Fill and Sign the Employers Application for Permission to Carry Its Own Risk Without Insurance Form

Page 1 of 3 OKLAHOMA WORKERS' COMPENSATION COURT 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105-4918 (405) 522-8600 EMPLOYERS APPLICATION FOR PERMISSION TO CARRY ITS O WN RISK WITHOUT INSURANCE To: The Oklahoma Workers' Compensation Court Date__________________________________ The undersigned, an employer subject to the provisi ons of the Workers' Compensation Act, hereby applie s for permission to carry its own risk without insurance. To enable the Workers' Com pensation Court to determine whether or not the applicant possesses sufficient financial ability to render certain the payment of any award made by the Court, said applicant hereby states the following: 1. Employer’s Name__________________________________ _______________________________________________ 2. Employer’s Federal Identification Number_________ ___________________________________________________ _ 3. Home Office Address______________________________ ________________________________________________ 4. Oklahoma principal office address_______________ ___________________________________________________ __ 5. Incorporated or organized under the laws of the S tate of ___________________________________________ _______ 6. If foreign corporation, give date licensed to do business in Oklahoma_______________________________ _________ 7. Nature of business_______________________________ _________________________________________________ 8. General Information on Company: a. Years engaged in continuous business___________ ______________, In Oklahoma_____________________ __ b. Payroll in each of the preceding three (3) year s: Year:_______, $___________________; Year:___ ____, $___________________; Year:_______, $________________ Payroll in Oklahoma in each of the preceding t hree (3) years: Year:_______, $___________________; Year:____ ___, $___________________; Year:_______, $________________ c. Number of employees presently employed_________ ______ In Oklahoma______________ d. Estimated payroll in Oklahoma for the next twel ve (12) months________________________ 9. Excess Insurance Information: a. Name of carrier__________________________________ ____________________________________________ b. Policy dates: Effective______________________ _______ Expiration_____________________________ __ c. Under this policy: Self Insured Retention____ ________________ Limits of Liability____________ _______ Note: A certificate of excess insurance or a valid binder issued by said carrier must be attached to this application. A copy of the policy must follow. 10. Estimated manual premium for your company_____ ________________________________________ FORM 1B Page 2 of 3 11. A. In the section below, state the loss history for the past five (5) fiscal/calendar years. Copy the requested information from your loss runs (if the hard copy of your loss runs are required you will be notified). Also include the current year's history, indicating how many months of the current year are included: Total incurred losses in Oklahoma (include for all injuries, both open & closed claims) Year $ Medical Paid $ Indemnity Paid $ Total Paid $ Tot al Reserves Outstanding mo Cases Opened Cases Reopened Cases Closed Death Cases B. Total Self Insurance Reserves Outstanding: $______________________ (for all years of self insurance) Total Self Insured Open Cases: __________ ______________________ (for all years of self insurance) 12. A. Enclose current audited financial report, in cluding balance sheets, income statements & notes. B. A governmental entity must provide a defin ite statement of the amount it has specifically appropriated for workers' compensation claims for the latest and the next fis cal year. Also, a description of how workers' comp ensation claims are funded must be submitted. 13. A. Is the applicant a subsidiary of another emp loyer? ______ If yes, submit the parent company's financial statements. B. Does the applicant have subsidiary compani es that it wants to include under this permit?___________________ (attach a list of the names and address es of ALL entities to be included under this permit , including subdivisions) C. If you answered yes to either question 13A or 13B , attach a copy of a written agreement whereby the ultimate parent employer guarantees that it will be fully responsib le for any liabilities that its subsidiaries may incur under the Oklahoma Workers' Compensation Act. 14. A. Name and address of the company's Third Party Administrator for the servicing of the self insurance claims. ___________________________________________________ __________________________ ___________________________________________________ __________________________ B. If an approved Third Party Administrator i s not employed, please submit qualifications of benefits administrator. Page 3 of 3 Insurance Department Oklahoma Workers' Compensation Court 1915 North Stiles Ave. Oklahoma City, OK 73105-4918 15. Attach a copy of your company's safety plan. 16. In consideration of the approval of this appli cation, the applicant hereby expressly agrees as fo llows: A. The applicant's privilege to carry its own risk without insurance may be revoked at any time f or good cause by the Administrator of the Workers' Compensation Court. B. The applicant will fully discharge by cash payment all installments of compensation for disabi lity promptly when due. The applicant will assume liability for physician's fee s, hospital services, and hospital supplies within 10 days after such liability is determined either by an agreement or an award. Include an annual application fee of $500, made pay able to the Oklahoma Workers' Compensation Court. I declare under penalty of perjury that I have exam ined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and co mplete. Signed this __________ Day of _________________, _ _______ __________________________________________________ Print Name and Title (note: person signing should b e authorized to bind the applicant to the agreements contained herein) __________________________________________________ Signature __________________________________________________ Mailing Address __________________________________________________ Street Address, if different from Mailing Address __________________________________________________ City, State Zip Code __________________________________________________ Telephone Number __________________________________________________ E-mail Address Send application to: Rev. 7/2007