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Form 07-6130 (Rev 08/2010) INSTRUCTIONS FOR RENEWING STATUS AS A SELF -INSURED EMPLOYER IN ALASKA REQUIREMENTS: 8 AAC 46.010 and 8 AAC 46.080 provide that an employer may renew their Certificate of Self Insurance in Alaska if the employer (1) demonstrates the financial ability to m eet the employer’s liability under the Alaska Workers’ Compensation Act (Act); (2) maintains a claims adjusting facility through its own staffed adjusti ng facilities located within this state , or through independent, licensed, resident adjusters with power to effe ct settlement within this state . For purposes of this paragraph, insurance companies with a certificat e of authority from the Division of I nsurance, Department of Community, Commerce and Economic Development, and with staff adjusters in this stat e, are considered independent, licensed, resident adjusters; (3) maintains a safety/loss control program; (4) in combination with its parent company or subsidiary companies, continues to employ a minimum of 100 employees either in Alaska or in another stat e or states; and (5 ) maintains a net worth of at least $10 ,000,000. FILING REQUIREMENTS: Application for renewal of Certificate of Self Insurance must be made on form 07- 6130. An applicant that has multiple subsidiaries must list each subsidiary to be covered under the certificate of self -insurance, including the legal name, mailing address, federal identification number, and ownership information for each subsidiary. If the applicant is a joint venture, the application must include financial information for each partner in the venture, and the application must be accompanied by a copy of the joint venture’s operating agreement. The application must be accompanied by the applicant's audited financial statements for the previous fiscal or calendar year imm ediately preceding the year in which the self -insured applies for renewal . The applicant may submit consolidated financial statements of its parent company if the applicant does not have its own audited financial statements and the employer is a majority -owned or wholly -owned subsidiary. A public entity must submit audited comprehensive annual financial reports, including detailed schedules. The applicant shall provide a summary of the employer’s or the employer’s parent company payroll and loss runs for the fiscal or calendar year immediately preceding the filing of the application. The summary must include the number of employees, amount of payroll, number of medical -only claims, number of indemnity claims, number of fatalities, the dollar amount of tot al incurred losses, the dollar amount of paid losses, the dollar amount of reserves for incurred but unpaid losses, the dollar amount of losses within the retention limit, the dollar amount of losses subject to reinsurance or excess recovery, and the dollar amount of losses subject to subrogation recovery. The applicant shall submit a description of its proposed excess insurance coverage, including effective dates, type of coverage, conditions and exclusions, with specific and aggregate retentions and polic y limits. Excess coverage must be written by a casualty insurance company or reinsurance company authorized to transact business in Alaska, and must be rated A - or higher with a stable outlook by a nationally recognized rating organization. The application for renewal of self -insurance must be accompanied by a security deposit in the form of an irrevocable letter of credit from a financial institution authorized to conduct business in Alaska under AS 06.01.010 -06.40.190, with the State of Alaska, Departmen t of Labor and Workforce Development Form 07-6130 (Rev 08/2010) listed as the beneficiary. The amount of the security deposit must be in the amount of $600,000 or 125% of the total outstanding accrued self -insured workers’ compensation liabilities for the year immediately preceding the application, whichever amount is greater. If the employer has been self insured in Alaska for five or more years, the employer may submit a written request for an exemption from posting a security deposit. The exemption request should state the reasons why the employer should not be required to post a security deposit. Each self -insurance renewal applicant is required to submit an independent actuary’s report once every three years, accompanied by a letter signed by an officer of the company that reser ves are adequate and have been accounted for in the company’s balance sheet. The above material shall be mailed to the Division of Workers’ Compensation at least 60 days prior to the expiration of its Certificate of Self Insurance. Form 07-6130 (Rev 08/2010) STATE OF ALASKA DIVISION OF WORKERS’ COMP ENSATION P. O. Box 115512 Juneau, AK 99811- 5512 RENEWAL OF CERTIFICATE OF SELF -INSURANCE All questions must be answered, and requested material submitted. If not applicable, use symbol N/A. 1. Legal Name of Alaskan Employer 2. Mailing Address of Alask an Employer 3. Name and Address of Person Responsible for the Self -Insured Program Name Title Mailing Address Telephone Number Fax Number Email Address 4. List past year’s compensation experience in Alaska Reporting Year Number of Alaskan Employees Total Alaskan Payroll Number of Incident Only & Medical Claims Number of Time -Loss Claims Number of Fatalities Total Amount of Incurred Losses in Year Total Amount of Paid Losses in Year Total Outstanding Loss Reserves at Year End Total Amount Within Retention Limit Total Amount Subject to Excess Coverage Total Amount Subject to Subrogation Recovery Annual Alaskan Workers’ Compensation Premium 5. An independent actuary’s report is due once every thr ee years, accompanied by a letter signed by an officer of the company that reserves are adequate and have been accounted for in the company’s balance sheet. 6. A security deposit is required for each Alaskan self -insured employer, unless the employer has sought and obtained an exemption from this requirement. The amount of the security deposit must be in the amount of $600,000 or 125% of the total outstanding accrued self -insured workers’ compensation liabilities for the year immediately preceding the appl ication, whichever amount is greater. 7. Description of proposed excess insurance Name of proposed excess insurance carrier Proposed Self Insurance Retention Specific: Aggregate: Proposed Policy Limits Specific: Aggregate: 8. Name and address of the Alaska Employer's adjuster handling claims in the State of Alaska Form 07-6130 (Rev 08/2010) 9. Applicant must provide the following documents with this application for renewal of their Certificate of Self Insurance • Audited financial statements for the year immediately preceding the year in which the self - insured applies for renewal. If the employer is a joint venture, financial statements must be submitted for each partner in the joint venture. • A list of subsidiaries to be covered under this application, including the legal name of each subsidiary, the mailing addresses of each, federal employer identification number, and the self - insured’s ownership information in each subsidiary. • Security Deposit, if applicable • Actuary Report, if applicable 10. In consideration of the appr oval of this application, the applicant expressly agrees • To comply with the excess insurance coverage retentions and limits required by the Alaska Workers Compensation Board. • To comply with the security deposits required by the Board. • That this privilege m ay be revoked at any time for cause at the discretion of the Alaska Workers Compensation Board. • That the applicant will promptly provide benefits within the time limits specified by the Alaska Workers Compensation Act. • That the applicant will discharge liability for compensation to injured employees or their dependents in accordance with the requirements of the Alaska Workers Compensation Act. • That the application or its adjuster will provide annual reports no later that March 1 st of each calendar year, and pay applicable Second Injury Fund and Workers’ Safety and Compensation Administration Account assessments due thereon. • That a request for renewal of the Employers Certificate of Self Insurance will be made annually on a form prescribed by the Alaska Worke rs Compensation Board. • That the applicant will notify the board within 30 days of any change in conditions which would affect the applicant's ability to administer its self insurance program, including sale, merger, or other organic changes in ownership i nterest. (Signature of Authorized Person) (Title of Authorized Person) State of County of , being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his/her knowledg e, information and belief. Sworn to and affirmed this day of , . (Notary Public) (Notary seal) My commission expires on