OKLAHOM A W ORKERS' COM PENSATION COURT 1915 NORTH STILES AVENUE OKLAHOM A CITY, OK 73105-4918 (405) 522-8600 FORM 1B EM PLOYERS APPLICATION FOR PERM ISSION TO CARRY ITS OWN RISK WITHOUT INSURANCE To: The Oklahoma W orkers' Compensation Court Date__________________________________ The undersigned, an employer subject to the provisions of the W orkers' Compensation Code, hereby applies for permission to carry its own risk without insurance. To enable the W orkers' Compensation Court to determine whether or not the applicant possesses sufficient financial ability to render certain the payment of any award made by the Court, said applicant hereby states the following: 1. Employer’s Name_________________________________________________________________________________ 2. Employer’s Federal Identification Number_____________________________________________________________ 3. Home Office Address______________________________________________________________________________ 4. Oklahoma principal office address____________________________________________________________________ 5. Incorporated or organized under the laws of the State of __________________________________________________ 6. If foreign corporation, give date licensed to do business in Oklahoma________________________________________ 7. Nature of business________________________________________________________________________________ 8. General Information on Company: a. Years engaged in continuous business_________________________, b. In Oklahoma_______________________ Payroll in each of the preceding three (3) years: Year:_______, $___________________; Year:_______, $___________________; Year:_______, $________________ Payroll in Oklahoma in each of the preceding three (3) years: Year:_______, $___________________; Year:_______, $___________________; Year:_______, $________________ c. d. 9. Number of employees presently employed_______________ In Oklahoma______________ Estimated payroll in Oklahoma for the next twelve (12) months________________________ Excess Insurance Information: a. Name of carrier______________________________________________________________________________ b. Policy dates: c. Under this policy: Effective_____________________________ Expiration_______________________________ Self Insured Retention____________________ Limits of Liability___________________ Note: A certificate of excess insurance or a valid binder issued by said carrier m ust be attached to this application. A copy of the policy m ust follow. 10. Estimated manual premium for your company_____________________________________________ Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 11. A. In the section below, state the loss history for the past five (5) calendar years. Copy the requested information from your loss runs (if the hard copy of your loss runs are required you will be notified). Also include the current year's history, indicating how many months of the current year are included: Total incurred losses in Oklahoma (include for all injuries, both open & closed claims) CY $ Medical Paid 2011 $ Indemnity Paid $ Total Paid Cases Reopened $ Total Reserves Outstanding Cases Closed mo 2010 2009 2008 2007 2006 CY Cases Opened 2011 Death Cases mo 2010 2009 2008 2007 2006 B. Total Self Insurance Reserves Outstanding: (for all years of self insurance) Total Self Insured Open Cases: (for all years of self insurance) 12. A. B. 13. A. $______________________ ________________________________ Enclose current audited financial report, including balance sheets, income statements & notes. A governmental entity must provide a definite statement of the amount it has specifically appropriated for workers' compensation claims for the latest and the next fiscal year. Also, a description of how workers' compensation claims are funded must be submitted. Is the applicant a subsidiary of another employer? ______ If yes, submit the parent company's financial statements. B. Does the applicant have subsidiary companies that it wants to include under this permit?___________________ (attach a list of the names and addresses of ALL entities to be included under this permit, including subdivisions) C. If you answered yes to either question 13A or 13B, attach a copy of a written agreement whereby the ultimate parent employer guarantees that it will be fully responsible for any liabilities that its subsidiaries may incur under the Oklahoma W orkers' Compensation Act. 14. A. Name and address of the company's Third Party Administrator for the servicing of the self insurance claims. _____________________________________________________________________________ _____________________________________________________________________________ B. If an approved Third Party Administrator is not employed, please submit qualifications of benefits administrator. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 15. Attach a copy of your company's safety plan. 16. 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 by the Administrator of the W orkers' Compensation Court. B. The applicant agrees to comply with all applicable statutes and the rules of the W orkers’ Compensation Court and the Court Administrator. Include an annual application fee of $1,000 as required by law, made payable to the Oklahoma W orkers' Compensation Court. I declare under penalty of perjury that I have examined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Signed this __________ Day of _________________, ________ __________________________________________________ Print Name and Title (note: person signing should be authorized to bind the applicant to the agreements contained herein) __________________________________________________ Signature __________________________________________________ Mailing Address __________________________________________________ Street Address, if different from Mailing Address __________________________________________________ City, State Zip Code __________________________________________________ Telephone Number __________________________________________________ E-mail Address Send application to: Rev. 8/2011 Insurance Department Oklahoma W orkers' Compensation Court 1915 North Stiles Ave. Oklahoma City, OK 73105-4918 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com