Application for Self-Insurance Workers' Compensation Division Read all instructions before completing this application. Answer all questions. Return this form to: Oregon Department of Consumer and Business Services Workers' Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Applicant's legal name, mailing address, and corporate website address: Desired self-insurance effective date: The employer (applicant) applies for certification as a self-insurer in the state of Oregon, as provided in the Oregon workers' compensation law. An applicant may not operate as a certified self-insurer until the division issues a Certificate of Approval to Self-Insure. 1. List the company representative for self-insurance: Name: Company name: Street address: City, state, ZIP: Telephone: 2. Corporate status: Individual Corporation 3. Nature of business: Fax: Email: Title: Partnership LLC Federal employer identification number (FEIN): a. Primary National Council on Compensation Insurance (NCCI) classification codes with greatest payroll in Oregon: (NCCI codes may be found on your recent workers' compensation insurance policy ­ NCCI webpage: www.ncci.com): b. Total number of employees in Oregon: Attachment Required ­ see Page 5, Item A. 4. 5. Incorporated or organized under the laws of the state of: Date of start of business in Oregon: on 6. If the applicant is a subsidiary, complete the following items: Exact legal name of ultimate parent: Date parent incorporated: State: FEIN: If applicant is subsidiary, include a completed Form 440-4966 ­ Indemnity Agreement by the Parent Corporation for Wholly Owned or Majority Owned Subsidiary. Attachment required ­ see Page 5, Item B. 440-1868 (08/14/DCBS/WCD/WEB) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 7. List the corporate officers for the ultimate parent or applicant if no parent (CEO, CFO, and/or Risk Manager): Officer name: Officer name: Officer name: Telephone: Telephone: Telephone: Email: Email: Email: Attachment required ­ organizational chart, see Page 5, Item C. 8. List the subsidiaries or legal entities to be included in the self-insurance program: Legal name: Legal name: Legal name: Complete Form 440-1865, Endorsement to Include Legal Entity in Self-Insured Certification, for each subsidiary to be added (if necessary, attach a list). Attachment required ­ see Page 5, Item D. 9. a. Provide the following claims information for your proposed self-insured operations in Oregon: Attachment Required ­ Detailed Loss Runs for the past three years, see Page 5, Item E. List the person responsible for submission of claim reports to the department and maintenance of all claim records (must be an employee of the applicant): Name: Telephone: b. Title: Email: List the name of the proposed claims service agency or third-party administrator to process claims in Oregon: [Must be a claims service agency that has been authorized by the Department of Consumer Business Services (DCBS)] Oregon law does not allow captive insurance companies to provide workers' compensation insurance or process claims in Oregon. Company name: Contact person: Address: City, state, ZIP: Telephone: Fax: Email: Up to two additional locations within Oregon may be approved for claims processing. A written request to the division is required. Attach additional pages if more than one company. Attachment required ­ see Page 5, Item F. c. If choosing to self-administer claims, list the Oregon certified claims examiner (must be an employee of the applicant and must include a copy of the Oregon Claims Examiner Certificate). Name: Email: Telephone: Attachment required ­ see Page 5, Item G. d. If choosing to self-administer claims at a location outside of Oregon, list the address where the records will be kept and the claims will be processed. Claims location address: 10. Provide most recent experience rating modification (ERM) worksheet and supporting documentation. Most recent ERM: Attachment required ­ ERM worksheet, see Page 5, Item H. 440-1868 (08/14/DCBS/WCD/WEB) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Title: Fax: 11. List person responsible for submitting quarterly payroll reports for the Workers' Benefit Fund assessment/premium assessment (must be an employee of the applicant): Name: Telephone: Email: 12. List person responsible for submitting required annual financial statements to the division (must be an employee of the applicant): Name: Telephone: Email: Attachment required ­ Certified Audited Financial Statement for the past three years, see Page 5, Item I 13. List person responsible for submitting required documents pertaining to the applicant's security deposit [surety bond or irrevocable standby letter of credit (ISLOC)], and excess insurance requirements (must be an employee of the applicant): Name: Telephone: Title: Fax: Title: Fax: Title: Fax: Email: If authorized broker or agent will be providing these documents or discussing confidential information regarding your application, an Exemption Provision Waiver is required under ORS 192.501(5). Attachment Required ­ Form 440-4965, Exemption Provision Waiver, see Page 5, Item J. 14. List name of the current workers' compensation insurance carrier: Name: Policy no.: Effective dates: to Attachment required ­ Declaration page from your workers' compensation policy, see Page 5, Item K. 15. List name of the proposed excess insurance policy and desired limits: Excess carrier: Liability limit: 16. List type of proposed security [must be a surety bond or an irrevocable standby letter of credit (ISLOC)]: Name of surety bond carrier: Name of bank providing ISLOC: Self-insurance retention (SIR): 440-1868 (08/14/DCBS/WCD/WEB) Page 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR SELF-INSURANCE AGREEMENTS The applicant agrees with the following conditions to be certified as a self-insurer under Oregon workers' compensation law: 1. To promptly pay compensation and other payments due to injured employees or their dependents in accordance with the Oregon workers' compensation law. 2. To promptly report compensable injuries, diseases, and deaths to the Workers' Compensation Division as required by law. 3. To promptly notify the Workers' Compensation Division if contemplating liquidation, sale, or transfer of ownership of the (applicant employer, self-insuring employer, entity, business), and early enough in advance of taking any such actions to enable the Workers' Compensation Division to e