Fill and Sign the Si Option Election for Workers Compensation Arizona Form

                                                                                                                                                                                               ICA USE ONLY:                               part time) in 1997:                                     INDUSTRIAL COMMISSION OF ARIZONA OPTION ELECTION FORM WORKERS' COMPENSATION SELF-INSURANCE PROGRAM (Name of Self-Insured Employer) SECTION ONE - OPTION ONE Please submit the following: A. Guaranty Bond or Securities (Minimum $250,000) B. Specific Excess Insurance (Maximum retention of $250,000, policy limit of not less than $10,000,000) SECTION TWO - OPTION TWO Please submit a Guaranty Bond or Securities, the amount determined from the table: AB C D E F G INCURRED LIABILITY PAID TO DATE FUTURE LIABILITY Number Indemnity Medical Indemnity Medical Indemnity Medical All Cases Open as of Dec.31,1997 1 All Cases Reported in 1998 2 All Cases Reported in 1997 3 All Cases Reported in 1996 4 All Cases Reported in 1995 5 Subtotal 6 Approved Date Tota l 7 Reinsurance Reimbursement 8 Estimated Future Liability 9 SECTION THREE - EMPLOYMENT Total Arizona employees (full x 125% 10 Calculated Bond 11 Total Arizona payroll for 1997: Submitted Bond 12 (Minimum security amount is $100,000) Presentations made are true to the best of my knowledge, information and belief. Date Completed Authorized Signature and Title INSTRUCTIONS FOR COMPLETING THE OPTION ELECTION FORM Complete the option Election Form (ICA Form 02-0058) according to the following instructions: GENERAL INSTRUCTIONS: 1 . 2. If you are selecting Option One, complete Sections One and Three of the form. If you are selecting Option Two, complete Sections Two and Three of the form. 3. In both cases, be sure to date and sign the form, including your title. 4. Return the form, along with the appropriate security deposits, prior to your renewal date . After all renewal requirements have been met, you will be notified of your authorization to continue to self-insure workers' compensation liabilities in Arizona. SECTION ONE INSTRUCTIONS: Check the box and return the form and the necessary certification of continuation of the bond and excess insurance. SECTION TWO INSTRUCTIONS: Check the box and complete the table for the calendar years indicated filling all columns. The purpose and intent of this table is to arrive at your total unpaid liabilities on all your claims while self-insured. Include all claims for all employers which are self- insured and carried under your umbrella authorization. Include all losses which have penetrated your excess coverage and for which you have received, or expect to receive, reimbursement. Round to the nearest dollar. Line 1 (indicated on the right-hand side) should contain all open cases for all years of self-insurance, as of the date shown. Line 2 should contain all cases for the current, partial year indicated. Line 3, 4 and 5 should contain all cases (open and closed) for the years indicated. Column A should contain the actual number of workers' compensation claims accepted for benefits up through your latest reporting period. Columns B and C should contain the total amounts incurred and reserved for all claims accepted, for each period indicated, for both medical and compensation. (Lifetime liability.) Columns D and E should contain the total amounts paid to claimants, through your latest reporting period, for the periods indicated, for both medical and compensation. Columns F and G should contain the amounts of unpaid liability, and should equal the re- sult of subtracting Columns D and E from Columns B and C, respectively. Complete as in-dicated for lines I and 2 only. Line 6 is the subtotal of Columns F and G for medical and compensation. Line 7 is the grand total of both medical and compensation added together. Line 8 should contain any amounts for which you expect reimbursement from your excess carrier(s). Line 9 is the result of subtracting line 8 from line 7. Multiply line 9 by 125% (1.25) to arrive at line 11. Line 11 displays the amount of bond necessary to comply with this Option. If this amount is less than $100,000, the minimum bond required is $100,000.You may round the amount of the actual bond submitted from the calculated bond amount if it is more convenient for you. For example: If $346,938 is the calculated amount, the bond submitted may be $346,940 or $347,000. SECTION THREE INSTRUCTIONS: List total number of Arizona employees and payroll for the year listed.