Section R20-5-703. Forms Prescribed by the Commission

The following forms are available upon request from the Commis- sion and contain requests for the information listed in each subsec- tion.

1.        Initial Application for Authority to Self-insure:

a.        Name of the pool;

b.        Address and telephone number of the pool’s princi- pal office;

c.        Effective date of formation of the pool;

d.        Name and address of each member of the pool;

e.        Two digit standard industrial classification code for each member of the pool;

f.         Name and address of the industry or trade associa- tion, or professional organization to which members of the pool belong;

g.        Effective date of formation of the industry or trade association, or professional organization to which members of the pool belong;

h.        Type of business in which members are engaged and length of time in business for each member;

i.         Explanation of how businesses of members are the same or similar;

j.         Amount of workers’ compensation insurance premi- ums paid by each member in the preceding year;

k.        Names and addresses of the board of trustees;

l.         Name, address, and telephone number of the admin- istrator appointed by the board of trustees;

m.      Name, address, and telephone number of the service company, if applicable;

n.        Names, titles, addresses, and telephone numbers of the persons in charge of the loss control and under- writing programs;

o.        Premium tax plan selection;

p.        Authorized signature and title of person signing ini- tial application;

q.        Statement that all information and assertions con- tained in the application and the documents accom- panying the application are factually correct and true; and

r.         Date of execution of the initial application.

2.        Renewal Application:

a.        Name of the pool;

b.        Address and telephone number of the pool’s princi- pal office;

c.        Name and address of each member of the pool and the effective date of membership;

d.        Renewal date of the pool;

e.        Effective date of initial authority to self-insure;

f.         Total number of member employees covered by the pool;

g.        Total payroll of the pool for the last fiscal year;

h.        Name, address, and telephone number of the admin- istrator;

i.         Name, address, and telephone number of the service company, if applicable;

j.         Name, address, and telephone number of the excess insurance carrier;

k.        Name and address of the companies providing guar- anty bond and fidelity policy;

l.         Name and address of individuals serving on the board of trustees;

m.      Names, titles, addresses, and telephone numbers of persons in charge of loss control and underwriting programs;

n.        Authorized signature and title of person signing renewal application;

o.        Statement that all information and assertions con- tained in the renewal application and the documents accompanying the renewal application are factually correct and true; and

p.        Date of execution of the renewal application.

3.        Self-Insurance Guaranty Bond Form:

a.        Pool identification;

b.        Names of fidelity and surety insurance companies;

c.        Description of the bond, including the amount and conditions of the bond obligations and liability of surety;

d.        Statement regarding the responsibility for fees and costs associated with the collection of the bond and the responsibility for payment of any award or judg- ment against the surety;

e.        Authorized signatures and titles by pool, surety, and agent; and

f.         Date of execution of the guaranty bond form.

4.        Option Election Form:

a.        Calculation and selection of type of guaranty bond and securities;

b.        Description of incurred liability and anticipated future liability (compensation and medical) on all

open cases for the preceding four years and the cur- rent year;

c.        Authorized signature and title of person signing option election form;

d.        Statement that all information and assertions con- tained in the form are factually correct and true; and

e.        Date of execution of the option election form.

5.        Self-insured Payroll Report:

a.        Description of the cumulative payroll for all mem- bers of the pool (classification codes, methods and types of pay);

b.        Amount paid in the preceding calendar year;

c.        Authorized signature and title of person signing self- insured payroll report;

d.        Statement that all information and assertions con- tained in the report are factually correct and true; and

e.        Date of execution of self-insured payroll report.

6.        Self-insured Medical Report:

a.        Description of costs relating to industrial injuries;

b.        Reinsurance premiums paid;

c.        Total expenditures for workers’ compensation and occupational disease claims;

d.        Authorized signature and title of person signing self- insured medical report;

e.        Statement that all information and assertions con- tained in the report are factually correct and true; and

f.         Date of execution of the self-insured medical report.

7.        Self-insured Injury Report:

a.        Description of specific information for the current year and three preceding years for each injury requiring payment in excess of $5000 which includes accumulated amount paid and reserved for each claim in excess of $5,000;

b.        Description of all injuries for the current year and three preceding years if individual injury required payment of less than $5,000;

c.        Authorized signature, title, and telephone number of person signing self-insured injury report;

d.        Statement that all information and assertions con- tained in the report are factually correct and true; and

e.        Date of execution of the self-insured injury report.

8.        Quarterly Tax Payment Form:

a.        Name and address of the pool;

b.        Description and calculation of the quarterly tax and designation of the applicable quarter;

c.        Amount of annual tax paid in the previous calendar year; amount of the quarterly tax paid adjusted for change in the tax rate;

d.        Description and calculation of any penalty due;

e.        Authorized signature, title and telephone number of person signing the quarterly tax payment form;

f.         Statement that all information and assertions con- tained in the form are factually correct and true; and

g.        Date of execution of the quarterly tax payment form.

9.        Application to Add a Member to Self-insured Pool:

a.        Name of the pool and name of the member to be added to the pool, including if applicable, addresses, corporation, subsidiary, partnership, and trust infor- mation;

b.        Nature and years in business of the member to be added;

c.        History of business in Arizona and elsewhere for the member to be added;

d.        Payroll data for each member to be added;

e.        Work force data for each member to be added;

f.         Financial data for each member to be added;

g.        Insurance data for each member to be added;

h.        Two digit standard industrial classification code for each member of the pool;

i.         Workers’  compensation  claims,  loss  and  perfor- mance history for the member to be added;

j.         Authorization by board resolution approving addi- tion of each new member;

k.        Authorized  signature  and  title  of  person  signing application;

l.         Statement that all information and assertions con- tained in the application are factually correct and true; and

m.      Date of execution of the application.

10.     Notice Confirming Addition of Member to Pool:

a.        Name of the pool;

b.        Name and address of the new member;

c.        Effective date of membership;

d.        Rate and code classification to be applied to new member;

e.        Standard industrial classification code for new mem- ber;

f.         Authorized  signature  and  title  of  person  signing notice;

g.        Statement that all information and assertions con- tained in the notice are factually correct and true; and

h.        Date of execution of the notice.

11.     Notice of Termination of Membership:

a.        Name and address of pool;

b.        Effective date of termination;

c.        Name and address of the member to be terminated, identified as follows:

i.         All names and addresses of every location used by the member;

ii.        If the member is a partnership, the names and addresses of all the partners;

iii.      If the member is a corporation doing business under a number of divisions, the notice shall state the names of all the divisions of the corpo- ration; and

iv.      If a member changes names, both the new and former names.

d.        Authorized signature, title and telephone number of person signing notice;

e.        Statement that all information and assertions con- tained in the notice are factually correct and true; and

f.         Date of execution of the notice.

Historical Note

Adopted effective September 9, 1998 (Supp. 98-3).