Fill and Sign the Oregon Entity Form

Endorsement to Include Legal Entity in Self-Insured Certification Read all instructions before completing this application. Answer all questions. Return this form to: Oregon Department of Consumer and Business Services Workers’ Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Certified self-insured employer:       Desired self-insurance effective date:      Insurer no.:      Federal employer identification number:      Legal entity applicant name and mailing address:       The above legal entity applicant applies for certification as a self-insurer in the state of Oregon, as provided in the Oregon workers’ compensation law. A legal entity applicant may not operate as a certified self-insurer until the division issues a Certificate of Consent to Self Insure Legal Entity. 1. List the company representative for self-insurance: Name:       Title:       Company name:       Street address:       City, state, ZIP:       Telephone:       Fax:       Email:       2. Corporate status (legal entity): Individual Partnership Corporation LLC Federal employer identification number:       3. Nature of business (legal entity):       a. Primary NCCI classification codes with greatest payroll in Oregon:       b. Total number of employees in Oregon:       c. Total number of locations in Oregon:       d. Total annual payroll for the last fiscal year for Oregon employees:       4. Incorporated or organized under the laws of the state of:       on       5. Date of start of business in Oregon:       6. Exact legal name of ultimate parent:       7. Federal employer identification number of ultimate parent:       440-1865 (2/18/DCBS/WCD/WEB) Page 1 8. List name of the current workers’ compensation insurance carrier: Name:       Policy no.:       Effective dates:       to       9. Provide the following claims information for your proposed self-insured operations in Oregon: a. A complete loss run for the past year to include the applicant’s most recently promulgated experience rating modification (ERM) worksheet and supporting documentation. b. Most recent ERM:       LIST OF ATTACHMENTS YOU MUST SUBMIT ALL OF THE FOLLOWING ITEMS BEFORE WE COMPLETE A REVIEW OF THE APPLICATION. A. Evidence of the applicant’s current experience rating modification factor. Explain if factor is greater than 1.00. B. An organizational chart showing the hierarchical position of all corporate entities, including the ultimate parent. Note the percentage of ownership and clearly indicate which entity with operations in Oregon is seeking coverage under the certificate of self-insurance. C. (1) The ultimate parent company’s audited financial statements for the most recent year. (2) If certified audited financial statements are not prepared, provide a draft financial statement for the most recent year. D. A detailed Oregon loss runs for the past year. See question 9. E. The total payroll for the past fiscal year for all Oregon employees. See question 3d. SUBMITTING AN INCOMPLETE APPLICATION MAY DELAY THE REVIEW PROCESS. 440-1865 (2/18/DCBS/WCD/WEB) Page 2 APPLICATION FOR SELF-INSURANCE FOR LEGAL ENTITY AGREEMENTS The applicant agrees with the following conditions to be certified as a self-insurer under Oregon workers’ compensation law: 1. To promptly pay benefits due to injured employees or their dependents in accordance with the Oregon workers’ compensation law. 2. To promptly report compensable injuries, diseases, and deaths to the Workers’ Compensation Division as required by law. 3. To promptly notify the Workers’ Compensation Division if contemplating liquidation, sale, or transfer of ownership of the (applicant employer, self-insuring employer, entity, business), and early enough in advance of taking any such actions to enable the Workers’ Compensation Division to ensure that arrangements satisfactory to the division have been made to pay all existing liabilities and any liabilities arising thereafter that are required in connection with the security deposit, or otherwise required by the division. 4. To promptly furnish all reports to the Workers’ Compensation Division that it may lawfully require under the Oregon workers’ compensation law. 5. To be joint and severally liable for the payment of any compensation and monies due to the State of Oregon, Department of Consumer and Business Services under ORS chapter 656, by the certified self-insured employer or any other entities included in the self-insured employer’s certification. This application should be signed and sworn to by the appropriate person or persons as stated below:  If the applicant is an individual, the owner must sign.  If the applicant is a partnership, all of the partners must sign.  If the applicant is a corporation, its president or vice president and its secretary or assistant secretary must sign. AFFIDAVIT State of       County of       Each person listed below, first being sworn on oath, deposes and states that he or she is acquainted with the affairs of this applicant employer, including the representations and statements set forth in this application; that he or she has read said application and all documents submitted, knows their contents, and verifies that the representations and statements are true in substance and in fact.       Applicant’s legal name Signature of affiant and date Signature of affiant and date             Name and title of affiant Name and title of affiant Subscribed and sworn to before me on       Notary Public 440-1865 (2/18/DCBS/WCD/WEB) Page 3