Application To Self-Insure Workers Compensation Liabilities Form. This is a South Dakota form and can be use in Workers Compensation.
Tags: Application To Self-Insure Workers Compensation Liabilities, South Dakota Workers Compensation,
1. STATEMENT OF EMPLOYER IN SUPPORT OF APPLICATION TO: State of South Dakota, Department of Labor and RegulationDivision of Labor and Management123 W. Missouri Ave.Pierre, South Dakota 57501-2291Phone: 605.773.3681(1.1) Name and address, including ZIP + 4 of applicant. (1.2) Federal Identification Number of applicant. The undersigned, having elected to remain under the provisions of the Workers' Compensation Law, hereby agrees to provide and pay all legal obligations under the Workers' Compensation Law, including but not limited to compensation for the injuries to employees as required by Title 62 of the South Dakota Codified Laws or as may be awarded by the South Dakota Department of Labor and Regulation. In making application for exemption from the insurance provisions of SDCL 62-5-1, the applicant hereby submits evidence of solvency and financial ability to pay compensation and other obligations contemplated. (1.3) Names and addresses, including ZIP + 4, of all businesses to be self-insured in South Dakota (if necessary, additional businesses may be added on "Additional Notes" tab). SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATIONDIVISION OF LABOR AND MANAGEMENT 123 W. Missouri Ave. Pierre, South Dakota 57501 Tel: 605.773.3681 þ Fax: 605.773.4211 þ dlr.sd.gov APPLICATION TO SELF-INSURE WORKERS' COMPENSATION LIABILITIES This application is for approval to self-insure workers compensation liabilities from September 1, 2018 to August 31, 2019. If the application is being made after September 1, 2018, the Certificate of Exemption will be valid only from the date of execution until August 31, 2019. A renewal application will be required for self-insurance during the 2019/2020 year. This is an application for employers seeking to self-insure workers' compensation in South Dakota. The attached schedules are to facilitate the submission of proof of solvency and financial ability to compensate under the provision of the Workers' Compensation Law of South Dakota. Answer all applicable questions fully. Specifically indicate N/A in any areas not applicable. If you are not completing this application electronically, please use black ink or type. If any questions are left unanswered, the application may be returned for completion, causing a delay in approval. DLR WORKERS' COMPENSATION SELF-INSURE Page 1 of 22REV 05/2018 American LegalNet, Inc. www.FormsWorkFlow.com (1.4) Federal Identification Number of all businesses to be self-insured in South Dakota. (1.6) Are all businesses listed on application authorized to operate in South Dakota? Yes No (1.5) Nature of businesses. (1.7) Name and address, including ZIP + 4, of person in South Dakota on whom legal service can be made. (1.8) Name(s), address(es), and title of owner(s), partners or senior corporate officers. DLR WORKERS' COMPENSATION SELF-INSURE GENERAL INFORMATIONPage 2 of 22REV 05/2018 American LegalNet, Inc. www.FormsWorkFlow.com 2. COMPANY BACKGROUND (2.1) Date Established. (2.2) If incorporated, under laws of what state? (2.3) Did firm succeed another firm? YesNo (2.4) If yes, state whom and date of transition. (2.5) Name(s) and addresse(es) of parent, subsidiary, and affiliate companies if any. Please specify affiliation. (2.6) Is the parent, subsidiary or affiliated company guaranteeing the workers' compensation of the applicant? Yes No *If yes, attach notarized Assumption of Self-Insurance Obligations form. 3. FINANCIAL DATA (2.7) List all subsidiaries and affiliates to be self-insured and state the self-insurance retention limit on each. If necessary, additional subsidiaries and affiliates may be added on "Additional Notes" tab. (2.8) List name and address, including ZIP + 4, of all administrative branch offices and/or locations in South Dakota (if necessary, use Additional Notes tab). If applicable, specify which are subsidiaries and which are divisions of the applicant. If the most recent audited annual financial statement does not report your financial position at a date within six (6) months of the beginning of the self-insurance year (September 1, 2018), provide an interim financial *If yes, the financial data below should relate to all entities to be self- insured and the guarantor. *If no, the financial data below should relate only to the entities to be self-insured. Please provide audited annual financial statements for the three (3) most recent years. If audited annual financial statements are not available, please provide a balance sheet, income statement and statement of change in financial position for each DLR WORKERS' COMPENSATION SELF-INSURE COMPANY AND FINANCIAL INFORMATIONPage 3 of 22REV 05/2018 American LegalNet, Inc. www.FormsWorkFlow.com 4. INSURANCE INFORMATION YesNoYesNo(4.5) If no, has applicant been an approved self-insurer during the last three (3) years?YesNo(4.6) If no, how was workers' compensation coverage provided?(4.7) Expiration date of workers' compensation policy now in effect. (4.8) Is applicant authorized to self-insure its workers' compensation liability in any other states?YesNoYesNo(4.11) If yes, please list state(s) and date(s) (including South Dakota). (4.12) Please fill out the Retention Limits Form below: Aggregate CoverageEffectiveLimitDate*Dollar Limit or "Statutory"(4.9) If yes, please list the name of each state. If necessary, additional states may be added on "Additional Notes" tab. (4.10) Has applicant ever been denied authority to self-insure its workers' compensation or other liability in any state, or has such authority ever been revoked or suspended?(4.1) Has applicant been approved by the South Dakota Department of Labor and Regulation to self-insure its workers' compensation liabilities in the State of South Dakota prior to this application? (4.3) Has applicant carried workers' compensation insurance in South Dakota during any or all of the last three (3 (4.2) If yes, date applicant commenced self-insurance. (4.4) If yes, please attach the name of insurer and attach declaration pages or binder for each policy showing policy effective date, experience modifications, and South Dakota class codes and payroll. Excess*LimitExcess Insurer Per Occurrence RetentionRetentionYear20132014201520162017 DLR WORKERS' COMPENSATION SELF-INSURE INSURANCE INFORMATIONPage 4 of 22 05/2018 American LegalNet, Inc. www.FormsWorkFlow.com YesNo 5. ADMINISTRATION OF SELF-INSURANCE PROGRAM YesNo (5.2) If so, please submit a copy of that plan. YesNo(5.5) Is the claim reserve a separate line item in the financial statement?YesNoYesNo(5.7) Is the claim reserve, if established, reflected on the balance sheet?YesNo(5.8) If yes, where? (5.6) Does the claim reserve include a provision for incurred but not reported (IBNR) claims? (5.10) How are case reserves established?(5.11) Key Claim Administrator (5.9) If the response to any of the immediately preceding questions is negative (No), please provide a response from your auditor regarding FASB 112 compliance. Name and TitleName of FirmAddress(4.13) Please provide a copy of Certificate of Insurance for the most recent year to verify excess coverage levels and insurers. (4.14) Does the applicant intend to maintain excess coverage through the upcoming self-insurance year (September 1, 2018 to August 31, 2019)?(5.1) If workers' compensation liabilities are currently self-insured, have you provided a scheme of compensation benefits whereby your South Dakota employees receive benefits that equal or exceed the benefits set forth in Title 62 (Workers' Compensation) of the South Dakota Codified Laws? (5.4) How is/will the self-insured workers' compensation claim experience be reflected in the applicant's financial statements?(5.3) If you do not have a specific scheme of compensation, is it your intent to simply follow the statutory benefit requirements?Telephone Number DLR WORKERS' COMPENSATION SELF-INSURE INSURANCE INFORMATIONPage 5 of 22 05/2018 American LegalNet, Inc. www.FormsWorkFlow.com YesNo(5.15) If no, please specify limits. (5.12) Indicate whether the following services are provided in-house or by an independent contractor. Services Provided In-House Contracted (5.14) Does this person have authority to pay (5.13) In