Section R20-5-708. Filing Requirements for Renewal Application for Self-Insurance License

A.      A self-insured pool seeking renewal of an authority to self- insure for workers’ compensation insurance shall file a renewal application 30 days before the existing certificate of authority expires. A pool shall maintain all bonds, policies, and contracts required under this Article while a renewal application is pending before the Commission. The Commis- sion shall deem a renewal application withdrawn if a pool fails to maintain all bonds, policies, and contracts required under this Article.

B.       A renewal application shall meet the following requirements:

1.        An application for renewal of authority to  self-insure shall be completed on a form approved by the Commis- sion;

2.        An application for renewal of authority to  self-insure shall be filed with the Division. An application is consid- ered filed when it is received at the office of the Division;

3.        An application shall be typewritten or written in ink in legible text;

4.        The administrator of a pool shall sign the application. The signature of the administrator shall be notarized; and

5.        The administrator shall verify, in writing, that the infor- mation contained in and submitted with the application is true and correct.

C.      A self-insured pool shall provide the following information at the time the pool files a renewal application:

1.        An updated, completed and signed Option Election Form;

2.        A continuation certificate for the guaranty bond or letter of credit signed by an authorized representative of the surety or bank in an amount equal to the amount set forth in the updated Option Election Form and that meets the requirements of R20-5-713;

3.        A confirmation of excess insurance policies issued by an authorized carrier that meet the requirements of R20-5- 715;

4.        A copy of a signed service contract that meets the requirements of R20-5-725 designating an approved ser- vice company or a written statement with supporting doc- umentation required under R20-5-726 requesting authorization to process claims in-house;

5.        A continuation certificate for the fidelity policy that meets the requirements of R20-5-712;

6.        A statement of any change made in the rates and code classifications utilized by the pool to calculate workers’ compensation premiums;

7.        A statement of any change in the calculation method of a premium for each member;

8.        A statement describing the expenses paid from the trustee fund and the loss fund expressed in a dollar amount and as a percentage of the total premiums collected by the pool in the preceding fiscal year;

9.        A copy of the current contract or agreement of hire between the pool and administrator; and

10.     A copy of the current delegation agreement between the board of trustees and administrator, if applicable, under R20-5-719(C).

D.      No later than 120 days after the end of a pool’s fiscal year, the pool shall file with the Division a copy of the pool’s most recent audited annual financial statements and a copy of the pool’s most recent actuarial review of:

1.        Losses and reserves for all known claims, and

2.        Reserves for incurred but not reported claims.

E.       The Commission shall deem a renewal application complete when a pool provides the information required under subsec- tions (C) and (D).

F.       If a pool does not file a renewal application, each member of the pool shall provide the Commission proof of compliance with A.R.S. § 23-961(A) no later than 10 days after the pool’s certificate of authority expires.

G.      If a pool’s renewal application is deemed withdrawn under this Section, each member of the pool shall provide proof of com- pliance with A.R.S. § 23-961(A) no later than 10 days after the date the Commission deems the application withdrawn.

Historical Note

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