Section R20-5-1108. Self-insurance Renewal

A.      A self-insurer that is required to post security under this Arti- cle shall request renewal of authorization to self-insure with the Division 30 days before the self-insurer’s anniversary date, by filing a Workers’ Compensation Liability form. The Com- mission shall deem the request for renewal complete if the self-insurer provides the following:

1.        A copy of the self-insurer’s most recent audited annual financial statement or internally reviewed and signed financial statement or annual report. A parent company shall submit a copy of its most recent audited annual financial statement or annual report;

2.        If the self-insured company is a subsidiary, a completed Parent Company Guaranty form signed and dated by the authorized representative of the parent company, or if the parent company of the subsidiary is different from the last filing approved by the Commission, a certified copy of the parent company board of director’s resolution autho-

rizing a designated officer to complete, sign, and file the Parent Company Guaranty form;

3.        Per claim data to support the summary information on the Workers’ Compensation Liability form. The self-insurer shall provide this information in the same format as in R20-5-1103(B)(2)(a) and (b);

4.        Deposit of security as shown on the completed Worker’s Compensation Liability form no later than the self- insurer’s anniversary date subject to R20-5-1127 and R20-5-1128;

5.        A certificate of excess insurance or a continuing certifi- cate of existing excess insurance if the self-insurer takes a credit for excess insurance under R20-5-1109;

6.        If medical care is directed under A.R.S. § 23-1070, a copy of the current medical or hospital medical agree- ment, or detailed statement of the arrangements, if not previously provided;

7.        A statement of the total number of full-time and part-time Arizona employees;

8.        If the Division determines that the self-insurer’s denial rate exceeds 12% of claims filed, a statement from the self-insurer identifying the reason for each denial of a workers’ compensation claim;

9.        If the Division determines that the self-insurer’s experi- ence modification rate is greater than 1.10, a statement from the self-insurer identifying the reasons for that level of losses;

10.     Name of the third-party administrator;

11.     Principal location of the self-insurer in Arizona;

12.     A description of the self-insurer’s current business in Ari- zona and a description of any changes in the nature of business in Arizona in the past year;

13.     List of any subsidiary company located in Arizona; and

14.     Primary and secondary points of contact, including addresses, telephone numbers, facsimile numbers, and e- mail information.

B.       A self-insurer that is exempt from the requirement to post security, shall request renewal of authorization to self-insure by filing an annual statement described under R20-5-1114(B) no later than the employer’s anniversary date. The Commis- sion shall deem the request for renewal complete if the self- insurer provides the following:

1.        Information required under subsections (A)(1), (A)(7) through (A)(10) and (A)(14); and

2.        A certified statement that contains the information described in R20-5-1114 (A) and (B).

Historical Note

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

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