Application For Self-Insurance {IC50}

ILLINOIS WORKERS' COMPENSATION COMMISSION APPLICATION FOR SELF-INSURANCE Read all instructions before completing this application. Answer all questions. RETURN TO: APPLICANT'S LEGAL NAME/MAILING ADDRESS/WEB SITE DESIRED SELF-INSURANCE EFFECTIVE DATE: Office of Self-Insurance Admin. 4500 S. Sixth St. Frontage Road Springfield, IL 62703-5118 The employer (applicant) applies for the privilege of being a certified self-insurer in the State of Illinois, as provided in the Illinois Workers' Compensation and Occupational Diseases Acts. An applicant may not operate as a certified selfinsurer until the Commission 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 E-mail address 2. APPLICANT'S FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) 3. STATUS: 4. NATURE OF BUSINESS Primary NAICS codes NAICS = North American Industry Classification System, which replaces SIC. Title Fax Individual Partnership Corporation 5. INCORPORATED OR ORGANIZED UNDER THE LAWS OF THE STATE OF 6. DATE OF COMMENCEMENT OF BUSINESS IN ILLINOIS 7. IF THE APPLICANT IS A SUBSIDIARY, COMPLETE THE FOLLOWING ITEMS. Exact legal name of ultimate parent Date parent incorporated FEIN 1 ON State Web site American LegalNet, Inc. www.FormsWorkFlow.com 8. LIST THE CORPORATE PRINCIPALS FOR THE ULTIMATE PARENT OR APPLICANT IF NO PARENT. If necessary, attach a list. NAME TITLE STREET ADDRESS, CITY, STATE, ZIP TELEPHONE 9. LIST THE SUBSIDIARIES OR AFFILIATES TO BE INCLUDED IN THE SELF-INSURANCE PROGRAM. If necessary, attach a list. LEGAL NAME DATE OF INCORP. STREET ADDRESS, CITY, STATE, ZIP FEIN NAICS CODE NATURE OF BUSINESS SUB. OR AFF.? 10. LIST THE PHYSICAL LOCATIONS OF EACH OPERATION TO BE SELF-INSURED. If attaching a list, follow the same format. OPERATION NAME AND ADDRESS FEIN NAICS CODE NATURE OF BUSINESS AVERAGE # OF EMPLOYEES IN PRODUCTION OFFICE/SALES 11. LIST THE NAME OF CURRENT WORKERS' COMPENSATION INSURANCE CARRIER. Name Policy number Effective dates: From to Provide evidence of applicant's current workers' compensation coverage. 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. INDICATE THE ESTIMATED ANNUAL WORKERS' COMPENSATION PREMIUM FOR THE LAST COMPLETED CALENDAR YEAR. INCLUDE THE PREMIUM OF ALL SUBSIDIARIES TO BE COVERED BY SELF-INSURANCE IN ILLINOIS. If necessary, attach a list. INSURANCE CLASS CODE INSURANCE CLASSIFICATION DESCRIPTION # EMPLOYEES EST. ANNUAL PAYROLL CURRENT MANUAL RATE EST. ANNUAL PREMIUM TOTAL 13. PROVIDE THE FOLLOWING CLAIMS INFORMATION FOR YOUR PROPOSED SELF-INSURED OPERATIONS IN ILLINOIS FOR THE LAST THREE COMPLETED YEARS. Attach detailed loss runs for the last three completed years. YEAR ENDING YEAR ENDING YEAR ENDING A. Number of accidents requiring only medical attention B. Number of accidents requiring lost time of more than 3 days C. Total dollars paid for claims D. Outstanding reserves (incl. medical, indemnity, & expenses) If the reserves vary by more than 20% during these years, provide an explanation. E. Total incurred losses (paid and reserves) F. Number of fatalities Attach a description of each fatality, including the employee's name, date of accident, cause of accident, current status of the claim, and the outcome of any OSHA investigation and/or citations relating to the fatality. 14. LIST THE PERSON TO WHOM INFORMATION REGARDING ASSESSMENTS FOR THE SELF-INSURERS SECURITY FUND, SECOND INJURY FUND, RATE ADJUSTMENT FUND. AND OPERATIONS FUND SHOULD BE SENT. Contact person Street address City/State/Zip Telephone E-mail address 15. LIST THE NAME OF THE PROPOSED CLAIMS SERVICE AGENCY. Company name Contact person Street address City/State/Zip Telephone E-mail address 3 American LegalNet, Inc. www.FormsWorkFlow.com Title Fax Title Fax 16. IF YOU DO NOT PLAN TO RETAIN A CLAIMS SERVICE AGENCY, LIST THE COMPANY REPRESENTATIVE WHO WILL BE RESPONSIBLE FOR THE SELF-INSURANCE PROGRAM. Contact person Street address City/State/Zip Telephone E-mail address Describe the experience and qualifications of this person. 17. LIST THE DESIGNATED SAFETY REPRESENTATIVE. Name Street address City/State/Zip Telephone E-mail address Title Fax Title Fax Attach a narrative description of the safety and loss control program components for your operations in Illinois. Do not send a manual. 18. WHAT MEDICAL FACILITIES ARE AVAILABLE TO YOUR EMPLOYEES? Local clinic Hospital Other (please explain) First aid In-plant doctor/nurse 19. IF ANY OF THE APPLICANT'S EMPLOYEES HAVE EXPOSURE IN ANY DEGREE TO SUBSTANCES THAT MAY CAUSE OCCUPATIONAL DISEASE, INDICATE THE SUBSTANCE AND APPROXIMATE PERCENTAGE OF EMPLOYEES EXPOSED. If necessary, attach a list. Include asbestos, silica dusts, any toxic, injurious, or hazardous substances, compounds, or chemicals, caustics, fumes, noise, radiation, communicable diseases, and any other occupational disease exposures. SUBSTANCE PERCENTAGE OF EMPLOYEES EXPOSED # ACCIDENT REPORTS FILED 20. HAS AN APPLICATION FOR WORKERS' COMPENSATION INSURANCE EVER BEEN REFUSED OR A POLICY CANCELLED? If yes, attach an explanation of circumstances, including the date, jurisdiction, and carrier. Yes No 21. HAS AN APPLICATION FOR SELF-INSURANCE EVER BEEN DENIED OR A CERTIFICATION REVOKED? If yes, attach an explanation of circumstances, including the date and jurisdiction. Yes No 22. IS THE APPLICANT SELF-INSURED IN ANY OTHER JURISDICTION? If yes, attach a list of jurisdictions. Yes No 23. IF THE APPLICANT IS RATED, PROVIDE THE LATEST RATINGS, INCLUDING THE DATE OF THE RATING. IF NOT RATED, MARK N/A. Use the parent company's rating if the applicant is a subsidiary. RATING DATE Moody's Investors Service Standard & Poor's Dun & Bradstreet Other 4 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR SELF-INSURANCE AGREEMENTS In consideration of being granted the privilege of self-insurance under the Illinois Workers' Compensation and Occupational Diseases Acts, the applicant hereby agrees: 1. To promptly pay benefits due to injured employees or their dependents in accordance with the Illinois Workers' Compensation and Occupational Diseases Acts. 2. To promptly report compensable injuries, diseases, and deaths to the Commission as required by law. 3. To promptly notify the Commission of any change in financial condition that will impact the company's ability to self-insure. 4. To immediately notify the Commission before the contemplation of liquidation, sale, or transfer of ownership is ma