Fill and Sign the Az Workers Form

     Guaranty bond Bonds or securities of the United States Letter of Credit $       $200,000.                        THE INDUSTRIAL COMMISSION OF ARIZONA 800 WEST WASHINGTON ST.P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 OPTION ELECTION FORM FOR WORKERS' COMPENSATION POOLS UNDER A.R.S. § 23-961.01 Part A 1. Please state the name of the workers' compensation pool filing an initial or renewal application to self-insure under A.R.S. § 23-961.01. 2. Please select the option elected by the workers' compensation pool named in question number 1. 3. Please state the amount of the guaranty bond, bonds or securities of the United States, or letter of credit obtained by the pool. which represents 125% of total outstanding accrued liability based on calculation set forth in Part B of this form (applicable only to workers' compensation pools filing a renewal application). Part B 1. Please provide the following information for all workers' compensation claims processed from the pool's initial effective date of authority to self-insure through December 31, 1998: a. Number of claims in which medical or compensation benefits are currently being paid by the pool. b. Total incurred and reserved liability for medical benefits, and temporary and permanent compensation benefits (lifetime liability). $ C. Total amount paid to date for medical benefits, and temporary and permanent compensation benefits through last reporting period. $ d. Total amount incurred, but not paid, for medical benefits, and temporary and permanent compensation benefits (I b - I c). $ Option Election Form Page I       $                         $       $       $       $      I ,       have authority to sign the option election form, that I am the                   2. Please provide the following information for all workers' compensation claims reported in 1999: a. Number of claims accepted. b. Total incurred and reserved liability for medical benefits, and temporary and permanent compensation benefits (lifetime liability). c. Total amount paid to date for medical benefits, and temporary and permanent compensation benefits through last reporting period. $ d. Total amount incurred, but not paid, for medical benefits, and temporary and permanent compensation benefits (2b - 2c). $ 3. Formula to determine 125% of the pool's total outstanding accrued liability. a. Total amount incurred, but not paid, for medical benefits, and temporary and permanent disability benefits for all years listed in Part B (1d + 2d). $ b. Amount of reimbursement received from reinsurance carrier or carriers. C. Estimated future liability (3a - 3b). d. 125 % of total outstanding accrued liability ( 3c x 125%). e. Amount of bond, United States bonds or securities, and letter of credit. , certify under penalty of perjury, that I (title) of the pool and in that capacity have knowledge of the information contain in the option election form, that I have read the option election form, and verify that the representations and statements contained in the option election form, are true to the best of my knowledge, information, and belief. Signature of Administrator Printed or typed name of Administrator The law requires that a workers' compensation pool obtain and maintain during all periods of self-insurance a guaranty bond, United States bonds or securities, or letter of credit in an amount equal to the greater of $200,000 or 125% of the total outstanding accrued liability as reflected in this form. Option Election Form Page 2