Application for Self-Insured Employer Group 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, Self-Insurance Registration & Reimbursements Unit 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 The self-insured employer group (applicant) applying for certification as a self-insurer in the state of Oregon, as provided in the Oregon workers' compensation law, may not operate as a certified self-insurer until the division issues a Certificate of Approval to Self-Insure, Form 440-1048. Self-insured group name, mailing address, and website address: Desired self-insurance effective date: 1. List the group administrator (For groups consisting of private employer members, the group's administrator may not be a member of the group or the group's board, or a trustee for the group): Name: Company name: Street address: City, state, ZIP: Phone: Fax: Email: Title: 2. Group Type: Private Public Corporate Status: Individual Partnership Corporation LLC Entity Type (e.g., intergovernmental entity under ORS 190.003 to 190.110): 3. Federal employer identification number (FEIN): 4. 5. Incorporated or organized under the laws of the state of: Date of start of business in Oregon: See Page 5, Item A on 6. List the name or names of group trustees: Trustee name: Trustee name: Trustee name: Phone: Phone: Phone: Email: Email: Email: 440-1867 (3/15/DCBS/WCD/WEB) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 7. List the legal business name of all individual employers seeking certification in the group and include required membership criteria for each member: Employer name: Employer name: Employer name: Employer name: Employer name: Phone: Phone: Phone: Phone: Phone: Email: Email: Email: Email: Email: See Page 5, Item F, for each member's required items. Attach additional pages in the same format for all additional members. 8. a. b. List the number of Oregon employees to be covered by the proposed group self-insurance plan: Will the number of Oregon employees covered under the proposed group self-insurance plan be materially increased in the next 12 months? Yes No If yes, by approximately how many? 9. At the date of this application, is there any litigation or legal proceeding pending or threatened, the result of which might have a substantial adverse effect on the financial condition, business, or operations of the group applicant named in Yes No Question 1, or any of its proposed members? If yes, explain (attach additional pages, if necessary): 10. Provide the following claims information for your proposed self-insured group's operations in Oregon: a. Detailed Loss Runs for the past four years for each member; see Page 5, Item E for required attachments.. b. 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: Phone: c. Title: Email: List the name of the proposed service company (third-party administrator) to process claims in Oregon. [Must be a service company 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: Phone: 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. 440-1867 (3/15/DCBS/WCD/WEB) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com d. 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: Phone: Email: Title: Fax: Attachment required ­ see Page 5, Item G. e. 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: 11. List person or entity responsible for submitting quarterly payroll reports for the Workers' Benefit Fund assessment/premium assessment (must be an employee of the applicant). For groups consisting of private employer members, the designated person or entity may not be a member of the group or the group's board, or a trustee for the group. Name: Phone: Email: 12. List person or entity responsible for submitting required annual audited financial statements of the self-insured group to the division (must be an employee of the applicant). For groups consisting of private employer members, the designated person or entity may not be a member of the group or the group's board, or a trustee for the group. Name: Phone: Title: Fax: Title: Fax: Email: Attachment required ­ A current financial statement for each member of the proposed self-insured group; see Page 5, Item F ­ third bullet and Item I. 13. List person or entity 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). For groups consisting of private employer members, the designated person or entity may not be a member of the group or the group's board, or a trustee for the group. Name: Phone: 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 type of proposed security deposit instrument [must be a surety bond or an irrevocable standby letter of credit (ISLOC) authorized by the director in accordance with ORS Chapter 656]: Name of surety bond carrier: Name of bank providing ISLOC: 15. List name of the proposed excess insurance policy with a required self-insured retention of $300,000 or higher. Excess carrier: Liability limit: 440-1867 (3/15/DCBS/WCD/WEB) Self-insurance retention (SIR): Page 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR SELF-INSURED EMPLOYER GROUP AGREEMENTS The applicant agrees with the following conditions to be certified as a self-insured group under Or