Application For Certificate Of Self Insurance

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION 21 Oak Street, Hartford, CT 06106 APPLICATION FOR CERTIFICATE OF SELF-INSURANCE:::::::Index No.Calendar No.JUDICIAL SUBPOENA(APPLICATION MUST BE COMPLETED IN FULL BY APPLICANT)Plaintiff(s) -against-Defendant(s)1.A.Name of employer: B.Form of business entity: C.Location of principal office: D.Contact person/Title:(phone no.) E.Number of years in business: 2.Locations of Connecticut operations (INDICATE IF SUBSIDIARY OR DIVISION): (Attach additional sheet if necessary.) A.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(S/D) B.(S/D)THE PEOPLE OF THE STATE OF NEW YORK TO3.Will the above subsidiary(s)/division(s) be covered under this Certificate?Yes No 4.Current number of employees in ConnecticutAll locations 5.(NEW APPLICANTS ONLY) Name of current workers' compensation insurance carrier and policy expiration date 6.Please provide the following information: A.GREETINGS:Self-insured retention amount $ per occurrence B.Surety underwriter C.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableSecurity amount $ Bond/LOC No. D.,Excess insurance limit per occurrence$ E.located at County ofExcess insurance carrier (Connecticut licensed only) Policy No. Policy Term: 7.o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomMost recent audited financial statements (Renewal Applications) or the last three years (New Applications) (please attach). FY FY FY 8.Requested effective date of Certificate of Self-Insurance (Not earlier than 90 days from date of application for new applicants. Renewals MUST be submitted at least 60 days prior to expiration of current certificate).Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.THE PRIVILEGE OF SELF-INSURANCE IS GRANTED TO THOSE EMPLOYERS WHO DEMONSTRATE THE CAPABILITY OF FINANCIAL STRENGTH AND STABILITY TO MAKE PAYMENT OF ALL WORKERS' COMPENSATION LIABILITIES. FAILURE TO MAINTAIN FINANCIAL STABILITY, e.g., BANKRUPTCY, SHALL RESULT IN IMMEDIATE REVOCATION PROCEEDINGS. I,, one of the Justices of theCourt in Witness, Honorableday of, 20 County,, hereby swear that the information provided with this Application for Self-Insurance is true and accurate. I make this statement subject to the penalties for perjury.(Attorney must sign above and type name below)SignatureMUST BE SIGNED BY CORPORATE OFFICER, PARTNER OR PROPRIETOR TitleAttorney(s) forSubscribed and sworn to before me this., 20day ofOffice and P.O. Address NotaryTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:WCC Application for Certificate of Self-Insurance -Eff. 10/15/02Page 1American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.9.Please attach the following: a. description of the light-duty programs at your Connecticut locations b. explanation of procedures used to notify workers of their rights and obligations when injured on the job c. procedures in effect to administer and investigate claimsCalendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)10.Payroll History For Connecticut Operations: Year Total Payroll $ Year Total Payroll $ Year Total Payroll $11.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Loss History For Last 3 Full Years For Connecticut Operations. Supporting documentation must be included, (i.e. , Loss Runs): Year# ClaimsAmount PaidAmount OpenTotal Incurred LossTHE PEOPLE OF THE STATE OF NEW YORK TO (medical)(medical)(medical) (indemnity)(indemnity)(indemnity)GREETINGS: (total paid)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable(total open)(total incurred),located at County ofYear# ClaimsAmount PaidAmount OpenTotal Incurred Losso'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room (medical)(medical)(medical) (indemnity)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.(indemnity)(indemnity) (total paid)(total incurred)(total open), one of the Justices of theCourt in Witness, Honorableday of, 20 County,Year# ClaimsAmount PaidTotal Incurred LossAmount Open (medical)(medical)(medical)(Attorney must sign above and type name below) (indemnity)(indemnity)(indemnity)Attorney(s) for (total paid)(total incurred)(total open)12.Total Reserves On All Self-Insured Claims (Renewals Only): $ Valued as of Office and P.O. Address13.Do you employ 25 or more employees? Yes No If yes, do you have a Safety Committee established per the CT WC Regulations? Yes No Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:WCC Application for Certificate of Self-Insurance -Eff. 10/15/02Page 2American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION 21 Oak Street, Hartford, CT 06106Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)CERTIFICATION OF CLAIMS SERVICING FORMNAME OF SELF-INSURERNAME OF CLAIMS AGENCY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A.THE PEOPLE OF THE STATE OF NEW YORK TOClaims Office Location: B.GREETINGS:Mailing Address (if different from above): C.Name of person responsible for adjusting claims: Connecticut Adjuster's License Number: Expiration Date: Phone: ()- Ext. Toll-Free number for out-of-state offices: (1-800) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Co