Section R20-5-1103. Forms

The following forms are available upon request from the Division or from the Commission’s Internet site at www.ica.state.az.us, and include the following information for each:

A.      Initial application for authority to self-insure:

1.        Legal name of the applicant and requested effective date for authority to self-insure;

2.        Mailing address and telephone number of applicant’s principal Arizona office and home office;

3.        Name of state under which applicant is incorporated, if applicant is a corporation;

4.        Name of parent company, if applicant is a subsidiary;

5.        Name, address, and status of partners (general, special, and limited), if applicant is a partnership;

6.        Length of time in business in Arizona and elsewhere, if applicable;

7.        Nature or type of business in Arizona;

8.        Arizona payroll data;

9.        Current workers’ compensation insurance data, including current expiration date;

10.     Statement of reasons for rejection or cancellation if an application for worker’s compensation insurance submit- ted by applicant has ever been rejected or a policy of workers’ compensation insurance held by the applicant has ever been cancelled;

11.     Listing of states where self-insurance was denied, if any, and where the applicant is currently self-insured;

12.     Arizona claims history and data for three years preceding application date;

13.     Arizona loss history and experience modification rates for three years preceding application date;

14.     Name of excess insurance carrier;

15.     Name, address, and telephone number of third-party administrator or individual responsible for processing Arizona workers’ compensation claims;

16.     Name and address of Arizona agent upon whom legal notice may be served;

17.     Selection of tax plan;

18.     Name, address, telephone and facsimile number, and e- mail address of person responsible for completing the premium tax information;

19.     Name, address, and telephone number of claims office where Arizona workers’ compensation claims will be processed;

20.     Name, address, telephone and facsimile number, and e- mail address of the primary and secondary points of con- tact for the application and self-insurance process;

21.     Statement that all information and assertions contained in the application and the documents accompanying the application are factually correct and true; and

22.     Listing of required attachments.

B.       Workers’ compensation liability form:

1.        Name of self-insurer;

2.        Selection and calculation of required securities and excess insurance, which includes calculation and report- ing the following:

a.        For all claims reported in the current calendar year, the number of open claims, total incurred liability, both medical and compensation, less the amount paid on these claims to equal the remaining liability or amount owing on these claims;

b.        For all open claims incurred in prior years and remaining open in the current year, the number of open claims, the total incurred liability, both medical and compensation, less the amount paid on these

claims to equal the remaining liability or amount owing on these claims;

c.        The total remaining liability on all open claims less any reimbursement for excess insurance ceded to equal the net remaining liability owing on all claims; and

d.        The amount calculated in subsection (B)(2)(c) multi- plied by 125%;

3.        Name  of  excess  insurance   carrier  that  provides  reim- bursement to self-insurer; and

4.        A statement by the Chief Financial Officer or Chief Exec- utive Officer attesting to the truthfulness of the informa- tion contained in the Workers’ Compensation Liability Form;

C.      Self-insurance workers’ compensation guaranty bond:

1.        Name of self-insurer;

2.        Name of the surety insurance company;

3.        Description of the bond, bond number, amount, and con- ditions of obligation;

4.        Statement regarding the responsibility for fees and costs associated with the collection of the bond and the respon- sibility for payment of any award or judgment against the surety; and

5.        Request for authorized signatures and titles of self- insurer, surety, and agent or attorney-in-fact, and a nota- rized power of attorney, and date of signing.

D.      Parent company guaranty:

1.        Name and state of incorporation of parent company;

2.        Name of self-insured subsidiary to be included in the guaranty;

3.        Statement that the parent company will assume the work- ers’ compensation liabilities of the subsidiary if the sub- sidiary is unable to honor these liabilities, which guarantee is for the benefit of and may be enforced by any and all employees of subsidiary; and

4.        Corporate seal.

E.       Self-insured payroll report:

1.        Name of self-insured;

2.        Tax plan selection;

3.        Period covered by report;

4.        Payroll description (classification codes, methods, and types of pay);

5.        Amount paid for period covered by the report;

6.        Statement that all information contained in the report is correct; and

7.        Request  for  authorized  signature,   date,  title,  and  tele- phone number of person signing the form.

F.       Self-insured medical report:

1.        Name of self-insured;

2.        Period covered by report;

3.        Amount paid relating to treatment of industrial injuries, including payment of medical personnel employed by the self-insurer and medical providers providing outside ser- vices;

4.        Compensation paid to worker’s compensation claimants;

5.        Insurance premiums paid;

6.        Total expenditures for workers’ compensation and occu- pational disease claims;

7.        Statement that all information contained in the report is correct; and

8.        Request  for  authorized  signature,   date,  title,  and  tele- phone number of person signing the form.

G.      Self-insured hospital report:

1.        Name of self-insurer;

2.        Period covered by report;

3.        Amount paid for operational expenses, including payroll, employee benefits, surgeon and physician fees, pharmacy costs, miscellaneous supplies and services, utilities, depreciation, licenses, and taxes;

4.        Amount of revenue, including charges for inpatient and outpatient care, miscellaneous revenue, employee-paid premiums, and employer-paid premiums;

5.        Reconciliation of cash account, including cash balance, total cash available, investments, operating expenses, dis- bursements, and net cash balance;

6.        Statement that all information contained in the report is correct; and

7.        Request for authorized signature, date, title, and tele- phone number of person signing the form.

H.      Self-insured injury report:

1.        Name of self-insurer;

2.        Period covered by report;

3.        Description of individual claims for the current year and three  preceding  years  requiring   payment  greater  than

$5,000.00 for each claim, including name of claimant, date of injury, nature of injury, accumulated amount paid, and the amount of any expenses incurred but not paid;

4.        The total amount paid, and the amount of any expenses incurred but not paid, for the current year and three pre- ceding years for all claims requiring a total payment less than $5,000.00 for each claim;

5.        Statement that all information contained in the report is correct; and

6.        Request for authorized signature, date, title, and tele- phone number of person signing the form.

I.        Quarterly tax payment:

1.        Name and address of the self-insurer;

2.        Designation of the applicable quarter;

3.        Amount of annual tax paid in the previous calendar year; amount of the quarterly tax paid adjusted for any change in the tax rate for the applicable quarter;

4.        Statement that all information contained in the form is correct; and

5.        Request for authorized signature, date, title, and tele- phone number of person signing the form.

J.        Notice of self-insurer’s termination of self-insurance:

1.        Name, address, and telephone number of self-insurer and all Arizona subsidiaries covered under the authority to self-insure, including if applicable:

a.        Names and addresses of all Arizona operations or locations covered by self-insurance authority;

b.        Names and addresses of all partners, if self-insurer is a partnership; and

c.        Current and former names of self-insurer if the self- insurer has undergone a name change since the most recent effective date of the authority to self-insure;

2.        Effective date of termination of authority to self-insure;

3.        Name and address of workers’ compensation insurance carrier providing coverage after the effective date of ter- mination;

4.        For the new coverage; effective date of workers’ compen- sation coverage;

5.        Statement that all information contained in the form is correct; and

6.        Request for authorized signature, date, title, and tele- phone number of person signing the form.

K.      Self-provider of medical benefits:

1.        Indication of whether the self-insurer is, or is not, direct- ing medical care for all of its employees;

2.        If the self-insurer is directing medical care for its employ- ees, the self-insurer shall:

(a)  Attach a copy of all contracts between the self-insurer and the medical providers; or

(b)  Submit a list of names and addresses of all medical providers with whom the self-insurer contracts; and

(c)   The effective date of the agreements between the employer and medical provider; and

3.        Authorized signature, date, and title of person signing the form.

Historical Note

New Section made by final rulemaking at 11 A.A.R.

1008, effective April 4, 2005 (Supp. 05-1).