carry Aggregate Excess Insurance ? ( Check appropriate answer) Yes No If yes: Aggregate Retention Aggregate Limits Note: A certificate of excess insurance or a valid binder issued by said carrier must be attached to this application. If coverage renews during the permit year, please send a copy of the certificate for the renewed coverage. 1 8 . For governmental entities : a. Amount appropriated for the current fiscal year American LegalNet, Inc. www.FormsWorkFlow.com Form SI Employer Page 4 Rev. 0 b. Amount appropriated for the next fiscal year (if available) c. Amount any other reserved open claims : 1 9 . Include the nonrefundable annual application fee of $1,000 , made payable to the Commission , and any required attachments indicated b elow with this application. All items may be emailed to InsuranceDepartment@wcc.ok.gov . However, we must receive the original parental guaranty via mail or courier. Signed Application Nonrefundable annual application fee $1000 made payable to: Proof of Excess Insurance ( the most current certificate ; a current certificate is required for final approval ) The as the Certificate Holder or Regulatory Authority . A completed Designation of Service Agent CC - Form 7 (even if there are no changes from last year) The most recent audited financial statements, including balance sheet, income statement, statement of cash flows, and notes ( If the company does not have audited financial statements, unaudited financial statements signed by two company executives may be submitted ) If the Employer is owned by another company, the audited financ ial statements for the parent company T he most recent interim financial statements available for the E mployer and any parent company , including balance sheet, income statement, and s tatement of cash flows . If the Employer has employees at multiple Oklahoma locations, a list of all locations, with the full addres s for each location . A list of any additional employers/companies to be included under the permit , including their Federal Identification Number (F EIN) and list of covered Oklahoma locations. If the Employer owns other employers/companies that should not be included on the permit, a list of the names, addresses, and federal employer identification numbers (FEIN) of ALL employers/companies to be excluded from the permit, including subdivisions. Advise whether those employers/companies are included under another Own Risk License , Carrier Name. Loss runs for the past five years. Loss runs should contain a summary for each year, containing total $ paid (including any expenses) and total reserve $ outstanding. D ata that identifies individual employees may be redacted. Actuarial reports are not required but are helpful if available . If the renewing Employer has a parental guaranty of funds and there are any changes to the named insureds on the permit applicant/renewal; then you must provide a new, notarized original parental guaranty from the parent or principal employer. For Governmental Entities A copy of the minutes from the board meeting where the budgeted amount was approved. For Governmental Entities If the financial statement or CAFRA does not indicate that the appropriated funds are placed into a segregated fund , in compliance with Commission Rule 810:2 5 - 9 - 11 , please provide documentation that the funds are placed in a segregated fund. American LegalNet, Inc. www.FormsWorkFlow.com Form SI Employer Page 5 Rev. 0 20 . PLEASE READ CAREFULLY In consideration of the approval of this application, the applicant hereby expressly agrees as follows: a. The applicant's privilege to carry its own risk without insurance may be revoked at any time for good cause